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Impaired Autoregulation Following Resuscitation Correlates with Outcome in Pediatric Patients: A Pilot Study
Julian Zipfel1, Konstantin L Hockel2,3, Ines Gerbig4
1Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany. julian.zipfel@med.uni-tuebingen.de.
Insights
In pediatric non-traumatic hypoxic-ischemic brain injury, prolonged impaired cerebral autoregulation after resuscitation is linked to poor neurological outcomes. Monitoring pressure reactivity index (PRx) helps predict prognosis.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Brain Injury Pathophysiology
Background:
- Impaired cerebral autoregulation is linked to poor outcomes in traumatic brain injury.
- The relationship between autoregulation and outcomes in non-traumatic hypoxic-ischemic brain injury (HIHBI) post-resuscitation is less understood.
Purpose of the Study:
- To investigate the correlation between the duration of impaired autoregulation and neurological outcomes in children with non-traumatic HIHBI.
- To explore the prognostic value of autoregulation monitoring in this patient population.
Main Methods:
- Pilot study involving 11 children post-resuscitation from non-traumatic HIHBI.
- Continuous monitoring of blood pressure and intracranial pressure (ICP) using ICM+ software.
- Active management of cerebral perfusion pressure (CPP) and calculation of the pressure reactivity index (PRx).
- Neurological outcomes assessed using the Glasgow Outcome Scale (GOS).
Main Results:
- No significant difference in ICP or CPP between favorable and unfavorable outcome groups in the first 72 hours.
- A significantly longer duration of PRx ≥ 0.2 (indicating impaired autoregulation) was observed in children with unfavorable outcomes.
- A PRx ≤ 0 (indicating intact autoregulation) was associated with favorable outcomes, except in one child.
- Magnetic resonance imaging revealed ischemic brain tissue in children with unfavorable outcomes.
Conclusions:
- The duration of impaired autoregulation within 72 hours post-insult is a significant predictor of unfavorable neurological outcomes in pediatric non-traumatic HIHBI.
- Initial poor autoregulation, coupled with an inability to restore it despite interventions, serves as a prognostic indicator of insult severity.
- ICP-based autoregulation monitoring may not detect localized ischemia (e.g., basal ganglia), which can lead to poor outcomes despite seemingly preserved global autoregulation.
Abstract:
In children with a traumatic brain injury, the duration of autoregulation impairment correlates with the neurological outcome. This pilot study explored whether a similar relation exists in nontraumatic hypoxic-ischemic brain injury following resuscitation.We investigated 11 children after resuscitation. Blood pressure and intracranial pressure (ICP) were monitored with ICM+ software and actively managed to maintain optimal cerebral perfusion pressure (CPP), using the pressure reactivity index (PRx). Outcomes were scored according to the Glasgow Outcome Scale.Three children died within 24 h. Three survivors had an unfavorable outcome and five had a favorable outcome. In the first 72 h, ICP and CPP values did not differ between, or predict, children with favorable or unfavorable outcomes. The duration of a PRx value ≥0.2 was significantly greater in children with an unfavorable outcome. A PRx value ≤0 was associated with a favorable outcome in all except one child. Children with an unfavorable outcome had areas of ischemic brain tissue on magnetic resonance imaging.The duration of poor autoregulation within the first 72 h is associated with an unfavorable outcome. Prognostic signs for insult severity are initially poor autoregulation plus inability to restore autoregulation despite active attempts to do so. Limited ischemia, especially in the basal ganglia, cannot be detected by ICP-based monitoring of autoregulation and may still result in an unfavorable outcome despite good global autoregulation.
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