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Vasoactive agents to improve brain perfusion

pathophysiology and clinical utilization

Steiner, Luzius A.a,b; Siegemund, Martina,b

Current Opinion in Critical Care: April 2019 - Volume 25 - Issue 2 - p 110–116
doi: 10.1097/MCC.0000000000000586
NEUROSCIENCE: Edited by Mauro Oddo
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Purpose of review This review highlights the aspects of pathophysiology that make it difficult to predict the effects of any attempt to improve brain perfusion and reviews the options to improve brain perfusion according to the needs of an individual patient, focusing on the choice of a suitable threshold for cerebral perfusion pressure.

Recent findings Typically, vasopressors or vasodilators that do not directly influence the cerebral vascular bed are used to improve cerebral perfusion. Positive inotropic substances are rarely used, as the relationship between cardiac output and cerebral blood flow is complex and difficult to measure. Combining perfusion pressure monitoring with monitoring of brain metabolism or oxygenation to adapt cerebral perfusion to the needs of an individual patient has been disappointing. Recently, attempts to individualize perfusion pressure based on measurements of cerebrovascular autoregulation have shown promising results in the management of traumatic brain injury and during cardiac surgery. Currently, only preliminary data are available linking optimized cerebral perfusion to improved outcome.

Summary Optimizing cerebral perfusion remains a difficult goal. All our attempts to manipulate brain perfusion are influenced in an unpredictable manner by underlying diseases. Autoregulation-based strategies to individualize cerebral perfusion management warrant further investigation.

aDepartment of Anesthesia, Surgical Intensive Care, Preclinical Emergency Medicine and Pain Therapy, University Hospital Basel

bDepartment of Clinical Research, University of Basel, Basel, Switzerland

Correspondence to Luzius A. Steiner, MD, PhD, Anesthesiology, Universitaetsspital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland. Tel.: +41 (0)61 265 72 54;. e-mail: luzius.steiner@usb.ch

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