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Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO

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A Correction to this article was published on 26 April 2023

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Abstract

Background

Cerebral autoregulation (CA) impairment is associated with neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Severe variations of arterial CO2 (PaCO2) and O2 (PaO2) tension after ECMO onset are common and associate with mortality and poor neurological outcome. The impact of gas exchange on CA among critically ill patients is poorly studied.

Methods

Retrospective analysis of data collected prospectively from 30 children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France. A correlation coefficient between the variations of regional cerebral oxygen saturation (rSO2) and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). Cox–MAP plots were investigated allowing determining lower limit of autoregulation (LLA) and upper limit of autoregulation (ULA) limits of autoregulation. Age-based normal blood pressure was used to adjust the MAP, LLA, and ULA data from each patient and then reported as percentage (nMAP, nLLA, and nULA, respectively). RSO2, COx, nMAP, nLLA, and nULA values were averaged over one hour before each arterial blood gas (ABG) sample during ECMO run.

Results

Thirty children (median age 4.8 months [Interquartile range (IQR) 0.7–39.1], median weight 5 kg [IQR 4–15]) experiencing 31 ECMO runs were included in the study. Three hundred and ninety ABGs were analyzed. The highest values of COx were observed on day 1 (D1) of ECMO. The relationship between COx and PaCO2 was nonlinear, but COx values tended to be lower in case of hypercapnia compared to normocapnia. During the whole ECMO run, a weak but significant correlation between PaCO2 and nULA was observed (R = 0.432, p = 0.02). On D1 of ECMO, this correlation was stronger (R = 0.85, p = 0.03) and a positive correlation between nLLA and PaCO2 was also found (R = 0.726, p < 0.001). A very weak negative correlation between PaO2 and nULA was observed within the whole ECMO run and on D1 of ECMO (R =  −0.07 p = 0.04 and R =  −0.135 p =  <0.001, respectively). The difference between nULA and nLLA representing the span of the autoregulation plateau was positively correlated with PaCO2 and negatively correlated with PaO2 (R = 0.224, p = 0.01 and R =  −0.051, p = 0.004, respectively).

Conclusions

We observed a complex relationship between PaCO2 and CA, influenced by the level of blood pressure. Hypercapnia seems to be globally protective in normotensive or hypertensive condition, while, in case of very low MAP, hypercapnia may disturb CA as it increases LLA. These data add additional arguments for very cautiously lower PaCO2, especially after ECMO start.

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Authors and Affiliations

  1. Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France

    Nicolas Joram, Jean-Michel Liet, Alexis Chenouard & Pierre Bourgoin

  2. Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France

    Nicolas Joram, Jean-Michel Liet, Alexis Chenouard & Pierre Bourgoin

  3. INSERM U955-ENVA, University Paris 12, Paris, France

    Nicolas Joram & Pierre-Louis Léger

  4. Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK

    Erta Beqiri, Chiara Robba, Marek Czosnyka & Peter Smielewski

  5. Department of Physiology and Transplantation, Milan University, Milan, Italy

    Erta Beqiri

  6. Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy

    Stefano Pezzato & Andrea Moscatelli

  7. Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy

    Chiara Robba

  8. Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France

    Pierre-Louis Léger

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  1. Nicolas Joram
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Correspondence to Nicolas Joram.

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Author Contributions

The study concept and design were given by NJ, PB, AC and PLL. Data acquisition was performed by NJ, EB, SP, AM, JML, AC, PB, MC and PS. Data analysis was performed by NJ, EB, MC and PS. NJ prepared the first draft of the manuscript. Interpretation of the data was done by NJ, EB, SP, AM, CR, JML, AC, PB, MC, PLL and PS. All authors provided critical feedback of the manuscript and approved the final version.

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Conflict of interest

Dr. Joram has nothing to disclose. Dr. Beqiri has nothing to disclose. Dr. Pezzato has nothing to disclose. Dr. Moscatelli has nothing to disclose. Dr. Robba has nothing to disclose. Dr. Liet has nothing to disclose. Dr. Chenouard has nothing to disclose. Dr. Bourgoin has nothing to disclose. Dr. Czosnyka reports personal fees from Cambridge Enterprise Ltd, UK, during the conduct of the study. Dr. Léger has nothing to disclose. Dr. Smielewski reports and receives part of licensing fees for the brain monitoring software ICM+ (Cambridge Enterprise Ltd, Cambridge, UK) used in this project.

Ethical Approval

The study was approved by the local Ethics Committee (Date 07/25/2018). Information of the parents was provided before inclusion. The only criterion for non-inclusion was a parental refusal.

Clinical Trial Registration

ClinicalTrials.gov (NCT04282525, February 21, 2020) https://clinicaltrials.gov/ct2/results?cond=&term=NCT04282525&cntry=&state=&city=&dist=

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Joram, N., Beqiri, E., Pezzato, S. et al. Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO. Neurocrit Care 35, 480–490 (2021). https://doi.org/10.1007/s12028-021-01201-8

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