837: CPPOPT CORRELATES WITH MEAN ARTERIAL PRESSURE IN PATIENTS WITH ACUTE BRAIN INJURY

Introduction: Hemodynamic instability is common after resuscitated out-of-hospital cardiac arrest (OHCA). However, data on hemodynamic treatment-goals are sparse. This study investigates mean arterial pressure (MAP) in patients surviving 48 hours after OHCA in relation to organ injury and survival as a post hoc analysis of a large multicenter trial cohort. Hypothesis: We hypothesized that low MAP during TTM was associated with more organ injury. Methods: Post-hoc analysis of the prospective randomized TTM-trial including 851 comatose OHCA patients surviving more than 48 hours with available blood pressure data. Neuron-specific enolase (NSE) (brain injury) was the primary endpoint and estimated glomerular filtration rate (eGFR) (renal function) was the secondary endpoint. Measurements and Main Results: Patients were stratified by mean MAP during TTM in the following groups; <70 mmHg (22%), 70-80 mmHg (43%), and >80 mmHg (35%). NSE at 24, 48 and 72 hours was inversely related to mean MAP: 28 ng/ml [95% confidence interval (CI) 24-33], 26 [23-29], 21 [19-24] ng/mL; p group =0.002 for low, intermediate and high MAP groups. After adjusting for potential confounders, this association remained significant (p group_adjusted =0.006). A similar result was seen for eGFR (p group_adjusted =0.003). Mean MAP was not associated with mortality after 180 days, however higher mean MAP was independently associated with lower odds of renal replacement therapy (odds ratio adjusted = 0.75 [95% CI, 0.63-0.88] per 5 mmHg increase; p < 0.001]) (figure 1). Conclusions: Lower mean MAP during TTM was independently associated with increased biomarkers of brain injury and initiation of renal replacement therapy in a large cohort of comatose OHCA patients. Increasing blood pressure above the guideline-recommended threshold of 65 mmHg during TTM could potentially mitigate organ injury and be renal-protective. This hypothesis should be investigated in prospective trials.

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Abstract 361: The Significance of Higher Mean Arterial Pressure After Inpatient Cardiac Arrests in Improving Neurological Outcome and Mortality

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.361 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Manishkumar Patel ◽

Sourabh Sourabh ◽

Victoria Gonzalez ◽

Ankita Aggarwal ◽

Fred Bittner ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Sample Size ◽

Small Sample Size ◽

Small Sample ◽

Inclusion Criteria ◽

Anoxic Brain Injury ◽

Significant Difference

Following cardiac arrest and the return of spontaneous circulation (ROSC), hemodynamic status can be critically unstable which may lead to the hypoperfusion of vital organs and poor clinical outcomes. In post-cardiac arrest survivors, studies have shown improved outcomes with a higher mean arterial pressure (MAP) compared with a lower MAP, however an ideal range of MAP post-ROSC is rarely explicitly defined in post-resuscitation care studies. The purpose of this study was to observe neurological and mortality outcomes in cardiac arrest patients with a lower range of post-ROSC MAP compared to a higher range of post-ROSC MAP.A retrospective single-center cohort study was used to design the project. Patients who met the inclusion criteria suffered a cardiac arrest while admitted to the hospital, achieved ROSC, and survived for at least 48 hours post-ROSC. Patients whose status was changed to DNR by 48 hours post-ROSC were excluded. The remaining patients were divided into two groups. The lower MAP group had an average MAP of 60 to 80 mmHg and the higher MAP group had an average MAP of 80 to 100 mmHg at 48 hours post-ROSC. The primary outcome analyzed was the presence of anoxic brain injury noted on EEG. Secondary outcomes were the length of intubation, ICU length of stay (LOS), and mortality rate. Of the total of 129 patients, 18 patients met our inclusion criteria. Of these, 10 patients met the lower MAP group and 8 patients met the higher MAP group. Anoxic brain injury was 20% in the lower MAP group compared to 12.5% in the higher MAP group (p>0.05). There was a 40% mortality in the lower MAP group, compared to 12.5% mortality in the higher MAP group (p>0.05) 48 hours post-ROSC. The mean length of intubation was 3.5 days in the higher MAP group compared to 4.9 days in the lower MAP group (p>0.05). There was no difference in the ICU LOS amongst the two groups. Our results showed a clinically significant difference between the two groups but could not reach statistical significance due to the small sample size. The optimal MAP for post-cardiac arrest patients has not been clearly defined by clinical trials. The simultaneous need to perfuse the post-ischemic brain adequately without putting unnecessary strain on the post-ischemic heart is unique to the post-cardiac arrest syndrome. The findings of this study show post-ROSC MAP maintained between 80 to 100 mmHg had a statistically insignificant tendency toward better neurological outcomes, decreased length of intubation and improved mortality compared to the group whose MAP was maintained between 60 to 80 mmHg at 48 hours. The small sample size is a limitation for this study, however, this preliminary study has shown promising results and it is predicted that a bigger population study with similar parameters will extrapolate similar results.

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Pressure autoregulation, intracranial pressure, and brain tissue oxygenation in children with severe traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.6.peds096 ◽

2009 ◽

Vol 4 (5) ◽

pp. 420-428 ◽

Cited By ~ 47

Author(s):

Anthony A. Figaji ◽

Eugene Zwane ◽

A. Graham Fieggen ◽

Andrew C. Argent ◽

Peter D. Le Roux ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Blood Flow ◽

Brain Injury ◽

Mean Arterial Pressure ◽

Intracranial Pressure ◽

Glasgow Coma Scale ◽

Arterial Pressure ◽

Clinical Factors ◽

Severe Tbi ◽

Pressure Autoregulation

Object Cerebral pressure autoregulation is an important neuroprotective mechanism that stabilizes cerebral blood flow when blood pressure (BP) changes. In this study the authors examined the association between autoregulation and clinical factors, BP, intracranial pressure (ICP), brain tissue oxygen tension (PbtO2), and outcome after pediatric severe traumatic brain injury (TBI). In particular we examined how the status of autoregulation influenced the effect of BP changes on ICP and PbtO2. Methods In this prospective observational study, 52 autoregulation tests were performed in 24 patients with severe TBI. The patients had a mean age of 6.3 ± 3.2 years, and a postresuscitation Glasgow Coma Scale score of 6 (range 3–8). All patients underwent continuous ICP and PbtO2 monitoring, and transcranial Doppler ultrasonography was used to examine the autoregulatory index (ARI) based on blood flow velocity of the middle cerebral artery after increasing mean arterial pressure by 20% of the baseline value. Impaired autoregulation was defined as an ARI < 0.4 and intact autoregulation as an ARI ≥ 0.4. The relationships between autoregulation (measured as both a continuous and dichotomous variable), outcome, and clinical and physiological variables were examined using multiple logistic regression analysis. Results Autoregulation was impaired (ARI < 0.4) in 29% of patients (7 patients). The initial Glasgow Coma Scale score was significantly associated with the ARI (p = 0.02, r = 0.32) but no other clinical factors were associated with autoregulation status. Baseline values at the time of testing for ICP, PbtO2, the ratio of PbtO2/PaO2, mean arterial pressure, and middle cerebral artery blood flow velocity were similar in the patients with impaired or intact autoregulation. There was an inverse relationship between ARI (continuous and dichotomous) with a change in ICP (continuous ARI, p = 0.005; dichotomous ARI, p = 0.02); that is, ICP increased with the BP increase when ARI was low (weak autoregulation). The ARI (continuous and dichotomous) was also inversely associated with a change in PbtO2 (continuous ARI, p = 0.002; dichotomous ARI, p = 0.02). The PbtO2 increased when BP was increased in most patients, even when the ARI was relatively high (stronger autoregulation), but the magnitude of this response was still associated with the ARI. There was no relationship between the ARI and outcome. Conclusions These data demonstrate the influence of the strength of autoregulation on the response of ICP and PbtO2 to BP changes and the variability of this response between individuals. The findings suggest that autoregulation testing may assist clinical decision-making in pediatric severe TBI and help better define optimal BP or cerebral perfusion pressure targets for individual patients.

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Escalating mean arterial pressure (MAP) in severe traumatic brain injury: a prospective, observational study

Journal of Neurotrauma ◽

10.1089/neu.2020.7289 ◽

2020 ◽

Author(s):

Chien Yew Kow ◽

Benjamin Harley ◽

Charles LI ◽

Phillip Romo ◽

Panagiota GKOLIA ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mean Arterial Pressure ◽

Observational Study ◽

Arterial Pressure ◽

Severe Traumatic Brain Injury ◽

Prospective Observational Study

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Arterial blood pressure during targeted temperature management after out-of-hospital cardiac arrest and association with brain injury and long-term cognitive function

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619860804 ◽

2019 ◽

Vol 9 (4_suppl) ◽

pp. S122-S130 ◽

Cited By ~ 4

Author(s):

Johannes Grand ◽

Gisela Lilja ◽

Jesper Kjaergaard ◽

John Bro-Jeppesen ◽

Hans Friberg ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Cognitive Function ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Neuron Specific Enolase ◽

Targeted Temperature Management ◽

Temperature Management ◽

Impaired Cognitive Function ◽

Hospital Cardiac Arrest

Objectives: During targeted temperature management after out-of-hospital cardiac arrest infusion of vasoactive drugs is often needed to ensure cerebral perfusion pressure. This study investigated mean arterial pressure after out-of-hospital cardiac arrest and the association with brain injury and long-term cognitive function. Methods: Post-hoc analysis of patients surviving at least 48 hours in the biobank substudy of the targeted temperature management trial with available blood pressure data. Patients were stratified in three groups according to mean arterial pressure during targeted temperature management (4–28 hours after admission; <70 mmHg, 70–80 mmHg, >80 mmHg). A biomarker of brain injury, neuron-specific enolase, was measured and impaired cognitive function was defined as a mini-mental state examination score below 27 in 6-month survivors. Results: Of the 657 patients included in the present analysis, 154 (23%) had mean arterial pressure less than 70 mmHg, 288 (44%) had mean arterial pressure between 70 and 80 mmHg and 215 (33%) had mean arterial pressure greater than 80 mmHg. There were no statistically significant differences in survival ( P=0.35) or neuron-specific enolase levels ( P=0.12) between the groups. The level of target temperature did not statistically significantly interact with mean arterial pressure regarding neuron-specific enolase ( Pinteraction_MAP*TTM=0.58). In the subgroup of survivors with impaired cognitive function ( n=132) (35%) mean arterial pressure during targeted temperature management was significantly higher ( Pgroup=0.03). Conclusions: In a large cohort of comatose out-of-hospital cardiac arrest patients, low mean arterial pressure during targeted temperature management was not associated with higher neuron-specific enolase regardless of the level of target temperature (33°C or 36°C for 24 hours). In survivors with impaired cognitive function, mean arterial pressure during targeted temperature management was significantly higher.

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