Noninvasive multimodal neuromonitoring in patients with post-cardiac arrest brain injury: a survey from China’s intensive care units

Abstract

Post-cardiac arrest brain injury (PCABI) exerts a profound impact on mortality and long-term disability of patients who undergo cardiac arrest (CA) and subsequently achieve the return of spontaneous circulation following cardiopulmonary resuscitation [1]. The primary aim of post-resuscitation therapy is to mitigate neurological damage to the greatest extent possible, necessitating comprehensive neurological monitoring and preventive strategies. The 2021 International Guidelines recommend several predictors for assessing the neurological prognosis of CA survivors [2]. Recently, a novel approach known as multimodal monitoring (MMM) has come to the fore [3], employing advanced technologies to monitor real-time brain pathophysiological changes and evaluate brain function. Nevertheless, the function of MMM in appraising neurological function and prognosticating outcomes among CA patients remains in the exploratory stage within intensive care units (ICUs). The objective of our survey was to provide a holistic understanding of the current practical applications of noninvasive MMM for patients with PCABI across various regions within Chinese ICUs.

The questionnaire was devised by our research team and comprised 13 questions, categorized into four primary themes: 1) information related to the healthcare organizations, 2) current practices concerning MMM items, 3) the existing provision of monitoring instruments and 4) assessment and expectations regarding MMM.

A cohort of 109 ICU professionals were identified across 7 Chinese regions. During the period from September to October 2024, participants were invited to complete the questionnaire via the WPS form. The collected responses were analyzed underwent descriptive analysis of quantitative and qualitative data.

Among the respondents predominantly working in Emergency Intensive Care Units, 73.4% were affiliated with Class IIIA medical units (Additional file 1: Table S1), and the majority located in Eastern China (67.9%). Regarding the bed capacity of the participants’ departments, those with 11–20 beds constituted the largest cohort at 31.2%. Furthermore, departments that admit CA patients and perform extracorporeal cardiopulmonary resuscitation (ECPR) annually reported rates of up to 46.8% and 54.1%, respectively.

The survey disclosed that merely 36.7% of participants employed MMM, falling short of 50%. A preponderant majority of respondents strongly concurred on the significance of MMM for early diagnosis, severity assessment, treatment planning, and prognostic evaluation. Furthermore, a majority of participants expressed a moderate level of trust in the results derived from MMM (68.8%) in clinical practice. Looking ahead, 89.0% of participants expressed their intention to actively introduce or augment the application of MMM in clinical settings (Additional file 1: Tables S2).

Among the assorted monitoring methods associated with MMM (Fig. 1), brain imaging examination (92.7%) emerged as the principal modality. In contrast, cerebral metabolism examinations (17.4%) were employed to a lesser extent. In terms of MMM-related equipment, EEG machines (68.8%) and TCD (42.2%) accounted for a significant proportion of usage. Conversely, NIRS (27.5%) and pupillometry (11.0%) were available in comparatively lower proportions, as depicted in Fig. 2. Notably, the majority opted for the combination of TCD with the EEG machine (32.1%). On the other hand, employed noninvasive MMM with all four instruments concurrently—TCD, the EEG machine, ONSD, and NIRS—this subgroup accounting for just 11.9% (Fig. 2).

Fig. 1

Neuromonitoring items utilization

Full size image

Fig. 2

Noninvasive multimodal neuromonitoring device utilization

Full size image

Accurately assessing neurological status is essential—not only to prevent the premature withdrawal of life-support treatment for patients who potential for recover but also to avoid ineffective treatments for patients with severe and irreversible damage. However, any single assessment often lacks accuracy and precision. Moreover, the complexity and variability in the pathophysiology of ICU patients, along with the effects of therapeutic intervention, render the assessment of neurological function challenging. Thus, the concurrent employment of multiple assessments is essential for improving predictions regarding neurological outcomes.

The strength of MMM lies in its ability to integrate multiple monitoring signals, thereby deepening our understanding of the dynamics occurring in the patient’s brain and facilitating the implementation of targeted strategies for personalized medicine [4]. Additionally, continuous monitoring enables exploration of subtle interactions between the nervous system and systemic physiological responses in critically ill patients, which is indispensable for comprehending the overall progression of the disease. Although no MMM-guided (phase III) clinical treatment-based results have yet shown a clear benefit, a prospective randomized control clinical trial (NCT06711016) being conducted by our team is currently recruiting participants. This trials not only epitomize cutting-edge exploration in the domain of MMM research but also indicate potential future breakthroughs that could provide advanced scientific insights applicable to clinical practice.

The main limitations of this study are, on the one hand, the sample remains selective, since not all clinicians practicing in an ICU participated in the survey. Second, the participant composition was heterogeneous, incorporating individuals from disparate regions and hospitals, as well as varying qualifications and levels of clinical experience. Notwithstanding these limitations, our study successfully spotlighted that the current state of MMM application in Chinese ICUs is concerning, and underlines the significant role of MMM in managing PCABI. Additionally, a growing number of hospitals are initiating implement of MMM approaches for the treatment of PCABI.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

EEG:

Electroencephalogram

ICP:

Intracranial pressure

ONSD:

Optic nerve sheath diameter

TCD:

Transcranial Doppler

NIRS:

Near-infrared spectroscopy

GICU:

General intensive care unit

1. Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intens Care Med. 2021;47(12):1393–414.

   Article CAS Google Scholar

2. Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, et al. European resuscitation council and european society of intensive care medicine guidelines 2021: post-resuscitation care. Intens Care Med. 2021;47(4):369–421.

   Article Google Scholar

3. Rajagopalan S, Sarwal A. Neuromonitoring in critically Ill patients. Crit Care Med. 2023;51(4):525–42.

   Article Google Scholar

4. Foreman B, Kapinos G, Wainwright MS, Ngwenya LB, O’Phelan KH, LaRovere KL, et al. Practice standards for the use of multimodality neuromonitoring: a delphi consensus process. Crit Care Med. 2023;51(12):1740–53.

   Article PubMed PubMed Central Google Scholar

Download references

Thank all the ICUs for their participation for their support.

This study was funded by Noncommunicable Chronic Diseases-National Science and Technology Major Project (2023ZD0505500).

Authors and Affiliations

1. School of Medicine, Shandong University, Jinan, 250012, Shandong, China

   Yankang Ren, Xiaoxue Nie, Haiyan Liu, Tao Jiang, Yuan Bian, Feng Xu, Yuguo Chen & Xianfei Ji

2. Department of Emergency Medicine, Qilu Hospital of Shandong University, No 107, Wenhua Xi Road, Jinan, 250012, Shandong, China

   Yankang Ren, Xiaoxue Nie, Haiyan Liu, Tao Jiang, Yuan Bian, Feng Xu, Yuguo Chen & Xianfei Ji

3. Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, 250012, China

   Yankang Ren, Xiaoxue Nie, Haiyan Liu, Tao Jiang, Yuan Bian, Feng Xu, Yuguo Chen & Xianfei Ji

4. Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Jinan, 250012, China

   Yankang Ren, Xiaoxue Nie, Haiyan Liu, Tao Jiang, Yuan Bian, Feng Xu, Yuguo Chen & Xianfei Ji

Authors

1. Yankang RenView author publications

   You can also search for this author in PubMed Google Scholar

2. Xiaoxue NieView author publications

   You can also search for this author in PubMed Google Scholar

3. Haiyan LiuView author publications

   You can also search for this author in PubMed Google Scholar

4. Tao JiangView author publications

   You can also search for this author in PubMed Google Scholar

5. Yuan BianView author publications

   You can also search for this author in PubMed Google Scholar

6. Feng XuView author publications

   You can also search for this author in PubMed Google Scholar

7. Yuguo ChenView author publications

   You can also search for this author in PubMed Google Scholar

8. Xianfei JiView author publications

   You can also search for this author in PubMed Google Scholar

Contributions

XF.J., F.X. and YG.C. design the study. YK.R., XF.J. and Y.B. compiled the questionnaire. YK.R., XX.N., HY.L. and T.J. acquired and analysised data. YK.R. and XF.J.wrote the main manuscript text. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Yuguo Chen or Xianfei Ji.

Ethics approval and consent to participate

Not applicable to practice surveys. An information letter was sent to all participants before they completed the questionnaire. No data identifying the professional or service was requested. No personal or health data were requested.

Consent for publication

Consent was obtained.

Competing interest

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional file 1.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

Cite this article

Ren, Y., Nie, X., Liu, H. et al. Noninvasive multimodal neuromonitoring in patients with post-cardiac arrest brain injury: a survey from China’s intensive care units. Crit Care 29, 69 (2025). https://doi.org/10.1186/s13054-025-05293-y

Download citation

• Received: 14 January 2025

• Accepted: 22 January 2025

• Published: 07 February 2025

• DOI: https://doi.org/10.1186/s13054-025-05293-y

Share this article

Anyone you share the following link with will be able to read this content:

Get shareable link

Sorry, a shareable link is not currently available for this article.

Copy to clipboard

Provided by the Springer Nature SharedIt content-sharing initiative