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Particular focus on the subgroup with epidemiological risk factors. See decision tree.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. García-Hernández, M.I. Espigares-López, F. Miralles-Aguiar, R. Gámiz-Sánchez, F.J. Arroyo Fernández, A. Pernia Romero, L.M. Torres, E. Calderón Seoane" "autores" => array:9 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "García-Hernández" ] 1 => array:2 [ "nombre" => "M.I." "apellidos" => "Espigares-López" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Miralles-Aguiar" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Gámiz-Sánchez" ] 4 => array:2 [ "nombre" => "F.J." "apellidos" => "Arroyo Fernández" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Pernia Romero" ] 6 => array:2 [ "nombre" => "L.M." "apellidos" => "Torres" ] 7 => array:2 [ "nombre" => "E." "apellidos" => "Calderón Seoane" ] 8 => array:1 [ "colaborador" => "on behalf of the CONVEHY® Research Group" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620301985" "doi" => "10.1016/j.redar.2020.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301985?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000111?idApp=UINPBA00004N" "url" => "/23411929/0000006800000002/v1_202103160736/S2341192921000111/v1_202103160736/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "The «new cerebral autoregulation curve», let's take a step further to keep learning" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "112" "paginaFinal" => "113" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L. Veiga Gil, A. Pavón Benito, G. Cerdán Rodríguez, J.R. Ortiz Gómez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Veiga Gil" "email" => array:1 [ 0 => "noraveigagil@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Pavón Benito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Cerdán Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J.R." "apellidos" => "Ortiz Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapia del Dolor, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital García Orcoyen, Estella, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La «nueva curva de autorregulación cerebral», demos un paso más para seguir aprendiendo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The editorial by García-Orellana et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> brings to mind Claude Bernard words: “It is what we think we know already that often prevents us from learning”. The classic cerebral autoregulation curve described in the 1950s by Lassen is physiologically inaccurate and prevents us from correctly interpreting what happens in clinical practice. Perhaps the time has come to go beyond this model and deal more effectively with changes in cerebral blood flow.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the incidence of perioperative adverse cardiac events has decreased in recent years, there is evidence of an increase in the incidence of stroke. This is why maintaining cerebral perfusion is a problem that transcends neurosurgery or cardiac surgery. The ageing of the surgical population in the western world has raised awareness of the need to prevent perioperative neurocognitive disorders, which are related to other complications, prolong hospital length of stay, consume resources, and affect the quality of life of patients and their families.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cerebral perfusion is a more complex process than that shown in the classic curve. In 2012, Tan<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> developed a new brain autoregulation curve. This author's investigations showed major intra- and interindividual variability in the shape of the curve, and revealed three things: first, that the autoregulation plateau is not always horizontal and is usually shorter than represented in the classic model – in some cases it may be reduced to a range of only 10<span class="elsevierStyleHsp" style=""></span>mmHg. Second, cerebral blood flow (CBF) adapts better to an increase in mean arterial pressure (MAP) than to a decrease in this pressure. And finally, the faster the MAP fluctuations, the greater the impact on CBF. In short, the limits of autoregulation are not universal and there is a greater risk of imbalance during episodes of sudden onset hypotension. As García-Orellana et al. point out, it is difficult to estimate safe MAP values if we do not know the patient's specific autoregulation curve and its capacity to respond and adapt.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Optimal MAP values can be found for each patient using computer programmes that establish statistical relationships in the form of blood pressure-to-surrogate CBF value ratios. The most common indices are calculated non-invasively from surrogate measurements of CBF obtained with Doppler or cerebral oximetry. These indices do not always establish perfect correlations because Doppler, for example, has a steep learning curve and must be performed correctly in order to avoid significant variations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most of the accumulated experience with oximetry indices comes from cardiac surgery. Maintaining perfusion within the autoregulation limits estimated using this method has been shown to predict postoperative complications, including stroke and delirium.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Interestingly, the appearance of delirium has been associated with accumulated time above the upper limit of autoregulation (ULA), while stroke is associated with time below the lower limit of autoregulation (LLA). The significance of these observations in the case of delirium is unclear, since it may be due to the formation of oedema or an increase in brain inflammation secondary to an ischaemia-reperfusion injury.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Brady et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> recently developed optimal MAP values based on observations made in cardiac surgery and the use of autoregulation indices. In their opinion, optimal MAP ranges between 67 and 89<span class="elsevierStyleHsp" style=""></span>mmHg, with an LLA of 53–77<span class="elsevierStyleHsp" style=""></span>mmHg and a ULA of 73–95<span class="elsevierStyleHsp" style=""></span>mmHg, depending on other factors such as use of diuretics, white matter degeneration, or cardiovascular history. At first glance, however, it is evident that instead of improving Lassen's curve, these fixed values create further confusion, since the values for each parameter overlap. Neither do they factor in the effect of accumulated time outside the autoregulation limits or the surgical position. The latter is important, because except for the beach chair position, the effect that patient positioning has on acceptable MAP values is often overlooked. Moreover, cerebral blood flow does not depend directly on MAP but on cerebral perfusion pressure, which can vary depending on venous drainage and intracranial pressure.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is interesting the note the extent to which surgical patients can tolerate hypotension. This is attributed, among other factors, to a “cerebral flow reserve” that is equivalent to the clinical tolerance found in awake patients with pressures below the LLA – a pressure-flow dependence grey area that does not cause symptoms of hypoperfusion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary, the use of computer programmes to process surrogate CBF values can help obtain individualised cerebral autoregulation parameters and, therefore, optimal blood pressure. Until then, available monitoring methods must be used, dispensing with fixed cut-off values and keeping an eye on the upper limits of autoregulation. For this reason, we believe it is more accurate to speak of values beyond autoregulation ranges than hypotension.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">All authors have received speakers’ fees from Medtronic® in connection with the INVOS® regional cerebral oxygen saturation monitor.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Veiga Gil L, Pavón Benito A, Cerdán Rodríguez G, Ortiz Gómez JR. La «nueva curva de autorregulación cerebral», demos un paso más para seguir aprendiendo. Rev Esp Anestesiol Reanim. 2021;68:112–113.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Es la presión arterial «normal» la presión arterial «óptima» para cada uno de nuestros pacientes?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. García-Orellana" 1 => "R. Valero" 2 => "N. 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Gottschalk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aeu319" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2014" "volumen" => "113" "paginaInicial" => "1009" "paginaFinal" => "1017" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25256545" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Personalizing the definition of hypotension to protect the brain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.M. Brady" 1 => "A. Hudson" 2 => "HoodR" 3 => "B. De Caria" 4 => "C. Lewis" 5 => "C.W. Hogue" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0000000000003005" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2020" "volumen" => "132" "paginaInicial" => "170" "paginaFinal" => "179" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31644437" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006800000002/v1_202103160736/S2341192921000196/v1_202103160736/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006800000002/v1_202103160736/S2341192921000196/v1_202103160736/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000196?idApp=UINPBA00004N" ]
Journal Information
Vol. 68. Issue 2.
Pages 112-113 (February 2021)
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Vol. 68. Issue 2.
Pages 112-113 (February 2021)
Letter to the Director
The «new cerebral autoregulation curve», let's take a step further to keep learning
La «nueva curva de autorregulación cerebral», demos un paso más para seguir aprendiendo
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