scholarly journals Systematic review of cognitive impairment and brain insult after mechanical ventilation

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Thiago G. Bassi ◽  
Elizabeth C. Rohrs ◽  
Steven C. Reynolds
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Cognitive Impairment ◽  
Brain Injury ◽  
Complex Problem ◽  
Causal Link ◽  
Mechanically Ventilated ◽  
Future Studies ◽  
Clinical Literature

AbstractWe conducted a systematic review following the PRISMA protocol primarily to identify publications that assessed any links between mechanical ventilation (MV) and either cognitive impairment or brain insult, independent of underlying medical conditions. Secondary objectives were to identify possible gaps in the literature that can be used to inform future studies and move toward a better understanding of this complex problem. The preclinical literature suggests that MV is associated with neuroinflammation, cognitive impairment, and brain insult, reporting higher neuroinflammatory markers, greater evidence of brain injury markers, and lower cognitive scores in subjects that were ventilated longer, compared to those ventilated less, and to never-ventilated subjects. The clinical literature suggests an association between MV and delirium, and that delirium in mechanically ventilated patients may be associated with greater likelihood of long-term cognitive impairment; our systematic review found no clinical study that demonstrated a causal link between MV, cognitive dysfunction, and brain insult. More studies should be designed to investigate ventilation-induced brain injury pathways as well as any causative linkage between MV, cognitive impairment, and brain insult.

scholarly journals Long-term cognitive impairment after acute respiratory distress syndrome: a review of clinical impact and pathophysiological mechanisms

Critical Care ◽  
2019 ◽  
Vol 23 (1) ◽  
Author(s):  
Cina Sasannejad ◽  
E. Wesley Ely ◽  
Shouri Lahiri
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Cognitive Impairment ◽  
Brain Injury ◽  
Blood Brain Barrier ◽  
Distress Syndrome ◽  
Brain Barrier ◽  
Pathophysiological Mechanisms ◽  
Blood Brain

Abstract Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation, and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations. Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission, effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimer’s-type pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability, optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce duration of delirium and may help prevent acquisition of long-term cognitive impairment.

scholarly journals Brain injury after 50 h of lung-protective mechanical ventilation in a preclinical model

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Thiago G. Bassi ◽  
Elizabeth C. Rohrs ◽  
Karl C. Fernandez ◽  
Marlena Ornowska ◽  
Michelle Nicholas ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Brain Injury ◽  
Neuronal Damage ◽  
Normal Lung ◽  
Preclinical Model ◽  
Negative Consequences ◽  
Mechanically Ventilated ◽  
Protective Mechanical Ventilation ◽  
Hippocampal Apoptosis ◽  
Lung Protective Mechanical Ventilation

AbstractMechanical ventilation is the cornerstone of the Intensive Care Unit. However, it has been associated with many negative consequences. Recently, ventilator-induced brain injury has been reported in rodents under injurious ventilation settings. Our group wanted to explore the extent of brain injury after 50 h of mechanical ventilation, sedation and physical immobility, quantifying hippocampal apoptosis and inflammation, in a normal-lung porcine study. After 50 h of lung-protective mechanical ventilation, sedation and immobility, greater levels of hippocampal apoptosis and neuroinflammation were clearly observed in the mechanically ventilated group, in comparison to a never-ventilated group. Markers in the serum for astrocyte damage and neuronal damage were also higher in the mechanically ventilated group. Therefore, our study demonstrated that considerable hippocampal insult can be observed after 50 h of lung-protective mechanical ventilation, sedation and physical immobility.

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation

2021 ◽  
pp. 088506662110487
Author(s):  
Stephanie Parks Taylor ◽  
John M. Hammer ◽  
Brice T. Taylor
Keyword(s):  
Mechanical Ventilation ◽  
Prolonged Mechanical Ventilation ◽  
Multidisciplinary Care ◽  
Potential Harm ◽  
Mechanically Ventilated ◽  
Multidisciplinary Care Team ◽  
Clinical Trial Evidence ◽  
Adults And Children ◽  
Trial Evidence

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

scholarly journals Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review

2018 ◽  
Vol 93 (1) ◽  
pp. 68-82 ◽  
Author(s):  
Amra Sakusic ◽  
John C. O'Horo ◽  
Mikhail Dziadzko ◽  
Dziadzko Volha ◽  
Rashid Ali ◽  
...  
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Cognitive Impairment ◽  
Critical Illness ◽  
Modifiable Risk Factors

scholarly journals Pharmacologic Neuroprotection for Functional Outcomes After Traumatic Brain Injury: A Systematic Review of the Clinical Literature

CNS Drugs ◽  
2016 ◽  
Vol 30 (9) ◽  
pp. 791-806 ◽  
Author(s):  
Shaun E. Gruenbaum ◽  
Alexander Zlotnik ◽  
Benjamin F. Gruenbaum ◽  
Denise Hersey ◽  
Federico Bilotta
Keyword(s):  
Systematic Review ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcomes ◽  
Clinical Literature

scholarly journals Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

2020 ◽  
Author(s):  
Eva Favre ◽  
Adriano Bernini ◽  
Paola Morelli ◽  
Jerôme Pasquier ◽  
John-Paul Miroz ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Brain Injury ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Potential Utility ◽  
Icu Patients ◽  
Mechanically Ventilated ◽  
Increased Risk ◽  
Infrared Pupillometry ◽  
Icu Delirium

Abstract Background. Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods. This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 hours. Starting at day 3, automated infrared pupillometry – blinded to ICU caregivers – was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/sec). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results. A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/sec) at day 3, and at all additional time-points tested ( p <0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p =0.03). Conclusions. Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

scholarly journals Sex differences in traumatic brain injury: a multi-dimensional exploration in genes, hormones, cells, individuals, and society

2019 ◽  
Vol 5 (1) ◽  
Author(s):  
Cheng Ma ◽  
Xin Wu ◽  
Xiaotian Shen ◽  
Yanbo Yang ◽  
Zhouqing Chen ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cognitive Impairment ◽  
Brain Injury ◽  
Treatment Options ◽  
Term Treatment ◽  
Neuroprotective Effects ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Long Term Treatment

Abstract Traumatic brain injury (TBI) is exceptionally prevalent in society and often imposes a massive burden on patients’ families and poor prognosis. The evidence reviewed here suggests that gender can influence clinical outcomes of TBI in many aspects, ranges from patients’ mortality and short-term outcome to their long-term outcome, as well as the incidence of cognitive impairment. We mainly focused on the causes and mechanisms underlying the differences between male and female after TBI, from both biological and sociological views. As it turns out that multiple factors contribute to the gender differences after TBI, not merely the perspective of gender and sex hormones. Centered on this, we discussed how female steroid hormones exert neuroprotective effects through the anti-inflammatory and antioxidant mechanism, along with the cognitive impairment and the social integration problems it caused. As to the treatment, both instant and long-term treatment of TBI requires adjustments according to gender. A further study with more focus on this topic is therefore suggested to provide better treatment options for these patients.

Erythropoietin in perinatal hypoxic-ischemic encephalopathy: a systematic review and meta-analysis

2019 ◽  
Vol 47 (4) ◽  
pp. 478-489 ◽  
Author(s):  
Abdul Razak ◽  
Asif Hussain
Keyword(s):  
Systematic Review ◽  
Cerebral Palsy ◽  
Cognitive Impairment ◽  
Brain Injury ◽  
Meta Analysis ◽  
Hypoxic Ischemic Encephalopathy ◽  
Cochrane Central Register ◽  
Risk Of Death ◽  
Ischemic Encephalopathy ◽  
Reduced Risk

Abstract Background Erythropoietin (EPO) appears to confer neuroprotection to the injured brain. Randomized clinical trials (RCTs) have demonstrated its safety in neonates with hypoxic-ischemic encephalopathy (HIE); however, the evidence is unclear. The objective of this study was to examine the role of EPO in perinatal HIE by a systematic review and meta-analysis. Methods Database search included Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Central Register of Controlled Trials (CENTRAL). RCTs reporting a death, neurodevelopmental outcomes or brain injury were included. Two authors extracted the data independently from included studies and assessed the level of evidence (LOE). Results Six RCTs (EPO=5 and darbepoetin α=1) involving 454 neonates were included. A trend toward a lower risk of death was identified in infants treated with EPO [EPO with or without hypothermia: five RCTs, 368 participants, relative risk (RR) 0.74, 95% confidence interval (CI) 0.47–1.19, LOE−low; EPO without hypothermia: four RCTs, 318 participants, RR 0.89, 95% CI 0.49–1.32, LOE−low]. EPO treatment without hypothermia compared to placebo resulted in a reduced risk of cerebral palsy (two RCTs, 230 participants, RR 0.47, 95% CI 0.27–0.80, LOE−moderate) and moderate to severe cognitive impairment (two RCTs, 226 participants, RR 0.49, 95% CI 0.28–0.85, LOE−moderate). A reduced risk of brain injury was identified in EPO treated infants (EPO with or without hypothermia, two RCTs, 148 participants, RR 0.70, 95% CI 0.53–0.92, LOE−moderate). Conclusion EPO administration in neonates with perinatal HIE reduces the risk of brain injury, cerebral palsy and cognitive impairment. The evidence is limited to suggest its role as an adjuvant to hypothermia. Larger powered trials are underway to overcome this limitation.

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