Cerebrovascular pressure reactivity monitoring using wavelet analysis in traumatic brain injury patients: A retrospective study

Autor: Peter Smielewski, Xiuyun Liu, Dong-Joo Kim, Joseph Donnelly, Danilo Cardim, Marek Czosnyka, Manuel Cabeleira, Christina Haubrich, Chiara Robba, Peter J. Hutchinson, Kenneth Martin Brady, Marcel J. H. Aries
Přispěvatelé: RS: FHML non-thematic output, Intensive Care, MUMC+: MA Medische Staf IC (9), Liu, Xiuyun [0000-0001-9540-4865], Donnelly, Joseph [0000-0002-6502-8069], Czosnyka, Marek [0000-0003-2446-8006], Cardim, Danilo [0000-0002-9261-1321], Hutchinson, Peter [0000-0002-2796-1835], Smielewski, Peter [0000-0001-5096-3938], Apollo - University of Cambridge Repository
Jazyk: angličtina
Rok vydání: 2017
Předmět:
Traumatic
Male
Critical Care and Emergency Medicine
Traumatic Brain Injury
Intracranial Pressure
Physiology
INTRACRANIAL-PRESSURE
Blood Pressure
030204 cardiovascular system & hematology
Vascular Medicine
Mathematical and Statistical Techniques
0302 clinical medicine
Blood Flow
Brain Injuries
Traumatic
Medicine and Health Sciences
Brain Damage
Coma
Prospective cohort study
Trauma Medicine
Wavelet Transforms
Intracranial pressure
Medicine (all)
Physics
TRANSFORM
General Medicine
Middle Aged
Prognosis
Body Fluids
Blood
PERFUSION-PRESSURE
England
Neurology
COHERENCE ANALYSIS
Physical Sciences
DYNAMIC CEREBRAL AUTOREGULATION
Cardiology
Medicine
Female
Sound Pressure
Anatomy
Traumatic Injury
ARTERIAL-BLOOD-PRESSURE
Research Article
Adult
medicine.medical_specialty
Monitoring
Death Rates
Traumatic brain injury
Wavelet Analysis
CIRCULATION
HEART-RATE
Research and Analysis Methods
Young Adult
03 medical and health sciences
AGE
Internal medicine
Heart rate
medicine
Humans
Cerebral perfusion pressure
Physiologic
Blood Pressure Determination
Monitoring
Physiologic
Reproducibility of Results
Retrospective Studies
Demography
Receiver operating characteristic
business.industry
Biology and Life Sciences
Acoustics
Blood flow
medicine.disease
Surgery
Blood pressure
Brain Injuries
People and Places
business
Neurotrauma
Mathematical Functions
030217 neurology & neurosurgery
Zdroj: PLoS medicine 14(7), e1002348 (2017). doi:10.1371/journal.pmed.1002348
PLoS Medicine, Vol 14, Iss 7, p e1002348 (2017)
PLoS Medicine, 14(7):e1002348. Public Library of Science
PLoS Medicine
ISSN: 1549-1277
Popis: Background After traumatic brain injury (TBI), the ability of cerebral vessels to appropriately react to changes in arterial blood pressure (pressure reactivity) is impaired, leaving patients vulnerable to cerebral hypo- or hyperperfusion. Although, the traditional pressure reactivity index (PRx) has demonstrated that impaired pressure reactivity is associated with poor patient outcome, PRx is sometimes erratic and may not be reliable in various clinical circumstances. Here, we introduce a more robust transform-based wavelet pressure reactivity index (wPRx) and compare its performance with the widely used traditional PRx across 3 areas: its stability and reliability in time, its ability to give an optimal cerebral perfusion pressure (CPPopt) recommendation, and its relationship with patient outcome. Methods and findings Five hundred and fifteen patients with TBI admitted in Addenbrooke’s Hospital, United Kingdom (March 23rd, 2003 through December 9th, 2014), with continuous monitoring of arterial blood pressure (ABP) and intracranial pressure (ICP), were retrospectively analyzed to calculate the traditional PRx and a novel wavelet transform-based wPRx. wPRx was calculated by taking the cosine of the wavelet transform phase-shift between ABP and ICP. A time trend of CPPopt was calculated using an automated curve-fitting method that determined the cerebral perfusion pressure (CPP) at which the pressure reactivity (PRx or wPRx) was most efficient (CPPopt_PRx and CPPopt_wPRx, respectively). There was a significantly positive relationship between PRx and wPRx (r = 0.73), and wavelet wPRx was more reliable in time (ratio of between-hour variance to total variance, wPRx 0.957 ± 0.0032 versus PRx and 0.949 ± 0.047 for PRx, p = 0.002). The 2-hour interval standard deviation of wPRx (0.19 ± 0.07) was smaller than that of PRx (0.30 ± 0.13, p < 0.001). wPRx performed better in distinguishing between mortality and survival (the area under the receiver operating characteristic [ROC] curve [AUROC] for wPRx was 0.73 versus 0.66 for PRx, p = 0.003). The mean difference between the patients’ CPP and their CPPopt was related to outcome for both calculation methods. There was a good relationship between the 2 CPPopts (r = 0.814, p < 0.001). CPPopt_wPRx was more stable than CPPopt_PRx (within patient standard deviation 7.05 ± 3.78 versus 8.45 ± 2.90; p < 0.001). Key limitations include that this study is a retrospective analysis and only compared wPRx with PRx in the cohort of patients with TBI. Prior prospective validation is required to better assess clinical utility of this approach. Conclusions wPRx offers several advantages to the traditional PRx: it is more stable in time, it yields a more consistent CPPopt recommendation, and, importantly, it has a stronger relationship with patient outcome. The clinical utility of wPRx should be explored in prospective studies of critically injured neurological patients.
Using continuous monitoring data in traumatic brain inury patients, Xiuyun Liu and colleagues compare the performance of cerebrovascular pressure reactivity monitoring using wavelet analysis to the pressure reactivity index.
Author summary Why was this study done? The brain is vulnerable to damage from too little (ischemia) or too much (hyperemia) blood flow following traumatic brain injury (TBI). A physiological mechanism called cerebral autoregulation (CA) exists to maintain stable blood flow even if cerebral perfusion pressure (CPP) is changing, and an assessment of CA as part of bedside neuro-monitoring of patients with TBI could facilitate individualized treatment. A robust method for assessing CA in TBI is not yet available. The traditional measure used, the pressure reactivity index (PRx), provides inherently noisy estimates and may not be reliable in various clinical circumstances. What did the researchers do and find? We studied a new method to assess cerebral CA using continuous, real-time assessment of CA from available neuro-monitoring data called transform-based wavelet pressure reactivity index (wPRx). Using data collected from the continuous monitoring of arterial blood pressure (ABP) and intracranial pressure (ICP) from 515 patients with TBI, we compared the performance of wPRx with PRx across 3 areas: its stability/reliability in time, its ability to give an optimal cerebral perfusion pressure (CPPopt) recommendation, and its relationship with patient outcome. We found a significant positive relationship between PRx and wPRx, with wPRx being more stable in time. wPRx performed better in distinguishing different patient outcome groups, while CPPopt calculated using wPRx had lower variance and higher overall yield (percent of time that the value could be calculated). What do these findings mean? In this study, we found wPRx to be more stable in time and yield a more consistent CPPopt recommendation compared to PRx. Importantly, wPRx had a stronger relationship with patient outcome compared to PRx in our study. The clinical utility of wPRx should be explored further in prospective studies of critically injured neurological patients, particularly in circumstances in which reliability of PRx has been questioned, e.g., inpatient after decompressive craniectomy.
Databáze: OpenAIRE
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