Developing Goal Directed Perfusion Therapy in SAH Neurocardiac Injury

描述：高达46%的蛛网膜下腔出血（aSAH）患者存活后经历了严重的长期残疾.新出现的证据表明，aSAH后心肌损伤（SAHMI），也称为“神经心脏损伤”，有助于继发性损伤的发展，因此预后较差。提高识别和管理这种并发症的能力可以降低不良后果的可能性。在之前的工作中，我们证明了31%的aSAH后患者表现出早期心肌肌钙蛋白I（cTnI）升高，其与aSAH严重程度递增相关，并与心肌局部室壁运动异常（RWMA）、射血分数（EF）降低和动态心律失常相关，超过一半的受影响患者在住院期间持续存在一定程度。我们进一步确定早期cTnI升高与身体和神经心理残疾相关。我们假设，SAHMI钝化动态全身和脑灌注，产生一段时间的附加灌注不足，这有助于较差的短期和长期的身体和神经心理功能的结果。护士负责aSAH患者的血流动力学和神经系统监测，但没有基于证据的建议来推动SAHMI灌注支持的临床决策。我们建议利用新的无创性宏观和微循环灌注监测，以确定SAHMI灌注的影响，并制定灌注支持的建议。我们的研究目标是根据与更好的患者功能结局相关的最佳灌注参数，为SAHMI患者制定灌注目标导向的治疗建议。我们将确定SAHMI对动态全身和脑灌注、功能恢复和SAHMI恢复轨迹的影响。我们将招募200例aSAH患者（年龄>21-75岁），通过超声心动图评估他们的心肌肌钙蛋白I升高、局部室壁运动异常和射血分数降低，并通过霍尔特监测评估动态异位和心律失常。我们还将利用FDA批准的新技术来评估宏观和微循环灌注的影响。这将通过SAHMI和无SAHMI受试者的连续无创心输出量监测（NICOM）、外周微循环（近红外光谱[NIRS]）、脑大循环（脑灌注压）和脑微循环[脑NIRS]）灌注监测来实现。我们还将确定SAHMI对身体功能和神经心理功能的影响，这是一种更敏感的恢复和重返社会措施，因此更能反映SAHMI带来的真正负担。然后，我们将使用这些证据来指导我们制定临床可行的灌注目标导向治疗建议。分析将包括各种回归建模方法以及分类和回归树。床旁靶向灌注治疗的应用有可能改善预后，减少aSAH对患者、护理系统和社会的负担。

DESCRIPTION: Up to 46% of patients surviving aneurysmal subarachnoid hemorrhage (aSAH) experience significant long- term disability. Emerging evidence suggests that post-aSAH myocardial injury (SAHMI), also called "neurocardiac injury" contributes to the development of secondary insult and therefore poorer outcomes. Improved ability to recognize and manage this complication could reduce the likelihood of adverse consequences. In prior work, we demonstrated that 31% of post-aSAH patients exhibit early elevated cardiac troponin I (cTnI) that is incrementally related to aSAH severity, and associated with myocardial regional wall motion abnormality (RWMA), depressed ejection fraction (EF), and dynamic cardiac arrhythmia that persists to some extent during hospitalization in over half of affected patients. We further determined that early elevated cTnI is associated with physical and neuropsychologic disability. We hypothesize that SAHMI blunts dynamic systemic and cerebral perfusion, producing a period of additive perfusion shortfall which contributes to poorer short and long term physical and neuropsychologic functional outcomes. Nurses are responsible for hemodynamic and neurologic monitoring of aSAH patients, but there are no evidence based recommendations driving clinical decisions for SAHMI perfusion support. We propose to utilize newer noninvasive macro and microcirculatory perfusion monitoring to determine SAHMI perfusion impact and develop perfusion supportive recommendations. Our study goal is to develop perfusion goal-directed therapeutic recommendations for SAHMI patients based upon the optimal perfusion parameters associated with better patient functional outcomes. We will determine the influence of SAHMI on dynamic systemic and cerebral perfusion, functional recovery, and SAHMI recovery trajectory. We will recruit 200 patients with aSAH (ages >21-75 years), and assess them for elevated cardiac troponin I, regional wall motion abnormalities and depressed ejection fraction on echocardiogram, and dynamic ectopy and arrhythmia via Holter monitoring. We will also utilize novel yet FDA-approved technologies to assess macro and microcirculatory perfusion impact. This will be accomplished with continuous noninvasive cardiac output monitoring (NICOM), peripheral microcirculatory (near-infrared spectroscopy [NIRS]), cerebral macro circulatory (cerebral perfusion pressure) and cerebral microcirculatory [cerebral NIRS]) perfusion monitoring in SAHMI and no-SAHMI subjects. We will also determine the impact SAHMI has on physical function as well as neuropsychologic function-a more sensitive measure of recovery and reintegration and therefore more reflective of the true burden imposed by SAHMI. We will then use this evidence to guide our development of clinically practicable perfusion goal-directed therapeutic recommendations. Analyses will include various regression modeling approaches as well as classification and regression trees. The application of targeted perfusion therapy at the bedside has the potential to improve outcomes and reduce aSAH burden on patients, the care system, and society.