Monitoring Cerebral Autoregulation in Patients Undergoing Traumatic Hip Fracture Surgery to Improve Postoperative Outcomes

监测接受创伤性髋部骨折手术的患者的大脑自动调节以改善术后结果

• 批准号: 10399004
• 负责人: Charles Hugh Brown
• 金额: $ 12.06万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-08-15 至 2023-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10399004
• 关键词: Address; Anesthetics; Blood Pressure; Cardiac Surgery procedures; Cerebral Ischemia; Cerebrovascular Circulation; Cerebrovascular Physiology; Cerebrum; Clinical Trials; Data; Delirium; Dementia; Development Plans; Elderly; Foundations; Goals; Hip Fractures; Homeostasis; Hypotension; Intervention; Knowledge; Leadership; Measures; Mentors; Mentorship; Methodology; Methods; Monitor; Morbidity - disease rate; Neurocognitive; Neurocognitive Deficit; Operative Surgical Procedures; Outcome; Patients; Perfusion; Perioperative; Population; Postoperative Period; Regulation; Research; Research Proposals; Risk Factors; Role; Scientist; Variant; Walking; adjudication; base; blood pressure variability; career; career development; cognitive change; dementia risk; design; feasibility trial; functional decline; functional outcomes; functional status; hip surgery; improved; improved outcome; individual patient; modifiable risk; neurocognitive test; novel strategies; pressure; prevent; real time monitoring; safety and feasibility; standard of care

PROJECT SUMMARY/ABSTRACT Background: Surgery for hip fracture can be devastating for older adults, with complications including delirium, increased risk of dementia, and inability to walk. As an anesthesiologist and clinician-scientist, I have focused on reducing delirium after surgery. In this proposal, I will build the foundation for a research career focused on the broader goals of reducing neurocognitive and functional decline after surgery in older adults. I will specifically focus on the role of optimizing intraoperative cerebral perfusion, because of pilot data suggesting that reduced cerebral perfusion during surgery is a modifiable risk factor for delirium. Career Development Plan: I am proposing specific educational goals that address gaps in my current knowledge. First, I will develop expertise in cerebrovascular physiology and monitoring under the mentorship of Dr. Koehler, an expert in cerebral blood flow regulation. Second, I will develop expertise in neurocognitive testing and dementia assessment under the mentorship of Dr. Kamath, a neuropsychologist, and Dr. Gottesman, an expert in dementia adjudication in the research setting. Third, I will gain expertise in clinical trials and measuring functional status through the mentorship of Drs. Sieber and Neuman (experts in perioperative clinical trials in older adults), and Dr. Walston (a geriatrician with expertise in functional status). Finally, I will develop as a leader through interactions with my mentors, courses, and leadership opportunities. Research Proposal: During hip fracture surgery, extreme variations in blood pressure are common in older adults, who are susceptible to cerebral ischemia and vulnerable to consequences of hypotension. However, there is no standard of care as to what constitutes adequate blood pressure during surgery. Our group has championed methodology to define optimal blood pressure in individual patients by real-time monitoring of cerebral autoregulation. Using these methods in cardiac surgery, we have shown that mean arterial pressure (MAP) below the limits of cerebral autoregulation is associated with postoperative morbidity, and that an intervention to target intraoperative MAP based on this monitoring may reduce delirium. Although promising, these results in cardiac surgery may not apply in hip fracture surgery. To address this gap in knowledge, I will extend these methods to hip fracture surgery patients. I will characterize (a) the extent of, and (b) risk factors for intraoperative MAP variation above and below the limits of cerebral autoregulation during hip fracture surgery (Aim 1). I will also examine associations of MAP variation with neurocognitive and functional outcomes (Aim 2). Based on these results, I will design a pilot feasibility/safety trial to determine whether targeting MAP within the limits of autoregulation could improve neurocognitive/functional outcomes (Aim 3). Summary: Promising results from this proposal would support a definitive trial, which would have the potential to fundamentally alter anesthetic strategies across a wide range of surgical populations. The educational plan in this proposal will support my career goal of improving outcomes for older adults after surgery.

项目总结/摘要 背景：髋部骨折的手术对老年人来说是毁灭性的，并发症包括 谵妄，痴呆风险增加，无法行走。作为一名麻醉师和临床科学家，我 专注于减少手术后的谵妄在这份建议书中，我将为我的研究生涯打下基础 重点关注减少老年人手术后神经认知和功能下降的更广泛目标。我 由于试点数据，我将特别关注优化术中脑灌注的作用 提示手术期间脑灌注减少是谵妄的可改变的危险因素。 职业发展计划：我提出了具体的教育目标，以解决我目前的差距 知识首先，我将在导师的指导下发展脑血管生理学和监测方面的专业知识 凯勒博士的大脑血流调节专家第二，我将发展神经认知方面的专业知识， 测试和痴呆症评估的指导下，博士卡马思，神经心理学家，博士。 Gottesman博士是研究背景下痴呆症裁定的专家。第三，我将获得临床专业知识， 通过Sieber和Neuman博士的指导进行试验和测量功能状态（专家 老年人围手术期临床试验）和Walston博士（功能状态方面的老年病专家）。 最后，我将通过与我的导师，课程和领导机会的互动，发展成为一名领导者。 研究提案：在髋部骨折手术期间，老年人血压的极端变化很常见 成年人易患脑缺血，易受低血压的影响。然而，在这方面， 在手术期间，没有关于什么构成适当血压的护理标准。我们集团 倡导的方法，以确定最佳的血压在个别患者的实时监测， 脑自动调节在心脏手术中使用这些方法，我们已经证明平均动脉压 (MAP)低于脑自动调节的限度与术后发病率有关， 基于该监测的靶向术中MAP的干预可以减少谵妄。虽然前景看好， 心脏手术中的这些结果可能不适用于髋部骨折手术。为了弥补这一知识差距，我将 将这些方法扩展到髋部骨折手术患者。我将描述（a）风险因素的程度和（B）风险因素 对于髋部骨折期间高于和低于脑自动调节极限的术中MAP变化， 手术（目标1）。我还将研究MAP变化与神经认知和功能的关系， （目标2）。根据这些结果，我将设计一个试点可行性/安全性试验，以确定是否 在自身调节的限度内靶向MAP可以改善神经认知/功能结果（目的3）。 总结：这项提议的有希望的结果将支持一项明确的试验，这将有可能 从根本上改变广泛手术人群的麻醉策略。教育规划 这份提案将支持我的职业目标，即改善老年人手术后的结果。

项目成果

Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.

• DOI: 10.1213/ane.0000000000003671
• 发表时间: 2019-03
• 期刊: Anesthesia and analgesia
• 影响因子: 5.7
• 作者: Cho BC;DeMario VM;Grant MC;Hensley NB;Brown CH 4th;Hebbar S;Mandal K;Whitman GJ;Frank SM
• 通讯作者: Frank SM

Comparing three wearable accelerometers to measure early activity after cardiac surgery.

• DOI: 10.1016/j.xjon.2022.05.011
• 发表时间: 2022-09
• 期刊: JTCVS open
• 作者: Brown, Charles H 4th;Yanek, Lisa;Healy, Ryan;Tsay, Tiffany;Di, Junrui;Goeddel, Lee;Young, Daniel;Zipunnikov, Vadim;Schrack, Jennifer
• 通讯作者: Schrack, Jennifer

Is Less Really More? Conscious Sedation or General Anesthesia for Transcatheter Aortic Valve Replacement.

少真的是多吗？

• DOI: 10.1161/circulationaha.117.031281
• 发表时间: 2017
• 期刊: Circulation
• 影响因子: 37.8
• 作者: Brown4th,CharlesH;Hasan,RaniK;Brady,MaryBeth
• 通讯作者: Brady,MaryBeth