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2</a>&#41;&#46; However&#44; this is associated with PaCO<span class="elsevierStyleInf">2</span> levels above those recommended for the optimization of cerebral blood flow &#40;CBF&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Through changes in extracellular pH&#44; CO<span class="elsevierStyleInf">2</span> modulates cerebrovascular tone&#44; cerebral blood volume and CBF&#46; An increase can generate ICP elevation if brain distensibility is deficient&#44; while a decrease can reduce the cerebral blood volume and CBF through vasoconstriction and give rise to secondary ischemic damage<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Depending on the clinical situation and the ICP of the patient&#44; the recommended PaCO<span class="elsevierStyleInf">2</span> values range from 30 to 45&#8239;mmHg<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; 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can affect cerebral circulation via two routes&#58; reduced venous return to the right side of the heart and through CO<span class="elsevierStyleInf">2</span>-mediated mechanisms&#46; The decrease in mean blood pressure due to increased PEEP and right atrial pressure can reduce CBF &#40;if cerebral self-regulation is altered&#41; or keep it constant and elevate ICP&#46; However&#44; if euvolemia is guaranteed&#44; mean blood pressure and cerebral perfusion pressure &#40;CPP&#41; do not experience significant variations<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; The decrease in cerebral venous return depends on the ICP-PEEP relationship and pressure transmission through the cerebral veins&#44; according to the Starling resistor model&#46; Positive end-expiratory pressure increases intrathoracic pressure and the pressure in the right atrium&#44; and thus also the pressure in the sagittal venous sinus&#44; which reduces cerebral venous flow and increases ICP&#46; Accordingly&#44; provided PEEP is lower than ICP&#44; venous return should not be hindered&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; PaCO<span class="elsevierStyleInf">2</span> resulting from the application of PEEP depends on its effects on gas exchange and respiratory mechanics&#46; Only those patients who in the face of PEEP elevation suffer increased lung elastance will be exposed to higher CO<span class="elsevierStyleInf">2</span> levels with significant ICP increments<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Therefore&#44; provided PEEP is lower than ICP&#44; the impact on brain hemodynamics will depend on the effect of PEEP in terms of lung recruitment or overdistension &#8212; though it must be noted that no study has clearly established what PEEP levels are harmful to patients with ABI&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What happens if even so the patient with ABI remains hypoxemic&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">This situation makes it necessary to balance the expected improvements in lung and brain oxygenation against the potentially harmful effects in relation to ICP and cerebral perfusion pressure&#46; The use of neuromuscular blockers is advised&#44; despite the low-level evidence&#44; due to the few risks and the positive impact on mortality<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; It should be reserved for patients suffering ARDS with PaFiO<span class="elsevierStyleInf">2</span> &#60;150 and in the early stages of the disorder&#46; Alveolar recruitment maneuvers can reduce atelectasis and increase lung volume&#59; however&#44; they are not advised&#44; since there is no consistent evidence justifying such use&#46; The improvements in oxygenation are usually temporary&#44; and the consequences pose high risks in patients with ABI&#46; Prone decubitus is the most controversial intervention due to its impact on survival in ARDS<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Based on the available evidence&#44; the experts strongly recommend prone decubitus in the case of low ICP&#44; though not so in the context of high ICP&#46; The benefits in terms of lung elastance and oxygenation&#44; maintaining adequate cerebral perfusion pressure&#44; may outweigh the risk of increased ICP&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Lastly&#44; the use of extracorporeal membrane oxygenation &#40;ECMO&#41; in patients with ABI historically has been limited by the risk of cerebral hemorrhage related to anticoagulation&#44; and although some recent reports have suggested a possible use of the technique in patients with ABI&#44; the body of evidence remains small&#46; In this context&#44; the possibility of adopting venovenous ECMO without heparin constitutes a field for future research&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Most patients with severe ABI require mechanical ventilation&#44; and of these&#44; many develop lung injuries&#46; Adequate and personalized ventilator management is crucial to avoid secondary lesions due to hypoxemia and hypo- or hypercapnia&#46; Protective ventilation strategies can be safely used in most patients with ABI&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Acute brain injury and hypoxemia: Personalized ventilatory support
Lesión cerebral aguda e hipoxemia: individualización del soporte ventilatorio
G.A. Plotnikowa,b,
Corresponding author
gplotnikow@hbritanico.com.ar

Corresponding author.
, M.R. del Bonoa
a Hospital Británico de Buenos Aires, Buenos Aires, Argentina
b Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Buenos Aires, Argentina
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develops in 20&#37; of these patients and is associated with poorer outcomes&#46; This constitutes a great challenge for healthcare teams&#44; since it reflects the differences between the recommendations for the management of patients with ABI and those considered to reflect &#8220;best practice&#8221; in patients with ARDS<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">How can we personalize mechanical ventilation in hypoxemic patients with ABI&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Concerning mechanical ventilation &#40;MV&#41;&#44; strategies in conflict with lung protection are often used in patients with ABI&#46; To reduce the risk of injury&#44; the ventilation strategy should focus on limiting the end-inspiratory pressures through the use of a low tidal volume &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; this is associated with PaCO<span class="elsevierStyleInf">2</span> levels above those recommended for the optimization of cerebral blood flow &#40;CBF&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Through changes in extracellular pH&#44; CO<span class="elsevierStyleInf">2</span> modulates cerebrovascular tone&#44; cerebral blood volume and CBF&#46; An increase can generate ICP elevation if brain distensibility is deficient&#44; while a decrease can reduce the cerebral blood volume and CBF through vasoconstriction and give rise to secondary ischemic damage<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Depending on the clinical situation and the ICP of the patient&#44; the recommended PaCO<span class="elsevierStyleInf">2</span> values range from 30 to 45&#8239;mmHg<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; However&#44; if the lung protection strategy prevails&#44; and PaCO<span class="elsevierStyleInf">2</span> consequently increases&#44; multimodal brain monitoring &#40;hemoglobin saturation in the bulbar zone of the internal jugular vein &#62;50&#37;&#44; and particularly brain tissue oxygen pressure &#62;15&#8239;mmHg&#41;&#44; together with systemic oxygenation measurements can allow PaCO<span class="elsevierStyleInf">2</span> values higher than those recommended&#44; including even hypercapnia in progressive ranges<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Oxygenation</span><p id="par0025" class="elsevierStylePara elsevierViewall">In the context of ABI&#44; hypoxemia implies greater secondary injury&#44; expressed as ischemia&#46; The Brain Trauma Foundation recommends avoiding PaO<span class="elsevierStyleInf">2</span> &#60;60&#8239;mmHg<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; corresponding to ranges somewhat above those proposed in the case of ARDS<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; However&#44; hyperoxia is also associated with poorer outcomes&#44; producing harmful effects as a consequence of excessive reactive oxygen species &#40;ROS&#41; production&#44; with damage at cardiovascular&#44; pulmonary and cerebral level<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; On the other hand&#44; PaO<span class="elsevierStyleInf">2</span> values within the normoxia range&#44; with the lowest possible FiO<span class="elsevierStyleInf">2</span>&#44; are recommended&#44; with consideration of the possibility of acting upon those variables that affect the relationship between DO<span class="elsevierStyleInf">2</span> and brain oxygen consumption&#44; in favor of transport &#8212; if so required by the situation of the patient<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Positive end-expiratory pressure &#40;PEEP&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Positive end-expiratory pressure &#40;PEEP&#41; can affect cerebral circulation via two routes&#58; reduced venous return to the right side of the heart and through CO<span class="elsevierStyleInf">2</span>-mediated mechanisms&#46; The decrease in mean blood pressure due to increased PEEP and right atrial pressure can reduce CBF &#40;if cerebral self-regulation is altered&#41; or keep it constant and elevate ICP&#46; However&#44; if euvolemia is guaranteed&#44; mean blood pressure and cerebral perfusion pressure &#40;CPP&#41; do not experience significant variations<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; The decrease in cerebral venous return depends on the ICP-PEEP relationship and pressure transmission through the cerebral veins&#44; according to the Starling resistor model&#46; Positive end-expiratory pressure increases intrathoracic pressure and the pressure in the right atrium&#44; and thus also the pressure in the sagittal venous sinus&#44; which reduces cerebral venous flow and increases ICP&#46; Accordingly&#44; provided PEEP is lower than ICP&#44; venous return should not be hindered&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; PaCO<span class="elsevierStyleInf">2</span> resulting from the application of PEEP depends on its effects on gas exchange and respiratory mechanics&#46; Only those patients who in the face of PEEP elevation suffer increased lung elastance will be exposed to higher CO<span class="elsevierStyleInf">2</span> levels with significant ICP increments<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Therefore&#44; provided PEEP is lower than ICP&#44; the impact on brain hemodynamics will depend on the effect of PEEP in terms of lung recruitment or overdistension &#8212; though it must be noted that no study has clearly established what PEEP levels are harmful to patients with ABI&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What happens if even so the patient with ABI remains hypoxemic&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">This situation makes it necessary to balance the expected improvements in lung and brain oxygenation against the potentially harmful effects in relation to ICP and cerebral perfusion pressure&#46; The use of neuromuscular blockers is advised&#44; despite the low-level evidence&#44; due to the few risks and the positive impact on mortality<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; It should be reserved for patients suffering ARDS with PaFiO<span class="elsevierStyleInf">2</span> &#60;150 and in the early stages of the disorder&#46; Alveolar recruitment maneuvers can reduce atelectasis and increase lung volume&#59; however&#44; they are not advised&#44; since there is no consistent evidence justifying such use&#46; The improvements in oxygenation are usually temporary&#44; and the consequences pose high risks in patients with ABI&#46; Prone decubitus is the most controversial intervention due to its impact on survival in ARDS<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Based on the available evidence&#44; the experts strongly recommend prone decubitus in the case of low ICP&#44; though not so in the context of high ICP&#46; The benefits in terms of lung elastance and oxygenation&#44; maintaining adequate cerebral perfusion pressure&#44; may outweigh the risk of increased ICP&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Lastly&#44; the use of extracorporeal membrane oxygenation &#40;ECMO&#41; in patients with ABI historically has been limited by the risk of cerebral hemorrhage related to anticoagulation&#44; and although some recent reports have suggested a possible use of the technique in patients with ABI&#44; the body of evidence remains small&#46; In this context&#44; the possibility of adopting venovenous ECMO without heparin constitutes a field for future research&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Most patients with severe ABI require mechanical ventilation&#44; 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ISSN: 21735727
Original language: English
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