Developing Goal Directed Perfusion Therapy in SAH Neurocardiac Injury

描述：高达46%的动脉瘤性蛛网膜下腔出血(ASAH)存活者经历了严重的长期残疾。新的证据表明，ASAH后心肌损伤(SAHMI)，也被称为“神经心脏损伤”，有助于二次损伤的发展，因此预后较差。提高识别和处理这种并发症的能力可以减少不良后果的可能性。在先前的工作中，我们发现31%的ASAH后患者表现出早期心肌肌钙蛋白I(CTnI)升高，这与ASAH的严重程度有关，并与心肌局部室壁运动异常(RWMA)、射血分数压低(EF)以及在超过一半的患者住院期间持续一定程度的动态心律失常有关。我们进一步确定早期升高的cTnI与生理和神经心理障碍有关。我们假设Sahmi钝化了动态的全身和大脑灌注，产生了一段时间的附加灌注不足，从而导致较差的短期和长期生理和神经心理功能结果。护士负责ASAH患者的血流动力学和神经学监测，但没有基于证据的建议推动Sahmi灌注支持的临床决定。我们建议利用新的无创性大循环和微循环灌注监测来确定Sahmi灌注的影响，并制定灌注支持性建议。我们的研究目标是基于与更好的患者功能结果相关的最佳灌流参数，为Sahmi患者开发以灌流目标为导向的治疗建议。我们将确定Sahmi对动态全身和脑血流灌注、功能恢复和Sahmi恢复轨迹的影响。我们将招募200名ASAH患者(年龄21-75岁)，通过动态心动图监测评估心肌肌钙蛋白I升高、超声心动图上局部室壁运动异常和射血分数下降，以及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循环和微循环的灌注影响。在Sahmi和非Sahmi受试者中，这将通过持续的无创性心输出量监测(NICOM)、外周微循环(近红外光谱[NIRS])、脑宏循环(脑灌注压)和脑微循环[脑NIRS]灌流监测来实现。我们还将确定Sahmi对身体功能和神经心理功能的影响--这是恢复和重返社会的更敏感的衡量标准，因此更能反映Sahmi施加的真实负担。然后，我们将使用这些证据来指导我们开发临床上可行的灌注目标导向的治疗建议。分析将包括各种回归建模方法以及分类和回归树。在床边应用靶向灌流疗法有可能改善预后，减轻患者、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.