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High-normal PaCO2 values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study.

ABSTRACT: BACKGROUND:While both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal PaCO2 values are better than low-normal values. We hypothesized that high-normal PaCO2 values have more detrimental than beneficial effects on outcome. METHODS:Consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university hospital were retrospectively analyzed regarding the influence of PaCO2 on favorable outcome, defined as modified Rankin scale score < 3 at discharge. Primary endpoint was the difference in the proportion of PaCO2 values above 40 mmHg in relation to all measured PaCO2 values between patients with favorable and unfavorable outcome. RESULTS:150 patients were included. Median age was 57 years (p25:50, p75:64), median Hunt-Hess score was 4 (p25:3, p75:5). PaCO2 values were mainly within normal range (median 39.0, p25:37.5, p75:41.4). Patients with favorable outcome had a lower proportion of high-normal PaCO2 values above 40 mmHg compared to patients with unfavorable outcome (0.21 (p25:0.13, p75:0.50) vs. 0.4 (p25:0.29, p75:0.59)) resulting in a lower chance for favorable outcome (OR 0.04, 95% CI 0.00-0.55, p = 0.017). In multivariable analysis adjusted for Hunt-Hess score, pneumonia and length of stay, elevated PaCO2 remained an independent predictor of outcome (OR 0.05, 95% CI 0.00-0.81, p = 0.035). CONCLUSIONS:A higher proportion of PaCO2 values above 40 mmHg was an independent predictor of outcome in patients with aSAH in our study. The results need to be confirmed in a prospective trial.

SUBMITTER: Reiff T

PROVIDER: S-EPMC6972024 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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High-normal P<sub>a</sub>CO<sub>2</sub> values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study.

Reiff Tilman T Barthel Oliver O Schönenberger Silvia S Mundiyanapurath Sibu S

BMC neurology 20200120 1

<h4>Background</h4>While both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal P<sub>a</sub>CO<sub>2</sub> values are better than low-normal values. We hypothesized that high-normal P<sub>a</sub>CO<sub>2</sub> values have more detrimental than beneficial effects on outcome.<h4>Methods</h4>Consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university ...[more]

PMID: 31959120

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Project description:Background and Purpose- Optimal blood pressure (BP) management during the early stages of aneurysmal subarachnoid hemorrhage remains uncertain. Observational studies have found worse outcomes in patients with increased hemodynamic variability, suggesting BP optimization as a potential neuroprotective strategy. In this study, we calculated personalized BP targets at which cerebral autoregulation was best preserved. We analyzed how deviation from these limits correlates with functional outcome. Methods- We prospectively enrolled 31 patients with aneurysmal subarachnoid hemorrhage. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation-a surrogate for cerebral blood flow-as well as intracranial pressure (ICP) in response to changes in mean arterial pressure using time-correlation analysis. The resulting autoregulatory indices were used to identify the upper and lower limit of autoregulation. Percent time that mean arterial pressure exceeded limits of autoregulation was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using ordinal multivariate logistic regression. Results- Personalized limits of autoregulation were computed in all patients (age 57.5±13.4, 23F, mean World Federation of Neurological Surgeons 2±1, monitoring time 67.8±50.8 hours). Optimal BP and limits of autoregulation were calculated on average for 89.5±6.7% of the total monitoring period. ICP- and NIRS-derived optimal pressures strongly correlated with one another (P<0.0001). Percent time that mean arterial pressure deviated from limits of autoregulation significantly associated with worse functional outcome at discharge (NIRS, P=0.001; ICP, P=0.004) and 90 days (NIRS, P=0.002; ICP, P=0.003), adjusting separately for age, World Federation of Neurological Surgeons, vasospasm, and delayed cerebral ischemia. Conclusions- Both invasive (ICP) and noninvasive (NIRS) determination of personalized BP targets after aneurysmal subarachnoid hemorrhage is feasible, and these 2 approaches revealed significant collinearity. Furthermore, exceeding individualized limits of autoregulation was associated with poor functional outcomes.

Project description:Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients.Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined.Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.

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High-normal PaCO2 values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study.

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High-normal P<sub>a</sub>CO<sub>2</sub> values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study.

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