Multimodal Brain Monitoring with NIRS and aeeg and their Clinical Significance
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1 Multimodal Brain Monitoring with NIRS and aeeg and their Clinical Significance The Best of IPOKRaTES: an Update in Neonatology September17-20, Leuven, Belgium
2 What can we monitor to assess adequacy of cerebral oxygenation-perfusion/function? Cerebral Oxygen Saturation /Extraction Cerebral Autoregulation Electrical Brain Activity (using aeeg)
3 What can we monitor to assess adequacy of cerebral oxygenation-perfusion/function? Cerebral Oxygen Saturation /Extraction Cerebral Autoregulation Electrical Brain Activity (using aeeg)
4 Cerebral Oxygenation monitored by Near Infrared Spectroscopy (NIRS) O 2 Hb and HHb
5 NIRS used as Cerebral Oximeter Regional (mixed) cerebral O 2 -saturation: rsco 2 ΔO 2 Hb ΔO 2 Hb+ΔHHb (ΔTHb) X 100 (%) Cerebral fractional tissue O2-extraction: cftoe* SaO2 - rsco2 SaO2 * Naulaers et al, Neonatology 2002
6 Reproducibility/Precision: rsco 2 rsco 2 Repeatability (precision) = 5.2% Menke et al, Biol Neon 2003 Sorensen J Biomed Opt 2006
7 What does rsco2 measure? rsco 2 reflects the cerebral O 2 -saturation in %, in mixture of venous-arterial-capillary vessels (75%:20%:5%) Due to the limits of Agreement of individual rsco2 measurements only substantial differences may indicate real changes in cerebral oxygenation NIRS-monitored rsco2 = Trend monitoring device!
8 Are there regional differences? Regional neural activation Hemispheric dominance Wijbenga et al, Pediatr Res 2011
9 Are there regional differences? (II) Positioning of sensors
10 Are there regional differences? (III) * * * * Wijbenga et al, Pediatr Res 2011 * p<0.05 vs Day 1
11 So, it may be reasonably safe to conclude that the rsco2 monitored with a single transducer provides us with the global state of oxygenation of the immature brain! However this may be not always true
12 SaO 2 (%) rsco 2 -Right (%) rsco 2 -Left (%) Pat A Minutes Minutes Pat B Lemmers et al, Pediatr Res, 2009
13 Pitfalls (II) GA <26 wks
14 What s around?
15
16 Neonatal vs Adult Sensors Dix et al, Pediatr Res 2014
17 Expected values in Premies (< 32 wks) rsco2 (%) TOI (%) Tina(Invos et al neo) (Invos Neo) Labarbe (freq domain) Roche-Labarbe (Freq domain) Danger zone Van Bel Bel Lemmers D1 Lemmers D2 (II) (Invos Adult) (Invos Neo) adult) (Invos neo) neo) Lemmers (I) (Invos Neo) Sorensen (NIRO 300 ) Sorensen (NIRO 300) Courtesy Gunnar Naulaers
18 Neonatal vs Adult Sensor (high rsco2) rsco (%) invos pediatric invos small adult Neonatal Hyperoxia(> +2SD) Adult Expected normal values (±2SD)
19 Relation rsco2 and Brain Damage 1) Hou et al (Newborn Piglets): - rsco2 < 40%: -Mitochondrial/hippocampal (CA1) damage 2) Kurth et al (Newborn Piglets): -rsco2 < 33-44%: -Functional impairment ( low ATP levels) 3) Dent et al (Open Heart, Newborns): -rsco2 <40-45%: -(new) Ischemic Regions on MRI 1) Physiol Meas 2007; 2) J Cereb Blood Flow Metab 2005; 3) J Thorac Cardiovasc Surg 2002
20 Clinical Practice
21 Standardized Monitoring SaO2 (pulse oximetry) Arterial blood pressure Heart rate rsco2/cftoe by NIRS aeeg Bedbase Collected on a PC for offline analysis
22 Patterns of variables depicted on Screen SaO Cheyenne 27 wks; 1000 g 2 MABP rsco minutes Corr: rsco2/mabp r=0.5 cftoe
23 Analysis offline analysis with Signalbase
24 Cerebral Oxygenation is especially endangered in case of Cerebral Perfusion Disturbances Artificial Ventilation Hypotension of the Preterm Hemodynamically Important PDA Lack of Cerebral Autoregulation
25 Artificial Ventilation can influence cerebral Oxygenation 26 4/7 wks; 925 g; SIMV; chorioamnionitis; day 1; SaO :30 15:50 16:10 16:30 16:50 17:10 17:30 17:50 18:10 18:30 18:50 19:10 19:30 19:50 20:10 20:30 20:50 21:10 21:30 21:50 22:10 22:30 22:50 23:10 23:30 pco2 (mmhg) rsco 2 MABP 20
26 29 5/7 wks; 1265 g; day 1; SIMV, fio , PIP 16, f PIP 18 (cm H2O) tc pco2 (mmhg) 10:05 10:10 10:15 10:20 10:25 10:30 10:35 10:40 10:45 10:50 10:55 11:00 11:05 11:10 11:15 11:20 11:25 11:30 11:35 11:40 11:45 11:50 11:55 12:00 12:05 12:10 12:15 12:20 12:25 12:30 12:35 12:40 12:45 12:50 12:55 13:00 13:05 13:10 13:15 13:20 13:25 13:30 13:35 13:40 13:45 13:50 13:55 rsco2 (%)
27 CO 2 Vaso-reactivity r=0.26 p<0.05 Vanderhaegen et al. Eur J Paediatr Neur 2008
28 Ventilation: pco2 (IV) cftoe Victor et al : Pediatr Res 58: , 2005 pco2 mmhg
29 Artificial Ventilation (HFO) can influence Systemic Hemodynamics 26,1 wks; 780 g; day 1; HFO severe RDS SaO 2 rsco 2 MABP MAP (18 16 cm H 2 O) Van Bel et al, Neonatology minutes
30 wk,, sepsis, HR (b/min) Hypotension (I) SaO 2 (%) rsco 2 (%) MABP (mmhg) 21:00 21:18 21:36 21:54 22:12 22:30 22:48 23:06 23:24 23:42 0:00:07 0:18:07 0:36:07 0:54:07 1:12:07 1:30:07 1:48:07 2:06:07 2:24:07 2:42:07 3:00:07 3:18:07 3:36:07 3:54:07 4:12:07 4:30:07 4:48:07 5:06:07 5:24:07 5:42:07 Erythrocytes Dopamine 10 Thrombo+FFP Dopamine 15 Dobutamine and steroids
31 Hypotension (II) (n=38) MABP rsco 2 cftoe (n=38) Bonestroo et al, Pediatrics 2011
32 rsco2 and Hemodynamically Important PDA Ductal Steal Hypotension
33 rsco2 and Hemodynamically Important Ductus Arteriosus rsco 2 (%) Indo1 Indo2 Indo PDA Day 1 Day 2 Day 3 MABP(mmHg) Lemmers et al., Pediatrics 2008
34 rsco2 Contr and PDA Infants Before Closure (controls matched for BW, GA, Gender, severity IRDS, PN-age) (n=70) (n=35) (n=35)
35 Postnatal age at ductal Closure
36 Brain Volume (MRI) at term equivalent age of hspda and matched Control Infants (I) - Ventricle Volume - White Matter - Gray Matter - Cerebellum - Brainstem - (Brain Volume) Anbeek and Benders, Pediatr Res 2008
37 What should we monitor to assess adequacy Of cerebral oxygenation-perfusion/function? Cerebral Oxygen Saturation /Extraction Cerebral Autoregulation Electrical Brain Activity (using aeeg)
38 rsco2 and Cerebral autoregulation (corr) rsco 2 CBF (corr) (no corr) CPP MABP Brady et al, Stroke 2007/2010; Wong et al, Pediatrics 2008 De Smet et al, Adv Exp Biol 2009/2011
39 Girl of 27 wk 890g, RDS, no autoregulatory ability rsco 2 MABP 75 % 55 % Corr: rsco2/mabp r=0.5
40 Boy of 31 wk 1350 g, intact autoregulatory ability rsco 2 75 % MABP 25 mmhg 60 min Corr: rsco2/mabp r=0.5
41 Cerebral Autoregulation and RDS % of Correlation Blood Pressure and rsco2 (r >0.50) * * 28 * * 32 No-RDS RDS Lemmers et al, Exp Brain Res 2006 Postnatal age (h)
42 rsco2 and Cerebral autoregulation(ii) MABP- rsco 2 Correlation - Estimation autoregulatory ability for bedside use: but lacks precision* Better estimate? MABP- rsco 2 Coherence - Estimation autoregulatory ability for bedside use: but better precision in time
43 What should we monitor to assess adequacy Of cerebral oxygenation-perfusion/function? Regional Cerebral Oxygen Saturation (rsco2)/extraction (cftoe) Cerebral Autoregulation Electrical Brain Activity (using aeeg)
44 Electrical Brain Monitoring (aeeg) in Clinical Practice
45 Background patterns aeeg = 10 min Continuous Discontinuous Burst Suppression Cont. Low Voltage Flat Trace
46 Seizures aeeg
47 rsco2 related to Maturation of aeeg in Extremely Preterm Infants?: A Preliminary Study Spontaneous Activity Transient (SAT: Bursts/min) Inter SAT (Burst) Interval (IBI: sec) <5 muv (% of Time) First Day of Life
48 aeeg, rsco2 and high pco2 A Terme, ventilated pco2 77 pco2 130 pco2 37 rsco2 63% rsco2 70% rsco2 65%
49 rsco2 and Surgical closure PDA aeeg BS start procedure CL-voltage BS end procedure rsco MABP :28 15:33 15:38 15:43 15:48 15:53 15:58 16:03 16:08 16:13 16:18 16:23 16:28 16:33 16:38 16:43 16:48 16:53 17:04 17:09 17:14 17:19 17:24 17:29 Lemmers et al, Arch Dis Child 2010
50 rsco2/aeeg before, during and after Hypothermia rsco2 (%) Temp down Long-term Outcome Adverse Favorable Mean rsco2 (%) Bars represent 95% CI Temp up Favorable outcome: n= ,0 4,0 aeeg (uv) Timepoint Long-term Outcome Adverse Favorable Adverse outcome: n=13 Mean aeeg BGP score 3,0 2,0 1,0 0,0 Bars represent 95% CI Timepoint Lemmers et al, Pediatr Res 2013
51 Prediction of Outcome Predictive values of rsco2, aeeg score and the Combined score 12 hours rsco2 aeeg Combined Sensitivity (%) Specificity (%) PPV (%) NPV (%) hours rsco2 aeeg Combined Sensitivity (%) Specificity (%) PPV (%) NPV (%) hours rsco2 aeeg Combined Sensitivity (%) Specificity (%) PPV (%) NPV (%) Lemmers et al, Pediatr Res 2013
52 Take Home Messages Current results of our studies in (premature) infants strongly suggest that Sa(p)O2 does not always reflect oxygenation (and perfusion) of the immature brain. Combining rsco2 with aeeg provides us with additional information Thus apart from monitoring SaO2 and blood pressure, monitoring rsco2, cerebral autoregulatory ability and aeeg can help to prevent brain damage.
53 UMC Utrecht, The Netherlands UZ Gasthuisberg Leuven, Belgium Petra Lemmers Wim Baerts Thomas Alderliesten Rianne Wijbenga Hilde Bonestroo Laura Dix Manon Benders Frank van Bel Alexander Caicedo Sabine Van Huffel Liesbeth Thewissen Gunnar Naulaers
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