Cerebral Autoregulation-Guided Optimal Blood Pressure in Sepsis-Associated Encephalopathy: A Case Series
Cerebral Autoregulation-Guided Optimal Blood Pressure in Sepsis-Associated Encephalopathy: A Case Series
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DOI：
10.1177/0885066619828293
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发表时间：
2020-12-01
影响因子：
3.1
通讯作者：
Nyquist, Paul
中科院分区：
文献类型：
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作者：
Rosenblatt, Kathryn;Walker, Keenan A.;Nyquist, Paul
背景：脓毒症相关性脑病(SAE)患者的高发病率和高死亡率可能与脑自我调节功能受损和脑低灌流有关。对脑自动调节的床边评估可能有助于个性化血流动力学指标，从而优化脑血流灌注。我们假设，近红外光谱(NIRS)衍生的脑氧仪可以确定SAE患者增强自我调节的血压范围，自我调节障碍与脑病的严重程度相关。方法：对直接由脓毒症引起的急性脑病的成人患者进行基于NIRS的多模式监测，连续12小时。用局部脑血氧饱和度与平均动脉压(MAP)的时间相关性来确定脑血氧指数(COX)作为脑自我调节的指标。为每个患者构建自动调节曲线，根据MAP对3个连续4小时时段的COX值进行排序；确定每个时段的最佳压力(MAP(OPT))，定义为与最稳健自动调节相关的MAP(最低COX)。用格拉斯哥昏迷评分(GCS)评定脑病严重程度。结果：6例颅外脓毒症患者符合严格的标准，包括无药物镇静或神经系统先天发病。所有患者的MAP均为最佳，范围为55至115毫米汞柱。此外，在监测期间，个体患者的MAP(OPT)随时间变化。以COX为基础的自我调节障碍与较差的神经状态(GCS<；13)相关，无论有没有控制年龄和脓毒症的严重程度(调整后的优势比[OR]：2.11；95%可信区间[CI]：1.77-2.52；P<；.001；OR：2.97；95%CI：1.63-5.43；P<；.001)。结论：在这个高保真的SAE患者组中，基于NIRS的连续监测可以确定改善自我调节的血压范围。考虑到大脑自我调节功能与脑病严重程度之间的关联，这一点很重要。采用床边自动调节监测的个体化血压目标可能比目前的做法更好地保存SAE的脑血流灌注。
Background:Impaired cerebral autoregulation and cerebral hypoperfusion may play a critical role in the high morbidity and mortality in patients with sepsis-associated encephalopathy (SAE). Bedside assessment of cerebral autoregulation may help individualize hemodynamic targets that optimize brain perfusion. We hypothesize that near-infrared spectroscopy (NIRS)-derived cerebral oximetry can identify blood pressure ranges that enhance autoregulation in patients with SAE and that disturbances in autoregulation are associated with severity of encephalopathy.Methods:Adult patients with acute encephalopathy directly attributable to sepsis were followed using NIRS-based multimodal monitoring for 12 consecutive hours. We used the correlation in time between regional cerebral oxygen saturation and mean arterial pressure (MAP) to determine the cerebral oximetry index (COx) as a measure of cerebral autoregulation. Autoregulation curves were constructed for each patient with averaged COx values sorted by MAP in 3 sequential 4-hour periods; the optimal pressure (MAP(OPT)), defined as the MAP associated with most robust autoregulation (lowest COx), was identified in each period. Severity of encephalopathy was measured with Glasgow coma scale (GCS).Results:Six patients with extracranial sepsis met the stringent criteria specified, including no pharmacological sedation or neurologic premorbidity. Optimal MAP was identified in all patients and ranged from 55 to 115 mmHg. Additionally, MAP(OPT) varied within individual patients over time during monitoring. Disturbed autoregulation, based on COx, was associated with worse neurologic status (GCS < 13) both with and without controlling for age and severity of sepsis (adjusted odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.77-2.52; P < .001; OR: 2.97; 95% CI: 1.63-5.43; P < .001).Conclusions:In this high-fidelity group of patients with SAE, continuous, NIRS-based monitoring can identify blood pressure ranges that improve autoregulation. This is important given the association between cerebral autoregulatory function and severity of encephalopathy. Individualizing blood pressure goals using bedside autoregulation monitoring may better preserve cerebral perfusion in SAE than current practice.