title: Identification of pressure passive cerebral perfusion and its mediators after infant cardiac surgery.
abstract: Cerebrovascular pressure autoregulation (CPA) regulates cerebral blood flow (CBF) in relation to changes in mean arterial blood pressure (MAP). Identification of a pressure-passive cerebral perfusion and the potentially modifiable physiologic factors underlying it has been difficult to achieve in sick infants. We previously validated the near-infrared spectroscopy-derived hemoglobin difference (HbD) signal (cerebral oxyhemoglobin - deoxyhemoglobin) as a reliable measure of changes in CBF in animal models. We now sought to determine whether continuous measurements of DeltaHbD would correlate to middle cerebral artery flow velocity (CBFV), allow identification and quantification of pressure-passive state, and help to delineate potentially modifiable factors. We enrolled 43 infants (2 d to 7 mo old) who were undergoing open cardiac surgery and cardiopulmonary bypass. At 6 and 20 h after surgery, we measured changes in HbD, CBFV (by transcranial Doppler), and MAP at different end-tidal CO(2) levels. We assigned a pressure-passive index (PPI) to each study on the basis of the relative duration of significant coherence between DeltaMAP and DeltaHbD. We found a significant relationship between DeltaHbD and DeltaCBFV at both time points. At 6 h after surgery, we showed high concordance (coherence > 0.5; PPI > or = 41%) between DeltaMAP and DeltaHbD, consistent with disturbed CPA in 13% of infants. End-tidal CO(2) values > or = 40 mm Hg and higher MAP variability both were associated with increased odds (p < 0.001) of autoregulatory failure. This approach provides a means to identify and quantify disturbances of CPA. High CO(2) levels and fluctuating MAP are two important preventable factors associated with disturbed CPA.
authors.affiliation: Department of Neurology, Children's Hospital, 300 Longwood Avenue, Boston MA 02115, USA.
authors.forename: Haim
authors.initials: H
authors.lastname: Bassan
authors.forename: Kimberlee
authors.initials: K
authors.lastname: Gauvreau
authors.forename: Jane W
authors.initials: JW
authors.lastname: Newburger
authors.forename: Miles
authors.initials: M
authors.lastname: Tsuji
authors.forename: Catherine
authors.initials: C
authors.lastname: Limperopoulos
authors.forename: Janet S
authors.initials: JS
authors.lastname: Soul
authors.forename: Gene
authors.initials: G
authors.lastname: Walter
authors.forename: Peter C
authors.initials: PC
authors.lastname: Laussen
authors.forename: Richard A
authors.initials: RA
authors.lastname: Jonas
authors.forename: Adré J
authors.initials: AJ
authors.lastname: du Plessis
mesh_terms: D001794:Blood Pressure; D002245:Carbon Dioxide / Q000378:metabolism; D002315:Cardiopulmonary Bypass; D002560:Cerebrovascular Circulation / Q000502:physiology*; D005260:Female; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D016017:Odds Ratio; D010108:Oxyhemoglobins / Q000378:metabolism; D010477:Perfusion; D011184:Postoperative Period; D011312:Pressure; D013055:Spectrophotometry, Infrared; D013997:Time Factors; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D006454:Hemoglobins; D010108:Oxyhemoglobins; D002245:Carbon Dioxide; C100003:deoxyhemoglobin