Determination of Cerebral Autoregulation at the Bedside: A Narrative Review.

IF 6 1区 医学 Q1 CRITICAL CARE MEDICINE
Jeffrey R Vitt, Spyridoula Tsetsou, Laura Galarza, Aarti Sarwal, Swarna Rajagopalan
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引用次数: 0

Abstract

Objectives: To summarize the current evidence on cerebral autoregulation (CAR) monitoring techniques in critical care settings, highlighting their advantages, limitations, and practical applications at the bedside to inform understanding and clinical decision-making for various acute brain injuries and systemic illnesses.

Data sources: Articles were retrieved using Ovid MEDLINE, PubMed, and Cochrane library using a comprehensive combination of subject headings and key words including "cerebral autoregulation," "transcranial Doppler," "near-infrared spectroscopy," and "intracranial pressure." See Supplemental Appendix A (https://links.lww.com/CCM/H763) for complete list of search terms. Relevant articles as well as those discovered through the review process (e.g., references in selected articles) were incorporated into the article.

Study selection: Original research, review articles, commentaries, and guidelines focusing on bedside CAR monitoring methodologies, their validation, and applications in critically ill patients were included. The review encompassed both acute brain injury and systemic critical illness conditions.

Data extraction: Data from included publications were evaluated and synthesized into a comprehensive narrative review examining CAR monitoring methods and clinical applications.

Data synthesis: Three commonly used bedside approaches for assessing CAR were identified. Transcranial Doppler ultrasound measures vessel flow velocity response to blood pressure changes, either through vasopressor administration or monitoring spontaneous fluctuations. Near-infrared spectroscopy evaluates regional cerebral oxygenation changes in response to hemodynamic alterations through continuous, noninvasive forehead sensors. Intracranial pressure monitoring enables assessment of pressure reactivity index through analyzing the correlation between intracranial and arterial blood pressure. CAR impairment is common across critical illness, from acute brain injury to systemic conditions like sepsis, cardiac surgery, and hepatic failure, where dysregulation can lead to secondary brain injury and worse outcomes. While each technique offers unique insights into CAR status, they vary in invasiveness, continuous monitoring capability, and technical requirements. Evidence suggests these methods can help to detect impaired CAR, identify optimal perfusion targets, and may guide individualized management strategies.

Conclusions: Bedside CAR monitoring represents a promising approach for personalizing hemodynamic management in critically ill patients. While current evidence supports its role in prognostication and management decisions, further research is needed to standardize assessment methods and validate CAR-guided therapy across different critical care conditions. Multimodal monitoring approaches may provide complementary information to optimize patient care.

床边大脑自动调节的测定:叙述性回顾。
目的:总结目前重症监护环境中脑自动调节(CAR)监测技术的证据,强调其优势、局限性和在床边的实际应用,为各种急性脑损伤和全身性疾病的理解和临床决策提供信息。数据来源:文章通过Ovid MEDLINE、PubMed和Cochrane图书馆检索,检索的主题标题和关键词包括“大脑自动调节”、“经颅多普勒”、“近红外光谱”和“颅内压”。参见补充附录A (https://links.lww.com/CCM/H763)获得完整的搜索词列表。相关文章以及通过审查过程中发现的文章(例如,选定文章中的参考文献)被纳入文章。研究选择:纳入了关注床边CAR监测方法、其验证和在危重患者中的应用的原始研究、综述文章、评论和指南。该综述包括急性脑损伤和全身性危重疾病。数据提取:对纳入出版物的数据进行评估并综合成一篇综合叙述性综述,研究CAR监测方法和临床应用。数据综合:确定了评估CAR的三种常用床边方法。经颅多普勒超声测量血管流速对血压变化的反应,无论是通过血管加压剂管理还是监测自发波动。近红外光谱通过连续的、无创的前额传感器来评估局部脑氧合变化对血流动力学改变的反应。颅内压监测通过分析颅内压与动脉压的相关性来评估压力反应性指数。CAR损伤在危重疾病中很常见,从急性脑损伤到败血症、心脏手术和肝功能衰竭等全身性疾病,其中调节失调可导致继发性脑损伤和更糟糕的结果。虽然每种技术都提供了对CAR状态的独特见解,但它们在侵入性、连续监测能力和技术要求方面各不相同。有证据表明,这些方法可以帮助检测受损的CAR,确定最佳灌注目标,并可能指导个性化的管理策略。结论:床边CAR监测是危重患者个性化血流动力学管理的一种很有前景的方法。虽然目前的证据支持其在预后和管理决策中的作用,但需要进一步的研究来标准化评估方法并验证car引导治疗在不同重症监护条件下的作用。多模式监测方法可以为优化患者护理提供补充信息。
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来源期刊
Critical Care Medicine
Critical Care Medicine 医学-危重病医学
CiteScore
16.30
自引率
5.70%
发文量
728
审稿时长
2 months
期刊介绍: Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the ICU and CCU, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.
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