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Neuroprotection and Treatment in Intensive Care and Perioperative Medicine

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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Global Health".

Deadline for manuscript submissions: closed (30 September 2021) | Viewed by 39138

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Special Issue Editors

Prof. Dr. Łukasz J. Krzych

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Guest Editor

Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
Interests: perioperative medicine; intensive care medicine; biomarkers; fluid therapy; hemodynamics; delirium

Dr. Mirosław Czuczwar

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Assistant Guest Editor

2nd Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, 20-081 Lublin, Poland
Interests: perioperative medicine; intensive care medicine; pharmacology; fluid therapy; nutrition
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Dr. Izabela Duda

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Assistant Guest Editor

Department of Anaesthesiology and Intensive Care, Medical University of Silesia, 40-752 Katowice, Poland
Interests: anesthesiology; neurosurgery; biomarkers; prognostication

Special Issue Information

Dear Colleagues,

Perioperative medicine covers a broad spectrum of pharmacological and nonpharmacological interventions needed to guarantee patients’ safety and to minimize the risk of complications. Both functional and structural neurologic injury represent a serious hazard of the compromised outcome in anesthesiology and intensive care medicine. In recent years, there has been a growing interest in preventive measures and treatment strategies that could be implemented to reduce insults to the brain. Goal-directed therapy is recommended to all subjects at risk of neurologic complications. However, effective neuroprotection and adequate treatment are still in question.

This Special Issue seeks high-quality manuscripts on neuroprotection and treatment of patients undergoing cardiac and noncardiac surgery, as well as in the critically ill. We welcome original papers, systematic reviews, and meta-analyses, and thorough reviews on this interesting topic. We would be happy if this Special Issue provides a complex source of up-to-date data used by anesthesiologists and intensive care specialists worldwide to improve perioperative care.

Prof. Łukasz J. Krzych
Ass. Prof. Mirosław Czuczwar
Dr. Izabela Duda
Guest Editors

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Keywords

Cognitive dysfunction and postoperative delirium in cardiac and noncardiac surgery
Potentially deleterious exposition on volatile agents in children and elderly patients
Biomarkers of neurological injury in anesthesiology and intensive care medicine
Perioperative stroke
Preventive strategies in neurosurgery and non-neurosurgery patients
Treatment of brain edema
Neurocognitive sequelae of critical illness

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Related Special Issue

2nd Edition: Neuroprotection and Treatment in Intensive Care and Perioperative Medicine in International Journal of Environmental Research and Public Health (1 article)

Published Papers (11 papers)

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Research

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11 pages, 4125 KiB

Open AccessArticle

Propofol and Sevoflurane Anesthesia in Early Childhood Do Not Influence Seizure Threshold in Adult Rats

by Paweł Piwowarczyk, Elżbieta Rypulak, Justyna Sysiak-Sławecka, Dorota Nieoczym, Katarzyna Socała, Aleksandra Wlaź, Piotr Wlaź, Waldemar Turski, Mirosław Czuczwar and Michał Borys

Int. J. Environ. Res. Public Health 2021, 18(23), 12367; https://doi.org/10.3390/ijerph182312367 - 24 Nov 2021

Cited by 1 | Viewed by 2054

Abstract

Experimental studies have demonstrated that general anesthetics administered during the period of synaptogenesis may induce widespread neurodegeneration, which results in permanent cognitive and behavioral deficits. What remains to be elucidated is the extent of the potential influence of the commonly used hypnotics on comorbidities including epilepsy, which may have resulted from increased neurodegeneration during synaptogenesis. This study aimed to test the hypothesis that neuropathological changes induced by anesthetics during synaptogenesis may lead to changes in the seizure threshold during adulthood. Wistar rat pups were treated with propofol, sevoflurane, or saline on the sixth postnatal day. The long-term effects of prolonged propofol and sevoflurane anesthesia on epileptogenesis were assessed using corneal kindling, pilocarpine-, and pentylenetetrazole-induced seizure models in adult animals. Body weight gain was measured throughout the experiment. No changes in the seizure threshold were observed in the three models. A significant weight gain after exposure to anesthetics during synaptogenesis was observed in the propofol group but not in the sevoflurane group. The results suggest that single prolonged exposure to sevoflurane or propofol during synaptogenesis may have no undesirable effects on epileptogenesis in adulthood. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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15 pages, 1141 KiB

Open AccessArticle

Decompressive Craniectomy Improves QTc Interval in Traumatic Brain Injury Patients

by Wojciech Dabrowski, Dorota Siwicka-Gieroba, Chiara Robba, Rafael Badenes, Katarzyna Kotfis, Todd T. Schlegel and Andrzej Jaroszynski

Int. J. Environ. Res. Public Health 2020, 17(22), 8653; https://doi.org/10.3390/ijerph17228653 - 21 Nov 2020

Cited by 2 | Viewed by 2253

Abstract

Background: Traumatic brain injury (TBI) is commonly associated with cardiac dysfunction, which may be reflected by abnormal electrocardiograms (ECG) and/or contractility. TBI-related cardiac disorders depend on the type of cerebral injury, the region of brain damage and the severity of the intracranial hypertension. Decompressive craniectomy (DC) is commonly used to reduce intra-cranial hypertension (ICH). Although DC decreases ICH rapidly, its effect on ECG has not been systematically studied. The aim of this study was to analyze the changes in ECG in patients undergoing DC. Methods: Adult patients without previously known cardiac diseases treated for isolated TBI with DC were studied. ECG variables, such as: spatial QRS-T angle (spQRS-T), corrected QT interval (QTc), QRS and T axes (QRS_ax and T_ax, respectively), STJ segment and the index of cardio-electrophysiological balance (iCEB) were analyzed before DC and at 12–24 h after DC. Changes in ECG were analyzed according to the occurrence of cardiac arrhythmias and 28-day mortality. Results: 48 patients (17 female and 31 male) aged 18–64 were studied. Intra-cranial pressure correlated with QTc before DC (p < 0.01, r = 0.49). DC reduced spQRS-T (p < 0.001) and QTc interval (p < 0.01), increased Tax (p < 0.01) and changed STJ in a majority of leads but did not affect QRS_ax and iCEB. The iCEB was relatively increased before DC in patients who eventually experienced cardiac arrhythmias after DC (p < 0.05). Higher post-DC iCEB was also noted in non-survivors (p < 0.05), although iCEB values were notably heart rate-dependent. Conclusions: ICP positively correlates with QTc interval in patients with isolated TBI, and DC for relief of ICH reduces QTc and spQRS-T. However, DC might also increase risk for life-threatening cardiac arrhythmias, especially in ICH patients with notably prolonged QTc before and increased iCEB after DC. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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12 pages, 542 KiB

Open AccessArticle

Hyperosmolar Treatment for Patients at Risk for Increased Intracranial Pressure: A Single-Center Cohort Study

by Agnieszka Wiórek, Tomasz Jaworski and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(12), 4573; https://doi.org/10.3390/ijerph17124573 - 25 Jun 2020

Cited by 2 | Viewed by 3763

Abstract

Treatment with osmoactive agents such as mannitol or hypertonic saline (HTS) solutions is widely used to manage or prevent the increase of intracranial pressure (ICP) in central nervous system (CNS) disorders. We sought to evaluate the variability and mean plasma concentrations of the water and electrolyte balance parameters in critically ill patients treated with osmotic therapy and their influence on mortality. This cohort study covered patients hospitalized in an intensive care unit (ICU) from January 2017 to June 2019 with presumed increased ICP or considered to be at risk of it, treated with 15% mannitol (G1, n = 27), a combination of 15% mannitol and 10% hypertonic saline (HTS) (G2, n = 33) or 10% HTS only (G3, n = 13). Coefficients of variation (Cv) and arithmetic means (mean) were calculated for the parameters reflecting the water and electrolyte balance, i.e., sodium (NaCv/NaMean), chloride (ClCv/ClMean) and osmolality (mOsmCv/mOsmMean). In-hospital mortality was also analyzed. The study group comprised 73 individuals (36 men, 49%). Mortality was 67% (n = 49). Median NaCv (G1: p = 0.002, G3: p = 0.03), ClCv (G1: p = 0.02, G3: p = 0.04) and mOsmCv (G1: p = 0.001, G3: p = 0.02) were higher in deceased patients. NaMean (p = 0.004), ClMean (p = 0.04), mOsmMean (p = 0.003) were higher in deceased patients in G3. In G1: NaCv (AUC = 0.929, p < 0.0001), ClCv (AUC = 0.817, p = 0.0005), mOsmCv (AUC = 0.937, p < 0.0001) and in G3: NaMean (AUC = 0.976, p < 0.001), mOsmCv (AUC = 0.881, p = 0.002), mOsmMean (AUC = 1.00, p < 0.001) were the best predictors of mortality. The overall mortality prediction for combined G1+G2+G3 was very good, with AUC = 0.886 (p = 0.0002). The mortality of critically ill patients treated with osmotic agents is high. Electrolyte disequilibrium is the independent predictor of mortality regardless of the treatment method used. Variations of plasma sodium, chloride and osmolality are the most deleterious factors regardless of the absolute values of these parameters Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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15 pages, 2603 KiB

Open AccessArticle

Biomarkers Facilitate the Assessment of Prognosis in Critically Ill Patients with Primary Brain Injury: A Cohort Study

by Izabela Duda, Agnieszka Wiórek and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(12), 4458; https://doi.org/10.3390/ijerph17124458 - 21 Jun 2020

Cited by 2 | Viewed by 2791

Abstract

Primary injuries to the brain are common causes of hospitalization of patients in intensive care units (ICU). The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system is widely used for prognostication among critically ill subjects. Biomarkers help to monitor the severity of neurological status. This study aimed to identify the best biomarker, along with APACHE II score, in mortality prediction among patients admitted to the ICU with the primary brain injury. This cohort study covered 58 patients. APACHE II scores were assessed 24 h post ICU admission. The concentrations of six biomarkers were determined, including the C-reactive protein (CRP), the S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinase 9 (MMP-9), and tissue inhibitor of metalloproteinase 1 (TIMP-1), using commercially available ELISA kits. The biomarkers were specifically chosen for this study due to their established connection to the pathophysiology of brain injury. In-hospital mortality was the outcome. Median APACHE II was 18 (IQR 13–22). Mortality reached 40%. Median concentrations of the CRP, NGAL, S100B, and NSE were significantly higher in deceased patients. S100B (AUC = 0.854), NGAL (AUC = 0.833), NSE (AUC = 0.777), and APACHE II (AUC = 0.766) were the best independent predictors of mortality. Combination of APACHE II with S100B, NSE, NGAL, and CRP increased the diagnostic accuracy of mortality prediction. MMP and TIMP-1 were impractical in prognostication, even after adjustment for APACHE II score. S100B protein and NSE seem to be the best predictors of compromised outcome among critically ill patients with primary brain injuries and should be assessed along with the APACHE II calculation after ICU admission. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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13 pages, 320 KiB

Open AccessArticle

A Questionnaire Survey of Management of Patients with Aneurysmal Subarachnoid Haemorrhage in Poland

by Mariusz Hofman, Norbert Hajder, Izabela Duda and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(11), 4161; https://doi.org/10.3390/ijerph17114161 - 11 Jun 2020

Cited by 5 | Viewed by 2385

Abstract

Background: Aneurysmal subarachnoid haemorrhage (aSAH) remains a potentially devastating threat to the brain with a serious impact on mortality and morbidity. We attempted to investigate correspondence between the current guidelines for aSAH management and real clinical practice in Poland. Methods: A web-based questionnaire was performed between 03.2019 and 06.2019. Centres performing neuro-interventional radiology procedures and neuro-critical care were included (n = 29). One response from each hospital was recorded. Results: In three (10.4%) centres, there was no clear protocol for an interventional treatment plan. Endovascular embolisation was predominantly used in 11 (37.9%) hospitals, and microsurgical clipping, in 10 (34.5%). A written protocol for standard anaesthetic management was established only in six (20.7%) centres for coiling and in five (17.2%) for microsurgical clipping. The diagnosis of cerebral vasospasm was based on transcranial Doppler as the first-choice method in seven (24.1%) units. “3-H therapy” was applied by 15 (51.8%) respondents, and “2-H therapy”, by four (13.8%) respondents. In only eight (27.6%) centres were all patients with aSAH being admitted to the ICU. Conclusion: Many discrepancies exist between the available guidelines and clinical practice in aSAH treatment in Poland. Peri-procedural management is poorly standardised. Means must be undertaken to improve patient-oriented treatment and care. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

6 pages, 967 KiB

Open AccessArticle

Ultrasonic Assessment of Optic Nerve Sheath Diameter in Patients at Risk of Sepsis-Associated Brain Dysfunction: A Preliminary Report

by Piotr F. Czempik, Jakub Gąsiorek, Aleksandra Bąk and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(10), 3656; https://doi.org/10.3390/ijerph17103656 - 22 May 2020

Cited by 9 | Viewed by 2761

Abstract

Sepsis-associated brain dysfunction (SABD) with increased intracranial pressure (ICP) is a complex pathology that can lead to unfavorable outcome. Ultrasonographic measurement of optic nerve sheath diameter (ONSD) is used for non-invasive assessment of ICP. We aimed to assess the role of ONSD as a SABD screening tool. This prospective preliminary study covered 10 septic shock patients (5 men; aged 65, IQR 50–78 years). ONSD was measured bilaterally from day 1 to 10 (n = 1), until discharge (n = 3) or death (n = 6). The upper limit for ONSD was set at 5.7 mm. Sequential organ failure assessment score was calculated on a daily basis as a surrogate formulti-organ failure due to sepsis in the study population. On day 1, the medians of right and left ONSD were 5.56 (IQR 5.35–6.30) mm and 5.68 (IQR 5.50–6.10) mm, respectively, and four subjects had bilaterally elevated ONSD. Forty-nine out of 80 total measurements performed (61%) exceeded 5.7 mm during the study period. We found no correlations between ONSD and sequential organ failure assessment (SOFA) during the study period (right: R = −0.13–0.63; left R = −0.24–0.63). ONSD measurement should be applied for screening of SABD cautiously. Further research is needed to investigate the exact role of this non-invasive method in the assessment of brain dysfunction in these patients. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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Review

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18 pages, 1588 KiB

Open AccessReview

Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review

by Palesa Motshabi-Chakane, Palesa Mogane, Jacob Moutlana, Gontse Leballo-Mothibi, Sithandiwe Dingezweni, Dineo Mpanya and Nqoba Tsabedze

Int. J. Environ. Res. Public Health 2021, 18(23), 12747; https://doi.org/10.3390/ijerph182312747 - 3 Dec 2021

Cited by 8 | Viewed by 4138

Abstract

Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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13 pages, 691 KiB

Open AccessReview

Intranasal Insulin Administration to Prevent Delayed Neurocognitive Recovery and Postoperative Neurocognitive Disorder: A Narrative Review

by Rafael Badenes, Ega Qeva, Giovanni Giordano, Nekane Romero-García and Federico Bilotta

Int. J. Environ. Res. Public Health 2021, 18(5), 2681; https://doi.org/10.3390/ijerph18052681 - 7 Mar 2021

Cited by 14 | Viewed by 3515

Abstract

Delayed neurocognitive recovery and postoperative neurocognitive disorders are major complications of surgery, hospitalization, and anesthesia that are receiving increasing attention. Their incidence is reported to be 10–80% after cardiac surgery and 10–26% after non-cardiac surgery. Some of the risk factors include advanced age, level of education, history of diabetes mellitus, malnutrition, perioperative hyperglycemia, depth of anesthesia, blood pressure fluctuation during surgery, chronic respiratory diseases, etc. Scientific evidence suggests a causal association between anesthesia and delayed neurocognitive recovery or postoperative neurocognitive disorders, and various pathophysiological mechanisms have been proposed: mitochondrial dysfunction, neuroinflammation, increase in tau protein phosphorylation, accumulation of amyloid-β protein, etc. Insulin receptors in the central nervous system have a non-metabolic role and act through a neuromodulator-like action, while an interaction between anesthetics and central nervous system insulin receptors might contribute to anesthesia-induced delayed neurocognitive recovery or postoperative neurocognitive disorders. Acute or chronic intranasal insulin administration, which has no influence on the blood glucose concentration, appears to improve working memory, verbal fluency, attention, recognition of objects, etc., in animal models, cognitively healthy humans, and memory-impaired patients by restoring the insulin receptor signaling pathway, attenuating anesthesia-induced tau protein hyperphosphorylation, etc. The aim of this review is to report preclinical and clinical evidence of the implication of intranasal insulin for preventing changes in the brain molecular pattern and/or neurobehavioral impairment, which influence anesthesia-induced delayed neurocognitive recovery or postoperative neurocognitive disorders. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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15 pages, 496 KiB

Open AccessReview

Postoperative Neurocognitive Disorders in Cardiac Surgery: Investigating the Role of Intraoperative Hypotension. A Systematic Review

by Marcelina Czok, Michał P. Pluta, Zbigniew Putowski and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2021, 18(2), 786; https://doi.org/10.3390/ijerph18020786 - 18 Jan 2021

Cited by 26 | Viewed by 3900

Abstract

Perioperative neurocognitive disorders remain a challenging obstacle in patients after cardiac surgery, as they significantly contribute to postoperative morbidity and mortality. Identifying the modifiable risk factors and mechanisms for postoperative cognitive decline (POCD) and delirium (POD) would be an important step forward in preventing such adverse events and thus improving patients’ outcome. Intraoperative hypotension is frequently discussed as a potential risk factor for neurocognitive decline, due to its significant impact on blood flow and tissue perfusion, however the studies exploring its association with POCD and POD are very heterogeneous and present divergent results. This review demonstrates 13 studies found after structured systematic search strategy and discusses the possible relationship between intraoperative hypotension and postoperative neuropsychiatric dysfunction. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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14 pages, 614 KiB

Open AccessReview

Antipsychotic Drugs in Prevention of Postoperative Delirium—What Is Known in 2020?

by Michał P. Pluta, Magdalena Dziech, Piotr F. Czempik, Anna J. Szczepańska and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(17), 6069; https://doi.org/10.3390/ijerph17176069 - 20 Aug 2020

Cited by 11 | Viewed by 4268

Abstract

Delirium is one of the most frequently reported neuropsychiatric complications in the perioperative period, especially in the population of elderly patients who often suffer from numerous comorbidities undergoing extensive or urgent surgery. It can affect up to 80% of patients who require hospitalization in an intensive care setting postoperatively. Delirium increases mortality, morbidity, length of hospital stay, and cost of treatment. An episode of delirium in the acute phase may lower the general quality of life and increases the risk of cognitive decline long-term. Since pharmacological treatment of delirium is not highly effective, focus of research has shifted towards developing preventive strategies. We aimed to perform a review of the topic based on the most recent literature. We conclude that, based on the available data, it seems impossible to make strong recommendations for using antipsychotic drugs in prophylaxis. Further research should answer the question what, if any, benefit patients receive from the pharmacological prevention of delirium, and which agents should be used. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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9 pages, 566 KiB

Open AccessReview

Sepsis-Associated Brain Dysfunction: A Review of Current Literature

by Piotr F. Czempik, Michał P. Pluta and Łukasz J. Krzych

Int. J. Environ. Res. Public Health 2020, 17(16), 5852; https://doi.org/10.3390/ijerph17165852 - 12 Aug 2020

Cited by 58 | Viewed by 6356

Abstract

Sepsis-associated brain dysfunction (SABD) may be the most common type of encephalopathy in critically ill patients. SABD develops in up to 70% of septic patients and represents the most frequent organ insufficiency associated with sepsis. It presents with a plethora of acute neurological features and may have several serious long-term psychiatric consequences. SABD might cause various pathological changes in the brain through numerous mechanisms. Clinical neurological examination is the basic screening method for SABD, although it may be challenging in subjects receiving with opioids and sedative agents. As electrographic seizures and periodic discharges might be present in 20% of septic patients, screening with electroencephalography (EEG) might be useful. Several imaging techniques have been suggested for non-invasive assessment of structure and function of the brain in SABD patients; however, their usefulness is rather limited. Although several experimental therapies have been postulated, at the moment, no specific treatment exists. Clinicians should focus on preventive measures and optimal management of sepsis. This review discusses epidemiology, clinical presentation, pathology, pathophysiology, diagnosis, management, and prevention of SABD. Full article

(This article belongs to the Special Issue Neuroprotection and Treatment in Intensive Care and Perioperative Medicine)

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