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Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation

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Abstract

Background

Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes.

Methods

This is a single-center prospective observational study. We measured COx, a surrogate measurement of cerebral blood flow measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure (MAP) and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT) and lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores.

Results

Fifteen patients (median age 57 years [interquartile range 47–69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO (VA-ECMO), and four were on veno-venous ECMO (VV-ECMO). Mean COx was higher on postcannulation day 1 than on day 2 (0.2 vs. 0.09, p < 0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO patients (0.12 vs. 0.06, p = 0.04). Median MAPOPT for the entire cohort was highly variable, ranging from 55 to 110 mm Hg. Patients with mRS scores 0–3 (good outcome) at 3 and 6 months spent less time outside MAPOPT compared with patients with mRS scores 4–6 (poor outcome) (74% vs. 82%, p = 0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on postcannulation day 1 than on day 2 (18.2% vs. 3.3%, p < 0.01).

Conclusions

In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between postcannulation days 1 and 2. CA was more impaired in VA-ECMO patients than in VV-ECMO patients. Spending less time outside MAPOPT may be associated with achieving a good neurologic outcome.

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Funding

This study received support from the Wenzel Family Foundation. The following authors are also supported by Grants: Charles H. Brown: Medtronic through Johns Hopkins (RF1AG072387); Sung-Min Cho: National Heart, Lung, and Blood Institute Grant (1K23HL157610) and Hyperfin Inc.; Romergryko Geocadin: National Heart, Lung, and Blood Institute Grant (5R01HL071568-18).

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Author notes

  1. Lucia Rivera-Lara and Sung-Min Cho are co-senior authors.

Authors and Affiliations

  1. Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA

    Lucy Q. Zhang, Henry Chang, Mariyam Humayun, Kathryn R. Rosenblatt, Vishank A. Shah, Romergryko G. Geocadin & Sung-Min Cho

  2. Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Andrew Kalra, Glenn J. R. Whitman & Sung-Min Cho

  3. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Kathryn R. Rosenblatt & Charles H. Brown

  4. Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Bo Soo Kim

  5. Department of Neurology and Center for Academic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA

    Lucia Rivera-Lara

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Consortia

the HERALD Investigators

Contributions

LQZ: first draft, data collection and analysis; HC, AK, MH: data collection; KRR, VAS: study design and data interpretation; RGG, CHB, BSK, GJRW: critical revision of manuscript; LR-L, S-MC: study design, data analysis, and data interpretation. All authors approved the final manuscript.

Corresponding author

Correspondence to Sung-Min Cho.

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Conflicts of Interest

Vishank A. Shah, MBBS, serves on the editorial board of Neurohospitalist and received personal fees of less than $1000 from AstraZeneca. All other authors have no conflicts of interests to declare.

Ethical Approval/Informed Consent

This prospective study adheres to ethical guidelines and has been approved by the institutional review board at Johns Hopkins University School of Medicine.

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Zhang, L.Q., Chang, H., Kalra, A. et al. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. Neurocrit Care (2024). https://doi.org/10.1007/s12028-023-01932-w

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