Editorials

3. Cloostermans MC, van Meulen FB, Eertman CJ, et al: Continuous 8. Rossetti AO, Tovar Quiroga DF, Juan E, et al: Electroencephalography
electroencephalography monitoring for early prediction of neurologi- Predicts Poor and Good Outcomes After Cardiac Arrest: A Two-
cal outcome in postanoxic patients after cardiac arrest: A prospective Center Study. Crit Care Med 2017; 45:e674e682
cohort study. Crit Care Med 2012; 40:28672875 9. Westhall E, Rossetti AO, van Rootselaar AF, et al; TTM-trial investiga-
4. Sivaraju A, Gilmore EJ, Wira CR, et al: Prognostication of post-car- tors: Standardized EEG interpretation accurately predicts prognosis
diac arrest coma: Early clinical and electroencephalographic predic- after cardiac arrest. Neurology 2016; 86:14821490
tors of outcome. Intensive Care Med 2015; 41:12641272 10. Amorim E, Rittenberger JC, Zheng JJ, et al; Post Cardiac Arrest
5. Hofmeijer J, Beernink TM, Bosch FH, et al: Early EEG contributes to Service: Continuous EEG monitoring enhances multimodal outcome
multimodal outcome prediction of postanoxic coma. Neurology 2015; prediction in hypoxic-ischemic brain injury. Resuscitation 2016;
85:137143 109:121126
6. Lamartine Monteiro M, Taccone FS, Depondt C, et al: The prognostic 11. Hofmeijer J, Tjepkema-Cloostermans MC, van Putten MJ: Burst-
value of 48-h continuous EEG during therapeutic hypothermia after suppression with identical bursts: A distinct EEG pattern with poor
cardiac arrest. Neurocrit Care 2016; 24:153162 outcome in postanoxic coma. Clin Neurophysiol 2014; 125:947954
7. Admiraal MM, van Rootselaar AF, Horn J: Electroencephalographic 12. Westhall E, Rosn I, Rossetti AO, et al: Interrater variability of EEG
reactivity testing in unconscious patients: A systematic review of interpretation in comatose cardiac arrest patients. Clin Neurophysiol
methods and definitions. Eur J Neurol 2017; 24:245254 2015; 126:23972404

Getting to Patients Heads Through Their Hearts*

James M. Blum, MD, FCCM user assess the depth of anesthesia, with a recommended range
Chief of Critical Care Medicine of 4060. Developed and marketed as a device to avoid anes-
Department of Anesthesiology thetic awareness, the BIS monitor, as it became to be known,
Emory University School of Medicine developed a limited presence in the ICU despite a lack of data
Emory University Hospital surrounding its validity in the critical care domain and lim-
Atlanta, GA; and ited evidence that it reduced awareness events in the operating
Chief of Anesthesiology room (59).
Atlanta VA Medical Center Although multiple technologies exist to assist in the EEG
Atlanta, GA and neuronal activity processing space, the concept that one
can assess sedation using HRV metrics is intriguing. HRV is

I
n this issue of Critical Care Medicine, Nagaraj et al (1) known to link to neural activity, particularly when examining
describe their continued work in developing a method to the frequency domain (1012). As such, it makes sense that a
predict sedation levels from heart rate variability (HRV) correlation between sedation state and HRV parameters does
measurements. The work in this study is an enhancement from indeed exist. The prior work by Nagaraj et al (1) is suggestive
their prior contributions, because they demonstrate the abil- that such a link may be assessable and useable by clinicians.
ity to personalize the metrics generated by calibrating against Despite the progress demonstrated by this study, there are
prior HRV measures integrated with prior Richmond Agita- significant limitations to the work. First and foremost, the
tion Sedation Scale (RASS) scores (2). Although incremental, study used a RASS measure that was routinely collected every
this does represents an advance in the field. 2 hours. There was no attempt to isolate episodes of increased
The importance of this work is recognized by the dedication agitation, which is infrequent, but highly disruptive in the
of many investigators to help develop improved monitoring of ICU patient population. The data provided from this study
sedation in the critical care environment. Electronic monitor-
do not demonstrate that patients were constantly at the pre-
ing of sedation states started with the introduction of elec-
dicted RASS, but only that they were at the level at the time of
troencephalogram (EEG) processing and direct monitoring
observation.
of brain activity over 20 years ago (3, 4). This is most notably
Of additional concern is the lack of a standardized sedation
identified by the introduction of the bispectral index monitor
(BIS) by Aspect Medical Systems (Norwood, MA) in 1994 (4). protocol utilized in the conduct of this study. Patients in this
Aspect processed EEG tracings using a proprietary algorithm study received a multitude of sedatives. This includes patients
to empirically derive a unit-less sedation metric. In practice, that could have been receiving dexmedetomidine or other
the device provides a single number from 1 to 100 to help the sedative medications that impact cardiac conductivity (13).
These medications may have inadvertently impacted the HRV
metrics and the subsequent correlation with HRV parameters.
*See also p. e683. Although the authors were able to demonstrate correlation
Key Words: bispectral index monitoring; brain function; heart rate
variability; neuronal activity; Richmond Agitation Sedation Scale
despite the medications that were being administered, the lack
Dr. Blum received funding from Intensix.
of any integration of the sedation being administered greatly
Copyright 2017 by the Society of Critical Care Medicine and Wolters limits the generalizability of the authors conclusions, particu-
Kluwer Health, Inc. All Rights Reserved. larly when considering the rapid rise in the use of -2 agonists
DOI: 10.1097/CCM.0000000000002422 in ICU sedation.

Critical Care Medicine www.ccmjournal.org 1257

Copyright 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Editorials

Despite these elementary concerns, when examining this REFERENCES

study and the general concept of HRV as a sedation monitor, 1. Nagaraj SB, Biswal S, Boyle EJ, et al: Patient-Specific Classification
of ICU Sedation Levels From Heart Rate Variability. Crit Care Med
the greatest concern is whether this is an appropriate method 2017; 45:e683e690
to monitor sedation. The authors argue that RASS and other 2. Nagaraj SB, McClain LM, Zhou DW, et al: Automatic classification of
sedation scales are subject to inter- and intraobserver variabil- sedation levels in ICU patients using heart rate variability. Crit Care
ity, and that electrocardiogram (ECG) monitoring is ubiqui- Med 2016; 44:e782e789
3. Lu CH, Man KM, Ou-Yang HY, et al: Composite auditory evoked
tous in the critical care population. They argue that it would potential index versus bispectral index to estimate the level of seda-
only make sense to incorporate additional knowledge from the tion in paralyzed critically ill patients: A prospective observational
ECG in the management of the patient. study. Anesth Analg 2008; 107:12901294
There is an issue with this logic as the target organ of seda- 4. Flaishon R, Windsor A, Sigl J, et al: Recovery of consciousness after
thiopental or propofol. Bispectral index and isolated forearm tech-
tion is the brain. Unlike other organs where we frequently are nique. Anesthesiology 1997; 86:613619
left to use surrogate markers of function and injury, the brain 5. LeBlanc JM, Dasta JF, Pruchnicki MC, et al: Bispectral index values,
offers us two clear methods of constant monitoring. The first is sedation-agitation scores, and plasma lorazepam concentrations in
critically ill surgical patients. Am J Crit Care 2012; 21:99105
simple observation of the patient and his/her ability to interact
6. Bilgili B, Montoya JC, Layon AJ, et al: Utilizing bi-spectral index (BIS)
appropriately. Although this is subject to inter- and intraob- for the monitoring of sedated adult ICU patients: A systematic review.
server variability, several methods have been developed and Minerva Anestesiol 2017; 83:288310
validated to monitor a patients level of sedation. 7. Avidan MS, Jacobsohn E, Glick D, et al: Prevention of intraoperative
The second method of monitoring is EEG. EEG is a direct awareness in a high-risk surgical population. N Engl J Med 2011;
365:591600
monitor of actual brain activity, and although limited channel 8. Mashour GA, Shanks A, Tremper KK, et al: Prevention of intraopera-
monitors like the BIS are now commonly available, multichan- tive awareness with explicit recall in an unselected surgical popula-
nel techniques offer a significant amount of information about tion. Anesthesiology 2012; 117:717725
the state of the brain (14). Although the idea of HRV monitor- 9. Myles P, Leslie K, McNeil J, et al: Bispectral index monitoring to pre-
vent awareness during anaesthesia: The B-Aware randomised con-
ing to assess sedation level is indeed intriguing and may provide trolled trial. Lancet 2004; 363:17571763
future insights into heart-brain connectivity, such monitoring is 10. Conte V, Guzzetti S, Porta A, et al: Spectral analysis of heart rate
likely using a surrogate marker. Although potentially effective, variability during asleep-awake craniotomy for tumor resection.
JNeurosurg Anesthesiol 2009; 21:242247
the use of HRV measures in this domain clearly relies on signifi-
11. Pyne JM, Constans JI, Wiederhold MD, et al: Heart rate variability:
cant trust in surrogate measures and will likely be treated with Pre-deployment predictor of post-deployment PTSD symptoms. Biol
skepticism by the end-user compared with direct measurements. Psychol 2016; 121:9198
In conclusion, the work by Nagaraj et al (1) is interesting 12. Pfurtscheller G, Schwerdtfeger AR, Seither-Preisler A, et al: Brain
and continues to advance the science of HRV and its con- heart communication: Evidence for central pacemaker oscillations
with a dominant frequency at 0.1Hz in the cingulum. Clin Neurophysiol
nection to brain function. However, the existing data suggest 2017; 128:183193
that there is much work to be done in a much larger, homog- 13. Cho JS, Kim SH, Shin S, et al: Effects of dexmedetomidine on
enous patient population to make the next advance. With changes in heart rate variability and hemodynamics during tracheal
intubation. Am J Ther 2016; 23:e369e376
this said, only time and continued investigation will tell if
14. Aho AJ, Kamata K, Jntti V, et al: Comparison of bispectral index and
studying your patients heart will tell you something useful entropy values with electroencephalogram during surgical anaesthesia
about their head. with sevoflurane. Br J Anaesth 2015; 115:258266

A Chamber With a View: The Size of the Right

Ventricle During Cardiopulmonary Resuscitation*

C
Frank M. P. van Haren, MD, PhD ardiac arrest (CA) is a condition frequently encoun-
Intensive Care Unit tered by emergency and critical care physicians. Despite
The Canberra Hospital; and advances in aspects of acute resuscitation over the
Australian National University Medical School last decades, survival from CA remains poor. There is a well-
Canberra, Australia described association between the mechanism of CA and the
outcome of initial resuscitation. The outcome is better when
*See also p. e695. the initial rhythm is a sustained ventricular tachyarrhythmia,
Key Words: advanced cardiac life support; cardiac arrest; compared with patients who have pulseless electrical activity
echocardiography; pulmonary embolism; thrombolysis
(PEA) or patients who present with or proceed to asystole. It
Dr. van Haren has disclosed that he does not have any potential conflicts
of interest. is essential to recognize potentially reversible and/or treatable
Copyright 2017 by the Society of Critical Care Medicine and Wolters
causes of CA in the subgroup of patients with PEA or asys-
Kluwer Health, Inc. All Rights Reserved. tole. Survival following CA in this subgroup is unlikely unless a
DOI: 10.1097/CCM.0000000000002357 reversible cause can be found and treated effectively (1).

1258 www.ccmjournal.org July 2017 Volume 45 Number 7

Copyright 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.