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Assessing Cerebral Autoregulation via Oscillatory Lower Body Negative Pressure and Projection Pursuit Regression
Published on: December 10, 2014
Experience with clinical cerebral autoregulation testing in children hospitalized with traumatic brain injury:
Thitikan Kunapaisal1,2, Anne Moore3, Marie A Theard1,2
1Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.
Insights
Implementing a clinical order set for cerebral autoregulation testing in children with traumatic brain injury (TBI) facilitated testing and led to changes in hemodynamic targets, demonstrating feasibility and safety.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Trauma surgery
Background:
- Traumatic brain injury (TBI) in children requires precise management of cerebral hemodynamics.
- Cerebral autoregulation (CA) testing is crucial for optimizing TBI care but can be challenging to implement.
- Standardizing CA testing protocols is essential for consistent clinical application.
Purpose of the Study:
- To evaluate the institutional experience with implementing a clinical order set and protocol for cerebral autoregulation testing in pediatric TBI patients.
- To assess the clinical use, feasibility, and safety of CA testing in hospitalized children with TBI.
- To determine the impact of CA testing on hemodynamic management strategies.
Main Methods:
- A retrospective review of pediatric patients (<18 years) with TBI between 2014-2021 was conducted.
- A standardized clinical order set and protocol for CA testing were introduced in 2018.
- Data collected included patient characteristics, testing frequency, completion rates, and reasons for test interruption.
Main Results:
- Testing increased significantly after order set implementation (64% vs. 36%).
- CA testing was frequently performed in mechanically ventilated children with severe TBI and invasive monitoring.
- 82% of tests were completed, with 14% leading to changes in hemodynamic targets; impaired CA prompted repeat testing.
Conclusions:
- The availability of a clinical order set and protocol significantly facilitated CA testing in pediatric TBI.
- CA testing is feasible and safe in this population, even with high therapeutic intensity.
- CA testing results influenced clinical decision-making, leading to adjustments in hemodynamic management.
Objective:
To report our institutional experience with implementing a clinical cerebral autoregulation testing order set with protocol in children hospitalized with traumatic brain injury (TBI).
Methods:
After IRB approval, we examined clinical use, patient characteristics, feasibility, and safety of cerebral autoregulation testing in children aged <18 years between 2014 and 2021. A clinical order set with a protocol for cerebral autoregulation testing was introduced in 2018.
Results:
25 (24 severe TBI and 1 mild TBI) children, median age 13 years [IQR 4.5; 15] and median admission GCS 3[IQR 3; 3.5]) underwent 61 cerebral autoregulation tests during the first 16 days after admission [IQR1.5; 7; range 0-16]. Testing was more common after implementation of the order set (n = 16, 64% after the order set vs. n = 9, 36% before the order set) and initiated during the first 2 days. During testing, patients were mechanically ventilated (n = 60, 98.4%), had invasive arterial blood pressure monitoring (n = 60, 98.4%), had intracranial pressure monitoring (n = 56, 90.3%), brain-tissue oxygenation monitoring (n = 56, 90.3%), and external ventricular drain (n = 13, 25.5%). Most patients received sedation and analgesia for intracranial pressure control (n = 52; 83.8%) and vasoactive support (n = 55, 90.2%) during testing. Cerebral autoregulation testing was completed in 82% (n = 50 tests); 11 tests were not completed [high intracranial pressure (n = 5), high blood pressure (n = 2), bradycardia (n = 2), low cerebral perfusion pressure (n = 1), or intolerance to blood pressure cuff inflation (n = 1)]. Impaired cerebral autoregulation on first assessment resulted in repeat testing (80% impaired vs. 23% intact, RR 2.93, 95% CI 1.06:8.08, p = 0.03). Seven out of 50 tests (14%) resulted in a change in cerebral hemodynamic targets.
Conclusion:
Findings from this series of children with TBI indicate that: (1) Availability of clinical order set with protocol facilitated clinical cerebral autoregulation testing, (2) Clinicians ordered cerebral autoregulation tests in children with severe TBI receiving high therapeutic intensity and repeatedly with impaired status on the first test, (3) Clinical cerebral autoregulation testing is feasible and safe, and (4) Testing results led to change in hemodynamic targets in some patients.
