Congenital Heart Disease and Critical Neurological Injury: Do Our Patients Belong in a Neurocritical Care Unit?

Transcription

1 Congenital Heart Disease and Critical Neurological Injury: Do Our Patients Belong in a Neurocritical Care Unit? Shriprasad R Deshpande, MBBS MS Assistant Professor of Pediatrics Medical Director, Mechanical Circulatory System Program Pediatric Cardiac Intensivist, Heart Failure and Heart Transplant Cardiologist Emory University, Children s Healthcare of Atlanta, Sibley Heart Center Cardiology Atlanta, GA

2 No disclosures

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5 Who?

6 Who?

7 Who?

8 Who are these patients? Intracardiac shunts Acquired Infective endocarditis Palliated single ventricle Kawasaki patients Prosthetic valves Mechanical circulatory support Cardiac arrhythmias Cardiac Arrest - CPR Bypass VAD ECMO

9 Who are these patients? Adults with CHD

10 How : Mechanism of neuroinjury? DISTRIBUTION OF STROKE Hemorrhagic 45% 55% Ischemic CHD Primary Risk Factors *AHA Scientific Statement 2008

11 14% 12% 10% 8% 6% 4% 2% 14% Neurologic Events 7% 4% 20 % 1% 14% 12% 2% Hemorrhage Infarction 0% Hemorrhage Seizures Infarction Brain Death Polito et al 2013, 2015

12 How? Neuroinjury in ECPR 12% 10% 9% 27% 11% 8% 6% 4% 2% 3% 4% 0% Hemorrhage Seizures Infarction Brain Death

13 When? Significant portion of strokes occur In early neonatal life In perioperative period During MCS Christine K. Fox et al. Stroke. 2015;46:

14 Complex, heterogeneous group of patients Uncommon complication 2.5 million 412 strokes Fox et al. Stroke. 2015;46: CHD (3.6%) 96.4% Non-CHD

15 Neurologic abnormalities in neonates undergoing cardiac surgery Total 1042 Normal 855 Abnormal 104 No screening ultrasound 83* No further follow up 626 Follow up study 229 No further follow up 63 Follow up study 41 Normal 176 Abnormal 53 Minor Abnormality 23 (56%) Major abnormality 5 (12%) Normal 13 Minor Abnormality 39 (17 %) Major Abnormality 14 (6.1%) 19/1042 (1.8%)

16 In this case, it is the heart! Uncommon occurrence When it does happen, its in complex cardiac patients Complex mechanisms and interplay Often in patients on MCS Often patients that may need cardiac interventions

17 Now, let s look at Neuro ICU.. Primary neurological Number (%) Primary medical Number (%) Status epilepticus 70 (18.9) TBI 53 (14.2) Respiratory failure 41 (11.0) Tumor 48 (12.8) Cardiovascular, non-cns 27 (7.2) Neurosurgical procedure, other 24 (6.4) Shock 22 (5.9) Hydrocephalus 17 (4.6) Cardiac arrest 14 (3.8) SAH/ICH 13 (3.5) Coma, unknown cause 14 (3.8) Stroke 7 (1.9) Ingestion 5 (1.3) Meningitis 5 (1.3) DKA 5 (1.3) Other 2 (0.5) Other 6 (1.6) Total 239 (64.1) 134 (35.9) Bell MJ, Neurocri care 2009

18 Now, let s look at Neuro ICU.. Early post-operative Patients on ECMO /VAD

19 Recommendations for Children With Stroke and Heart Disease Class II Recommendations Class I Recommendations Therapy for congestive heart failure is indicated and may reduce the likelihood of cardiogenic embolism (Class I, Level of Evidence C). When feasible, congenital heart lesions, especially complex heart lesions with a high stroke risk, should be repaired both to improve cardiac function and to reduce the subsequent risk of stroke (Class I, Level of Evidence C). This recommendation does not yet apply to PFOs. Resection of an atrial myxoma is indicated given its ongoing risk of cerebrovascular complications (Class I, Level of Evidence C). For children with a cardiac embolism unrelated to a PFO who are judged to have a high risk of recurrent embolism, it is reasonable to initially introduce UFH or LMWH while warfarin therapy is initiated and adjusted (Class IIa, Level of Evidence B). Alternatively, it is reasonable to use LMWH initially in this situation and to continue it instead of warfarin (Class IIa, Level of Evidence C). In children with a risk of cardiac embolism, it is reasonable to continue either LMWH or warfarin for at least 1 year or until the lesion responsible for the risk has been corrected (Class IIa, Level of Evidence C). If the risk of recurrent embolism is judged to be high, it is reasonable to continue anticoagulation indefinitely as long as it is well tolerated (Class IIa, Level of Evidence C). For children with a suspected cardiac embolism unrelated to a PFO with a lower or unknown risk of stroke, it is reasonable to begin aspirin and to continue it for at least 1 year (Class IIa, Level of Evidence C). Surgical repair or transcatheter closure is reasonable in individuals with a major atrial septal defect both to reduce the stroke risk and to prevent long-term cardiac complications (Class IIa, Level of Evidence C). This recommendation does not apply to individuals with a PFO pending additional data. There are few data to govern the management of patients with prosthetic valve endocarditis, but it may be reasonable to continue maintenance anticoagulation in individuals who are already taking it (Class IIb, Level of Evidence C).

20 What I do suggest.. Development of a Care Team Development of a Stroke Protocol Collaborate

21 Need Investment..

22 Low cardiac output Hypoxia - Acidosis Hypercarbia ICP Cerebral flow Neuroinjury

23 Can Edaravone prevent neuroinjury in various injury models?

24 Monitoring : Neuro-biomarkers GFAP NSE S-100B

25 Prognosis..

26 Congenital Heart Disease and Critical Neurological Injury: Do Our Patients Belong in a Neurocritical Care Unit? Gil Wirnovsky 12/9/2016 at am Cardiac intensivists are the best neurologists No*

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28 TPIS Recommendations.. Clinicians comprising the acute stroke team with expertise in pediatric stroke, including neurologists, neurosurgeons, interventional radiologists, hematologists, emergency medicine physicians, and pediatric intensivists Continuous coverage by pager to assemble a rapid response acute stroke team and institutional mechanisms for first-line providers to activate a rapid response Order sets or care protocols in the emergency department and intensive care unit for both in-hospital and out-of-hospital patients with acute stroke Urgent neuroimaging protocols with 24/7 availability of either MRI with MRA or CT scan with CT angiography; this requires the availability of pediatric radiologists, anesthesiologists for sedated scans, and radiology technologists Input and support from pharmacy and nursing leadership Cross-disciplinary medical education, quality improvement initiatives, and research infrastructure

29 OPN is a better plasma biomarker than MMP9 and GFAP

30 ECMO and Neuroinjury What we know What we think we know What we (I) don t know

31 What we (I) don t know. Prevention Monitoring Outcomes

32 Prevention.. Edaravone : - Scavenges free radicals - Inhibits lipid peroxidation - Cellular apoptosis Extensive clinical data Phase III clinical trials in Europe

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35 Ecmo patients VAD pts Primary cardiac event Nursing and house staff Continuity Consult vs primary responsibility Volume llow Patient selection Neuro response team /stroke response Recognition of challenges in managing complex cardiac pts Who are pts who get stroke = carrie s data..other references Post bypass rare Common pts MCS acutely, Fontan and SV, rarely endocarditis, heparinzed, mechanical valves, neonates with IVH Role of CRIU At pitssburgh 400 admissions a year for neuroicu Heme, pact