An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: Time to drop 'one-size-fits-all' hemodynamic targets?
An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: Time to drop 'one-size-fits-all' hemodynamic targets?
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DOI：
10.1016/j.resuscitation.2015.03.001
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发表时间：
2015-05-01
期刊：
影响因子：
6.5
通讯作者：
DeDeyne, C.
中科院分区：
文献类型：
--
作者：
Ameloot, K.;Genbrugge, C.;DeDeyne, C.
目的：心脏骤停（CA）后伴有脑自动调节紊乱的ROSC患者亚组可能受益于较高的平均动脉压（MAP）。我们的目的是（1）表型患者与干扰自动调节，（2）调查这些患者是否有更差的预后，（3）定义一个个人的最佳MAP每名患者和（4）调查是否在这个个人的最佳MAP下的时间与outcome.Methods：前瞻性观察研究在51后CA患者监测近红外光谱。（1）18/51例（35%）患者存在自身调节紊乱。从表型上看，较高比例的自动调节紊乱的患者患有CA前高血压（31 +/- 47 vs 65 +/-49%，p = 0.02），表明自动调节的右移是由脑血流对较高血压的慢性适应引起的。(2)在多变量分析中，保留自身调节的患者（n = 33，65%）的180天生存率显著较高（OR 4.62，95% CI [1.06：20.06]，p = 0.04]。基于自动调节指数（考克斯），COX预测的最佳平均动脉压在自动调节功能正常的患者中为85 mmHg，在自动调节功能紊乱的患者中为100 mmHg。(3)在33/51例患者中可以确定个体最佳MAP。(4)个体最佳MAP下的时间与生存率呈负相关（OR 0.97，95% CI [0.96：0.99]，p = 0.02）。根据以前提出的固定目标（65，70，75，80毫米汞柱）的时间是不相关的差异生存率。结论：脑自动调节显示在35%的CA后患者，其中大多数有CA前高血压的干扰。CA后24小时内的脑自动调节紊乱与预后不良相关。与统一的MAP目标相反，患者根据自身调节指数定制的最佳MAP所花费的时间与生存率呈负相关。(C)2015爱思唯尔爱尔兰有限公司版权所有。
Aims: A subgroup of patients with ROSC after cardiac arrest (CA) with disturbed cerebral autoregulation might benefit from higher mean arterial pressures (MAP). We aimed to (1) phenotype patients with disturbed autoregulation, (2) investigate whether these patients have a worse prognosis, (3) define an individual optimal MAP per patient and (4) investigate whether time under this individual optimal MAP is associated with outcome.Methods: Prospective observational study in 51 post-CA patients monitored with near infrared spectroscopy.Results: (1) 18/51 patients (35%) had disturbed autoregulation. Phenotypically, a higher proportion of patients with disturbed autoregulation had pre-CA hypertension (31 +/- 47 vs 65 +/- 49%, p = 0.02) suggesting that right shifting of autoregulation is caused by chronic adaptation of cerebral blood flow to higher blood pressures. (2) In multivariate analysis, patients with preserved autoregulation (n = 33, 65%) had a significant higher 180-days survival rate (OR 4.62, 95% CI [1.06: 20.06], p = 0.04]. Based on an index of autoregulation (COX), the average COX-predicted optimal MAP was 85 mmHg in patients with preserved and 100 mmHg in patients with disturbed autoregulation. (3) An individual optimal MAP could be determined in 33/51 patients. (4) The time under the individual optimal MAP was negatively associated with survival (OR 0.97, 95% CI [0.96: 0.99], p = 0.02). The time under previously proposed fixed targets (65, 70, 75, 80 mmHg) was not associated with a differential survival rate.Conclusion: Cerebral autoregulation showed to be disturbed in 35% of post-CA patients of which a majority had pre-CA hypertension. Disturbed cerebral autoregulation within the first 24 h after CA is associated with a worse outcome. In contrast to uniform MAP goals, the time spent under a patient tailored optimal MAP, based on an index of autoregulation, was negatively associated with survival. (C) 2015 Elsevier Ireland Ltd. All rights reserved.