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Canonical correlation analysis in the study of cerebral and peripheral haemodynamics interrelations with systemic variables in neonates supported on ECMO.
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PMID:  22879010     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
Neonates supported on extracorporeal membrane oxygenation (ECMO) are at high risk of brain injury due to haemodynamic instability. In order to monitor cerebral and peripheral (muscle) haemodynamic and oxygenation changes in this population we used a dual-channel near-infrared spectroscopy (NIRS) system. In addition, to assess interrelations between NIRS and systemic variables, collected simultaneously, canonical correlation analysis (CCA) was employed. CCA can quantify the relationship between a set of variables and assess levels of dependency. In four out of five patients, systemic variables were found to be less inter-related with cerebral rather than peripheral NIRS measurements. Moreover, during ECMO flow manipulations, we found that the interrelation between the systemic and the NIRS cerebral/peripheral variables changed. The CCA method presented here can be used to assess differences between NIRS cerebral and NIRS peripheral responses due to systemic variations which may be indicative of physiological differences in the mechanisms that regulate oxygenation and/or haemodynamics of the brain and the muscle.
Authors:
Alexander Caicedo; Maria D Papademetriou; Clare E Elwell; Aparna Hoskote; Martin J Elliott; Sabine Van Huffel; Ilias Tachtsidis
Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Advances in experimental medicine and biology     Volume:  765     ISSN:  0065-2598     ISO Abbreviation:  Adv. Exp. Med. Biol.     Publication Date:  2013  
Date Detail:
Created Date:  2012-08-10     Completed Date:  2012-12-11     Revised Date:  2014-06-03    
Medline Journal Info:
Nlm Unique ID:  0121103     Medline TA:  Adv Exp Med Biol     Country:  United States    
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Languages:  eng     Pagination:  23-9     Citation Subset:  IM    
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MeSH Terms
Descriptor/Qualifier:
Brain / physiopathology*
Cerebrovascular Circulation*
Child, Preschool
Extracorporeal Circulation*
Extracorporeal Membrane Oxygenation / methods*
Hemodynamics
Humans
Infant
Infant, Newborn
Models, Statistical*
Monitoring, Physiologic*
Oxygen / metabolism*
Respiratory Insufficiency / prevention & control*
Spectroscopy, Near-Infrared
Grant Support
ID/Acronym/Agency:
G0701458//Medical Research Council
Chemical
Reg. No./Substance:
S88TT14065/Oxygen
Comments/Corrections

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Journal Information
Journal ID (nlm-ta): Adv Exp Med Biol
Journal ID (iso-abbrev): Adv. Exp. Med. Biol
Journal ID (publisher-id): Adv. Exp. Med. Biol.
ISSN: 0065-2598
Publisher: Springer
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© Springer Science+Business Media New York 2013
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Electronic publication date: Year: 2013
Volume: 765First Page: 23 Last Page: 29
PubMed Id: 22879010
ID: 4038010
DOI: 10.1007/978-1-4614-4989-8_4

Canonical Correlation Analysis in the Study of Cerebral and Peripheral Haemodynamics Interrelations with Systemic Variables in Neonates Supported on ECMO
Alexander Caicedoch4.Aff1
Maria D. Papademetriouch4.Aff2
Clare E. Elwellch4.Aff2
Aparna Hoskotech4.Aff3
Martin J. Elliottch4.Aff3
Sabine Huffelch4.Aff1
Ilias Tachtsidisch4.Aff2 Email: iliastac@medphys.ucl.ac.uk
Katholieke Universiteit Leuven, ESAT/SCD, Department of Electrical Engineering & IBBT Future Health Department, Leuven, Belgium
University College London, Department of Medical Physics and Bioengineering, 18 Dickensons Lane, London, WC1E 6BT, UK
Great Ormond Street Hospital for Children, London, UK

Introduction

Extracorporeal membrane oxygenation (ECMO) is a life support system for patients with intractable cardio-respiratory failure. Neonates supported on ECMO often suffer from periods of haemodynamic instability, hypoxia and/or hypercapnia. In addition, the ECMO procedure itself may cause physiological changes due to ligation of the major neck vessels, heparinization and haemodilution, which can cause alterations in cerebral blood flow and potentially disrupt autoregulation [1]. Consequently, ECMO patients have increased risk for brain injury with reported abnormal neuroimaging ranging from 28 to 52%, depending on the imaging technique used [2].

Several studies have described changes in the cerebral haemodynamics before, during and after ECMO procedure. Liem et al. [1] reported that mean arterial blood pressure (MABP), arterial oxygen saturation (SaO2) and partial pressures of oxygen and CO2 measured transcutaneously were some of the variables that better explained changes in cerebral total haemoglobin (HbT) measured by NIRS. Ejike et al. [3] reported that the regional cerebral oxygenation presented a negative correlation with arterial partial pressure of CO2 (pCO2) and no significant correlation with changes in ECMO flow. Papademetriou et al. [4] used dual-channel NIRS system during ECMO flow changes and reported the presence of low frequency oscillations (<0.1 Hz) in peripheral oxyhaemoglobin (HbO2), which are not present in cerebral HbO2, demonstrating differences between cerebral and peripheral haemodynamics in this patient group.

Several studies have investigated the relationship between spontaneous changes in MABP and cerebral NIRS signals as assessment of brain autoregulation [57]. Brady et al. [6] investigated the correlation between NIRS and MABP in paediatric patients undergoing cardiac surgery with cardiopulmonary bypass for correction of congenital heart defects. They found an association between hypotension during cardiopulmonary bypass and impairment of autoregulation. We have also previously [7] studied the relation between MABP and haemoglobin difference (HbD = HbO2 − HHb, oxy minus reduced haemoglobin) and tissue oxygenation index (TOI = HbO2/HbO2 + HHb) by means of correlation, coherence and partial coherence analysis, and its use in clinical outcome prediction; although higher values were found in the population with adverse clinical outcome, indicating a stronger relation between MABP and HbD/TOI, no strong evidence was established. However, ECMO is a complex procedure and study of the interrelation of haemodynamic variables, only, with MABP may not be sufficient.

In this study we describe the use of canonical correlation analysis (CCA) to investigate the differences between the interrelations in cerebral and peripheral NIRS measurements with the systemic variables in ECMO patients. In our analysis the systemic variables were defined as the independent dataset, while the cerebral and peripheral NIRS measurements were defined as dependent variables.


Methods

CCA is a statistical method that analyzes the interrelation between variables in multidimensional datasets. CCA can be seen as an extension to normal correlation analysis, in which the proximity between two multidimensional datasets, instead of vectors, is analyzed by means of canonical angles [8]. CCA determines how strongly the variables in both datasets are related. It is also possible to determine which and how many of the independent variables explain most of the variation in the dependent dataset.

Measurements from five subjects (ranging from 1 to 1,825 days) on veno-arterial (VA) ECMO procedure were used in this study. A dual-channel near-infrared system (NIRO 200, Hamamatsu Photonics KK) was used to measure the changes in HbO2, HHb and TOI using spatially resolved spectroscopy. From these signals HbD and total haemoglobin changes (HbT = HbO2 + HHb) were calculated and used, together, with TOI for further analysis. NIRS data were collected at a frequency of 6 Hz. Channel 1 was placed on the forehead in order to assess cerebral NIRS changes, while channel 2 was placed on the calf to assess peripheral NIRS changes. A full set of systemic data including MABP, central venous pressure (CVP), endtidal carbon dioxide pressure (EtCO2), heart rate (HR), respiration rate (RR), core and skin temperatures and SaO2 were continuously measured in real time at the bedside (IntelliVue MP70, Philips Medical). All signals were down-sampled to 1 Hz and artefacts were removed manually by means of interpolation. Figure 4.1 shows an example of the systemic and NIRS measurements from one neonate. Measurements were done during stepwise changes in the ECMO flow; the flow was reduced from baseline (100% ECMO flow) in steps of 10%, approximately every 10 min, until 70% of the baseline ECMO flow was reached, afterwards the flow was increased back to baseline following the same profile. In cases where the patients could not accommodate a 30% reduction in ECMO flow it was only reduced by a total of 20%. The interrelations between the set of peripheral and cerebral NIRS changes with the systemic variables were studied using two different approaches. The first approach used the complete measurement period and the ECMO flow when available as a parameter in the analysis. In the second approach, the signals were segmented in epochs of constant ECMO flow and the methods were applied separately to each epoch. In addition, in order to normalize the results to be comparable between patients, we estimated the ratio between the percentage of variance in the peripheral NIRS explained by the systemic variables and the percentage of variance of the cerebral NIRS explained by the systemic variables. We call this index the peripheral to cerebral haemodynamic ratio (PCHR). PCHR can be used to quantify the differences in the interrelations between both cerebral and peripheral circulation mechanisms versus systemic variations. PCHR values lower than 1 indicate that variations in the systemic variables are more likely to be reflected in the muscle than in the brain.


Results

Table 4.1 shows PCHR for different ECMO flows and for the full measurement period. Results for the full measurement period show that only patient 4 presented a PCHR > 1, indicating that the variations in the systemic variables were more likely to be reflected in the brain NIRS measurements rather than the peripheral in that patient; in the other patients the peripheral NIRS changes are more likely to be affected by variations in the systemic variables. In addition, patient 3, in contrast with the other patients, was the only one who, at every ECMO flow rate, consistently presented PCHR < 1 and as it happened was the only patient in our group that the clinicians were confident to reduce the flow down to 70% from baseline. Table 4.2 shows which systemic variables contributed more to the changes in cerebral/ peripheral NIRS variables, when analyzing the complete measurement period. HR and skin temperature were the systemic variables that most affected the cerebral and/or peripheral haemodynamic variables in the patients. MABP, CVP, skin temperature, SaO2 and ECMO affected the NIRS variables to a lesser extent.


Discussion

PCHR < 1, but close to 1, were observed in four out of five patients when analyzing the full measurement period. Earlier studies on neonates supported on ECMO indicate that autoregulation may be disrupted [1]; this can be the cause of PCHR values close to 1 as the brain haemodynamic and oxygenation changes will respond passively to systemic variations. In addition, when reducing ECMO flows it is expected that the peripheral circulation will be more affected by systemic changes than the brain circulation. At baseline level (100% ECMO flow) all patients reported a PCHR < 1; when reducing the flow to 90% three out of five patients reported PCHR > 1, indicating that systemic changes were more reflected in the cerebral circulation than in the peripheral circulation, while patient 5 could not accommodate extra reductions in the flow and was returned to baseline level. At 80% flow two out of four patients presented PCHR > 1; furthermore, in this stage, three of the four patients could not accommodate more reductions in the flow and were returned to baseline level. Only patient 3 was able to accommodate a reduction to 70% in the ECMO flow and was the only patient who consistently presented PCHR < 1. When returning ECMO flow to baseline level, three out of four patients presented PCHR ≥ 1. These results suggest that at low ECMO flows cerebral circulation is more vulnerable to changes in systemic variables and this effect is apparent in the most vulnerable patients.

In the population studied HR and skin temperature were the variables that most affected the cerebral and peripheral NIRS signals. Out of five patients, MABP was correlated with cerebral and peripheral haemodynamic variables in three and two patients, respectively. Out of four patients, SaO2 was correlated with cerebral and peripheral haemodynamic variables in three and two patients, respectively. Out of four patients EtCO2 was correlated with the cerebral haemodynamic variables in one patient. Furthermore, ECMO flow presented a strong correlation with cerebral and peripheral NIRS variables in all three patients with flow measurements. The lack of homogeneity in relation to the systemic variables that affect the cerebral or peripheral circulation in our study suggests differences in the clinical condition of each patient; however, due to the small patient numbers it is difficult to present a clinical hypothesis. Interestingly, and in contrast with these results, Tisdall et al. [9] in healthy adults found that changes in SaO2 and EtCO2 make a large contribution to changes in the cerebral NIRS TOI signal. In addition, CCA indicated that variation in the skin temperature strongly affects the cerebral and peripheral NIRS changes; conversely, Harper et al. [10] reported that a change in core temperature in adults can produce changes in blood flow due to changes in blood viscosity and metabolic rate (among other reasons). Whilst, Davis et al. [11] reported that changes in temperature produce changes in skin blood flow that can have a significant impact in the NIRS derived signals; therefore, special care should be taken when analyzing these results.

Several factors should be taken into account before interpreting the results provided by CCA. Among the limitations, the length of the signal under analysis and the presence of noise, non-linearities and nonstationarity can be cited. In order to overcome some of these problems, and compare the results between patients, normalization such as the PCHR ratio should be used; otherwise, the results should be interpreted carefully. Cerebral and peripheral haemodynamic and oxygenation changes are affected by multiple factors; hence underlying the necessity of measuring several systemic variables in order to obtain a general idea of the mechanisms affecting them. CCA is a useful tool to investigate this problem as it helps to assess and quantify the interrelation between a multiple set of variables, simultaneously.


Acknowledgments

A.C.D. was supported by the Flemish fund for research FWO, and author I.T. is a Wellcome Trust Research Fellow (088429/Z/09/Z).


References
1. Liem K,Hopman J,Oesenburg B,et al. Cerebral oxygenation and haemodynamics during induction of extracorporeal membrane oxygenation as investigated by near infrared spectrophotometryPediatricsYear: 1995935555617700758
2. Bulas D,Glass P. Neonatal ECMO: neuroimaging and neurodevelopmental outcomeSemin PerinatolYear: 200529586515921154
3. Ejike J,Schenkeman K,Seidel K,et al. Cerebral oxygenation in neonatal and pediatric patients during veno-arterial extracorporeal life supportPediatr Crit Care MedYear: 2006715415816446597
4. Papademetriou MD,Tachtsidis I,Leung TS,et al. Cerebral and peripheral tissue oxygenation in children supported on ECMO for Cardio-respiratory failureAdv Exp Med BiolYear: 201066244745320204828
5. Wong FY,Leung TS,Austin T,et al. Impaired autoregulation in preterm infants identified by using spatially resolved spectroscopyPediatricsYear: 20081213e604e61118250118
6. Brady KM,Mytar JO,Lee JK,et al. Monitoring cerebral blood flow pressure autoregulation in pediatric patients during cardiac surgeryStrokeYear: 2010411957196220651273
7. Caicedo A,De Smet D,Vanderhaegen J,et al. Impaired cerebral autoregulation using near-infrared spectroscopy and its relation to clinical outcomes in premature infantsAdv Exp Med BiolYear: 201170123323921445792
8. Hotelling H. Relations between two sets of variatesBiometrikaYear: 19368321377
9. Tisdal MM,Taylor C,Tashtsidis I,et al. The effect on cerebral tissue oxygenation index of changes in the concentrations of inspired oxygen and end-tidal carbon dioxide in healthy adult volunteersAnesth AnalYear: 20091093906913
10. Harper AM,Jennet S. Cerebral blood flow and metabolismYear: 1990Manchester University PressManchester20
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Figures

[Figure ID: F1]
Fig. 4.1  Systemic and haemodynamics measurements recorded from patient 3.

The dashed vertical lines represent the changes in ECMO flow 4 Canonical Correlation Analysis in the Study



Tables
[TableWrap ID: T1] Table 4.1  Ratio between the percentage of the variance in the cerebral haemodynamics and the peripheral haemodynamics explained by variations in the systemic variables (PCHR), for different ECMO flow percentages and the full measurement period
ECMO flow percentage
Age (days) 100% 90% 80% 70% 80% 90% 100% Full period
Patient 1 180 0.56 0.76 1.19 1.59 1.00 0.85
Patient 2 1 0.68 1.55 1.61 0.55 0.82
Patient 3 2 0.91 0.95 0.49 0.89 0.91 0.47 0.38 0.91
Patient 4 4 0.66 1.68 0.73 0.71 1.00 1.21
Patient 5 1,825 0.75 1.42 1.33 0.82

TFN1A PCHR lower than 1 indicates that the variations in systemic variables are more likely to be reflected in the muscle than in the brain. Spaces marked with a dash (–) indicate that it was not possible to perform the analysis due to the lack of measurements


[TableWrap ID: T2] Table 4.2  Systemic variables that presented a correlation higher than 0.5, in absolute value, with cerebral/peripheral haemodynamic variables represented by a C&P sign, respectively
Patient HR MABP CVP CoreT SkinT SaO2 RR EtCO2 Flow
1 C C&P C P
2 C&P C C C C&P P C&P C&P
3 P P C&P C&P C&P C C&P
4 C&P P C&P C&P
5 C&P C C&P C&P C&P

TFN2The blank spaces indicate no correlation, and a dash (–) indicates that the parameter was not used in the analysis due to lack of measurements or distortion by artefacts



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