The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study
Filippo Sanfilippo, Agnieszka Uryga, Lorenzo Ball, Denise Battaglini, Ida Giorgia Iavarone, Peter Smielewski, Erta Beqiri, Marek Czosnyka, Nicolò Patroniti, Chiara Robba
Abstract
Abstract Background Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts. Methods The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO 2 ). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs. Results Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8 mm Hg) and reduced CPP (ΔCPP = −12.8 mm Hg) and mean arterial pressure (difference in mean arterial pressure = −5.2 mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O 2 = 4 mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO 2 marginally decreased (ΔrSO 2 = −0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = −0.1 cm; p < 0.001) with a tendency toward increased RV basal diameter ( p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP ( p = 0.040) and a larger RV basal diameter ( p = 0.034) at baseline. Conclusions In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM’s impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.