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Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study

Abstract

Objective

Cerebral autoregulation (CA) impairment may pose a risk factor for neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Our first objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment and to describe its evolution over time. The second objective was to analyze the association between CA impairment and neurological outcome.

Design

Observational prospective study.

Patients and Setting

Twenty-nine children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France, and the PICU of the IRCCS Giannina Gaslini Institute in Genoa, Italy.

Measurements

A correlation coefficient between the variations of regional cerebral oxygen saturation and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). A COx > 0.3 was considered as indicative of autoregulation impairment. COx—MAP plots were investigated allowing determining optimal MAP (MAPopt) and limits of autoregulation: lower (LLA) and upper (ULA). Neurological outcome was assessed by the onset of an acute neurological event (ANE) after ECMO start.

Results

We included 29 children (median age 84 days, weight 4.8 kg). MAPopt, LLA, and ULA were detected in 90.8% (84.3–93.3) of monitoring time. Mean COx was significantly higher during day 1 of ECMO compared to day 2 [0.1 (0.02–0.15) vs. 0.01 (− 0.05 to 0.1), p = 0.002]. Twelve children experienced ANE (34.5%). The mean COx and the percentage of time spent with a COx > 0.3 were significantly higher among ANE+ compared to ANE− patients [0.09 (0.01–0.23) vs. 0.04 (− 0.02 to 0.06), p = 0.04 and 33.3% (24.8–62.1) vs. 20.8% (17.3–23.7) p = 0.001]. ANE+ patients spent significantly more time with MAP below LLA [17.2% (6.5–32.9) vs. 5.6% (3.6–9.9), p = 0.02] and above ULA [13% (5.3–38.4) vs. 4.2% (2.7–7.4), p = 0.004], respectively.

Conclusion

CA assessment is feasible in pediatric ECMO. The first 24 h following ECMO represents the most critical period regarding CA. Impaired autoregulation is significantly more severe among patients who experience ANE.

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Funding

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Author information

Authors and Affiliations

Authors

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.

Corresponding author

Correspondence to Nicolas Joram.

Ethics declarations

Conflict of Interest

Joram has nothing to disclose. Beqiri has nothing to disclose. Pezzato has nothing to disclose. Moscatelli has nothing to disclose. Robba has nothing to disclose. Liet has nothing to disclose. Chenouard has nothing to disclose. Bourgoin has nothing to disclose. Czosnyka reports personal fees from Cambridge Enterprise Ltd, UK, during the conduct of the study. Léger has nothing to disclose. 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/Informed Consent

The study was approved by the local Ethics Committees. Information of the parents was provided before inclusion.

Trial Registration

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

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12028_2020_1111_MOESM1_ESM.doc

Supplemental Digital Content-table 1. Autoregulation parameters during ECMO run according to the type of cannulation (DOC 39 kb)

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Joram, N., Beqiri, E., Pezzato, S. et al. Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study. Neurocrit Care 34, 935–945 (2021). https://doi.org/10.1007/s12028-020-01111-1

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Keywords

  • ECMO
  • Cerebral autoregulation
  • Acute neurological event
  • Children