Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine. Baltimore, MD.
Crit Care Med. 2019 Oct;47(10):1409-1415. doi: 10.1097/CCM.0000000000003908.
This study investigated whether comatose patients with greater duration and magnitude of clinically observed mean arterial pressure outside optimal mean arterial blood pressure have worse outcomes than those with mean arterial blood pressure closer to optimal mean arterial blood pressure calculated by bedside multimodal cerebral autoregulation monitoring using near-infrared spectroscopy.
Prospective observational study.
Neurocritical Care Unit of the Johns Hopkins Hospital.
Acutely comatose patients secondary to brain injury.
None.
The cerebral oximetry index was continuously monitored with near-infrared spectroscopy for up to 3 days. Optimal mean arterial blood pressure was defined as that mean arterial blood pressure at the lowest cerebral oximetry index (nadir index) for each 24-hour period of monitoring. Kaplan-Meier analysis and proportional hazard regression models were used to determine if survival at 3 months was associated with a shorter duration of mean arterial blood pressure outside optimal mean arterial blood pressure and the absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure. A total 91 comatose patients were enrolled in the study. The most common etiology was intracerebral hemorrhage. Optimal mean arterial blood pressure could be calculated in 89 patients (97%), and the median optimal mean arterial blood pressure was 89.7 mm Hg (84.6-100 mm Hg). In multivariate proportional hazard analysis, duration outside optimal mean arterial blood pressure of greater than 80% of monitoring time (adjusted hazard ratio, 2.13; 95% CI, 1.04-4.41; p = 0.04) and absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure of more than 10 mm Hg (adjusted hazard ratio, 2.44; 95% CI, 1.21-4.92; p = 0.013) were independently associated with mortality at 3 months, after adjusting for brain herniation, admission Glasgow Coma Scale, duration on vasopressors and midline shift at septum.
Comatose neurocritically ill adults with an absolute difference between clinically observed mean arterial blood pressure and optimal mean arterial blood pressure greater than 10 mm Hg and duration outside optimal mean arterial blood pressure greater than 80% had increased mortality at 3 months. Noninvasive near-infrared spectroscopy-based bedside calculation of optimal mean arterial blood pressure is feasible and might be a promising tool for cerebral autoregulation oriented-therapy in neurocritical care patients.
本研究旨在探讨与通过近红外光谱床边多模态脑自动调节监测计算的最佳平均动脉压相比，平均动脉压处于最佳平均动脉压之外时间更长且幅度更大的昏迷患者的预后是否更差。
前瞻性观察性研究。
约翰霍普金斯医院神经重症监护病房。
继发于脑损伤的急性昏迷患者。
无。
连续监测近红外光谱脑氧饱和度指数，最长可达 3 天。最佳平均动脉压定义为每个 24 小时监测期间平均动脉压最低时的平均动脉压（最低指数）。采用 Kaplan-Meier 分析和比例风险回归模型来确定 3 个月时的生存率是否与平均动脉压处于最佳平均动脉压之外的时间更短以及临床观察到的平均动脉压与最佳平均动脉压之间的绝对差值有关。共纳入 91 例昏迷患者。最常见的病因是脑出血。可计算 89 例患者（97%）的最佳平均动脉压，中位最佳平均动脉压为 89.7mmHg（84.6-100mmHg）。在多变量比例风险分析中，监测时间超过 80%的平均动脉压处于最佳平均动脉压之外（调整后的危险比，2.13；95%CI，1.04-4.41；p=0.04）和临床观察到的平均动脉压与最佳平均动脉压之间的绝对差值超过 10mmHg（调整后的危险比，2.44；95%CI，1.21-4.92；p=0.013）与 3 个月时的死亡率独立相关，调整了脑疝、入院格拉斯哥昏迷量表、升压药使用时间和中隔偏移。
与最佳平均动脉压相比，临床观察到的平均动脉压差值大于 10mmHg，且平均动脉压处于最佳平均动脉压之外时间大于 80%的昏迷神经重症患者在 3 个月时死亡率更高。基于近红外光谱的床边非侵入性最佳平均动脉压计算是可行的，可能是神经重症患者脑自动调节导向治疗的一种有前途的工具。
