\r\n\tIn particular, this book presents topics related to Audio Signal Processing based on the different perspectives of the following: pattern recognition on audio, audio processing, forensic audio, digital filtering, and frequency analysis, and digital signal processing chip for audio, although other topics can be included, too. The most innovative advances on Audio Signal Processing will be included in this book, in order to show the reader, the new researched and developed approaches.
\r\n
\r\n\tSpecific cases of voice applications are welcome, where the Voice over IP (VoIP), internet of things (IoT), deep learning (DL) approaches, etc., are very useful including the recent technologies applied on voice and audio.
",isbn:"978-1-83962-876-4",printIsbn:"978-1-83962-875-7",pdfIsbn:"978-1-83962-877-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"95a662956526e566e5885e68c1d500ed",bookSignature:"Dr. Carlos M. Manuel Travieso-Gonzalez",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8213.jpg",keywords:"Pattern Recognition, Audio Identification, Audio Processing Algorithm, Audio Enhancer, Human Voice Patterns, Text to Speech, Forensic Audio Enhancement, Audio Evidence, Filtering Audio, Wavelet Analysis, Microprocessor for Audio, DSP for Audio",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 24th 2019",dateEndSecondStepPublish:"November 14th 2019",dateEndThirdStepPublish:"January 13th 2020",dateEndFourthStepPublish:"April 2nd 2020",dateEndFifthStepPublish:"June 1st 2020",remainingDaysToSecondStep:"a month",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,editors:[{id:"27170",title:"Dr.",name:"Carlos M.",middleName:"Manuel",surname:"Travieso-Gonzalez",slug:"carlos-m.-travieso-gonzalez",fullName:"Carlos M. Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Dr. Carlos M. Travieso-González received his M.Sc. degree in 1997 in Telecommunication Engineering at the Polytechnic University of Catalonia (UPC), Spain; and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a Full Professor and the Head of the Signals and Communications Department at ULPGC a. He is teaching in ULPGC from 2001 on signal processing and learning theory subjects and he has been a supervisor on 8 Ph.D. Thesis (9 more in the process), and 130 Master Thesis. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. Dr. Travieso-González has contributed research in more than 50 International and Spanish Research Projects, some of them as the head researcher, and is the co-author of 4 books, co-editor of 24 Proceedings Books, Guest Editor for 8 JCR-ISI international journals and up to 24 book chapters. He has over 430 papers published in international journals and conferences (70 of them indexed on JCR – ISI - Web of Science). Dr. Travieso-González has also published 7 patents on Spanish Patent and Trademark Office. He has been a reviewer in different indexed international journals (<70) and conferences (<200) since 2001. Dr. Carlos M. Travieso-González is the Associate Editor on Computational Intelligence and Neuroscience journal and Entropy, and evaluator on European Projects (H2020), ANECA (Spain), DAAD (Germany), MRC (UK), ANR (France) and other institutions. He is a member of IASTED Technical Committee on Image Processing from 2007 and a member of IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. Dr. Carlos M. Travieso-González is also the founder of The IEEE IWOBI conference series and President of its Steering Committee, the founder of The InnoEducaTIC conference series and the founder of The APPIS conference series. He was the Vice-Dean from 2004 to 2010 in Higher Technical School of Telecommunication Engineers in ULPGC; and the Vice-Dean of Graduate and Postgraduate Studies from March 2013 to November 2017.",institutionString:"University of Las Palmas de Gran Canaria",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"24",title:"Technology",slug:"technology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"192910",firstName:"Romina",lastName:"Skomersic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/192910/images/4743_n.jpg",email:"romina.s@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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1. Introduction
Solar thermal energy (STE) is a form of solar energy to generate electrical energy or thermal energy for use in the residential and commercial sectors and in industry.
Concentrating solar power (CSP) plants use mirrors to concentrate the rays of sun and produce heat for electricity generation through a conventional thermodynamic cycle. These kinds of plants are candidates for providing the solar electricity needed within the next few decades.
According to thermodynamics and Planck’s equation, the conversion of solar heat to mechanical work is limited by the Carnot efficiency, and then to achieve maximum conversion rates, the energy should be transferred to a thermal fluid or reactants at temperatures closer to that of the sun.
Solar radiation is a source of high temperature and energy. But for terrestrial use in average we have 1 kW/m2. Therefore, it is an essential requisite for solar thermal power plants and high-temperature solar chemistry applications to make use of optical concentration devices that enable the thermal conversion to be carried out at high solar flux and with relatively little heat loss.
The high radiative flux solar furnace (HFSF) is the solar concentrator system with greater concentration ratio. This type of system uses large concentrators with dimensions of several meters, which cannot be constructed in one piece; they are built with multiple segments.
A key to these large concentrators operate efficiently is the alignment of the segments. This kind of concentrators has hundreds of segments that must be aligned with high precision and in a short time, until now; there is no known solution to this problem by the authors. The method that we propose in this chapter is a solution that was tested in the solar furnace high radiative flux of Mexico successfully.
The era of modern solar furnaces had started in the 1950s. Among the first furnaces built were the furnace of Arizona State College in the United States in 1956 [1] and the furnace of the Government Institute for Industrial Research in Japan in 1956 [2].
Several applications of the solar furnace focus on the study of properties such as expansion coefficients, emissivity, thermal conductivity, melting points [2], crystal growth, and purification of materials. Also began developing methods for the measurement of high temperatures in receivers [3] and the flux density of concentrated radiation [4]. The later have evolved calorimetric techniques [5, 6].
The combination of a stationary concentrator and a heliostat has come to be known as solar furnace. The advantage of this combination when compared with a parabolic dish directly tracking the sun is that the focus is stationary. Both concentrator and instrumentation can be placed indoors.
The estimated yearly average insolation in México is 5.5 kWh/m2 per day higher than all other countries. For this reason, in Mexico a high radiative flux solar furnace, HFSF, was built to initiate the development of concentrating solar technologies for the production of solar fuels such as hydrogen. This development is part of a larger project known as “National Laboratory for Solar Concentration Systems and Solar Chemistry” [7].
The initial design considered an intercepted power of approximately 30 kW, with a target peak concentration of approximately 10,000 suns. A global standard deviation of the optical errors less than or equal to 4 mrad was chosen to reach such a goal. The optical design of the whole HFSF consists of a heliostat of 81 m2 (9 m by 9 m), a shutter and a multifaceted concentrator of 409 spherical mirrors. Once the concentrator was built and aligned, it was verified that it generates a thermal power of 30 KW, with peaks of 18,000 suns (about 18,000 kW/m2) and less than or equal to 10 cm in diameter sunspot.
The optical design of the concentrator of the new high radiative flux solar furnace is carried out through ray tracing simulation. In this large HSFS, the concentrator is a mirror with hundreds of facets and these facets must be aligned to achieve the desired energy distribution.
We consider the concentrator of HFSF formed with 409 mirror facets of hexagonal contour with a diameter of 40 cm each of them, each one being a spherical first surface mirror [8]. These facets are grouped in five sets of different focal length, placed on a spherical supporting structure, and with corrected orientations in order that the incident radiation on each facet is reflected to the same focus (see Figure 1 and Table 1) [8].
\n\t\t
\n\t\t
\n\t\t
\n\t\t
\n\t\t
\n\t\t\t
\n\t\t\t\tGroup\n\t\t\t
\n\t\t\t
\n\t\t\t\tNumbers of facets\n\t\t\t
\n\t\t\t
\n\t\t\t\tRadius of curvature (mm)\n\t\t\t
\n\t\t\t
\n\t\t\t\tFocal distance(mm)\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
A
\n\t\t\t
85
\n\t\t\t
7500
\n\t\t\t
3750
\n\t\t
\n\t\t
\n\t\t\t
B
\n\t\t\t
104
\n\t\t\t
8000
\n\t\t\t
4000
\n\t\t
\n\t\t
\n\t\t\t
C
\n\t\t\t
130
\n\t\t\t
8500
\n\t\t\t
4250
\n\t\t
\n\t\t
\n\t\t\t
D
\n\t\t\t
64
\n\t\t\t
9000
\n\t\t\t
4500
\n\t\t
\n\t\t
\n\t\t\t
E
\n\t\t\t
16
\n\t\t\t
9500
\n\t\t\t
4750
\n\t\t
\n\t
Table 1.
Number of facets in each mirror group, corresponding to different radii of curvature.
Figure 1.
Arrangement of facets in the concentrator. Each color corresponds to a single focal length group.
To reduce manufacturing time and cost of the mirrors, they all have spherical surfaces. This means that the spatial and angular position of each mirror is calculated to compensate the aberrations and to reduce the spot size. Thus, the precise alignment of each mirror is essential for the proper operation of concentrator. Preliminary results of this method were reported by Vazquez et al [9].
In the optical design of the concentrator, the position of each mirror was calculated for collimated light. But it was not possible to use the sun as a light source for the alignment process due to the high temperature in the focal region (above 3000 K). The second reason for not using the sun in the alignment is that such a procedure would require the use of the HFSF heliostat to illuminate the concentrator. This would introduce an additional source of uncertainty, due to the imperfections in heliostat facet alignment and due to the sun tracking mechanism accuracy [9]. To decouple these sources of error from the process of concentrator facets alignment, a different procedure had to be proposed.
2. Alignment procedure facets
We proposed the following goals to be met by the alignment method:
Use a light source other than the sun.
The positioning of each facet can be achieved with the required accuracy.
It is an easy method to implement.
It works well in the environment where the concentrator is installed, independent of weather conditions.
It does not require the use of the heliostat of the HFSF.
To fulfill those requirements, our method uses a quasi-point source, generated by a 25 mW HeNe laser (wavelength of 633 nm), together with a 60× microscope objective of 0.65 numerical aperture. This source is placed near the center of curvature of the set of mirrors to be aligned and the divergent light beam illuminates the concentrator. The light is reflected by each one of the mirror group. The reflection from each mirror forms a separate image at an observation screen. In the observation screen, the theoretical image produced by each mirror is calculated previously using the ray trace software. Alignment procedure is to match the actual spots with those calculated theoretically, by rotating the mirror around its supporting point. To this end, mirrors are attached to mechanisms enabling their movement in six degrees of freedom: displacement in three perpendicular directions and rotation around three axes. Each mirror is moved until the image matches the image generated theoretically. Figure 2 shows the optical arrangement used [9].
In Figure 3, a picture of the laser and the microscope objective used for generating the quasi-point light source is shown.
For each set of mirrors with the same radius of curvature, we place the point source generated by the optical arrangement of Figure 3 in a position near the center of curvature, then we need to find the correct position of the observation screen, this position is where the spots are clearly defined and the spots are not overlapping each other.
Figure 2.
Scheme with the optical arrangement for the alignment of the HRFSF facets.
Figure 3.
Optical components for generating the quasi-point light source.
Figure 4.
Simulation of images generated by mirrors with radius of curvature of 800 cm. Top left to bottom right, the images correspond to the following positions: –800 cm,– 802 cm,– 804 cm,– 806 cm, –808 cm,– 810 cm, –812 cm, and –814 cm.
To establish the position of the observation screen, we made a simulation with the software ZEMAX OpticStudio by varying the position of the screen and observing the generated image. In Figure 4, we show simulation images for the mirror set of radius of curvature of 800 cm, the light source is placed at –810 cm and the screen was placed at positions –800 cm, –802 cm, –804 cm, –806 cm, –808 cm, –810, –812 cm, and –814 cm. As shown, the size and position of the spots change with the position of the screen. If the screen is placed in front of the light source, there is a central spot causing noise during alignment and with this the intensity of the spots is reduced; however, if the screen is positioned behind the light source, the central spot disappears.
Figures 5 and 6 show the theoretically calculated alignment screens and mirrors corresponding to two sets of mirrors.
In Figure 7, a picture with the real spots on the alignment screen is shown. In the picture the spots generated by the mirrors with radius of curvature of 8500 mm and 9000 mm can be appreciated.
Figure 5.
Screen and mirrors corresponding to 850 cm curvature radius.
Figure 6.
Screen and mirrors corresponding to 900 cm curvature radius.
Figure 7.
Picture with the real spots on the alignment screen [9].
3. Experimental results
After applying the alignment procedure for each of the concentrator mirrors, different tests were conducted to evaluate the accuracy of alignment. The first test was qualitative; the objective of this test was to observe the images of objects reflected by the concentrator [9]. As you can see, the images display excellent continuity and quality as a result of the alignment of the facets. It is a very good indication of the proper alignment of facets, see Figure 8.
Figure 8.
Images reflected in the hexagonal facets after the alignment process [9].
For the second test, we use the 81 m2 heliostat in conjunction with the concentrator, and the sun as a source of light. A water-cooled Lambertian target was positioned on the focal plane, and pictures of the solar image produced by the HFSF were taken with a charge-coupled device, CCD, camera [9], as can be seen in Figure 9.
Figure 9.
Water-cooled Lambertian target and example of solar image on the target.
To obtain the spot size and the distribution of irradiance we use MATLAB® software. With the results we estimate a spot diameter of 8 cm, and that 90% of the energy falls into a diameter of 6 cm. Comparing these results with ray tracing simulations, we conclude that our alignment procedure meets all requirements and that the standard deviation of the global optical error is of 2.7 ± 0.2 mrad.
Figure 10 shows an example of experimental image, the following steps to process the image and the resulting irradiance profile from the computer code.
The images obtained were compared with the results of the ray-tracing program called Tonalli [10]. The code calculates the irradiance flux on a focal plane using the convolution technique. We assume that the error distribution corresponds to a bidimensional Gaussian distribution characterized by a global standard deviation. The sun’s model was taken from a standard solar radiation cone [10].
Figure 10.
In (a) CCD picture from spot at the receiver at the focal point. (b) Picture translated to the computer for processing. The units of the image frame are mm. The values of the color scale must be multiplied by 100 W. (c) Image centered and processed. The units of the image frame are cm. The color scale is normalized. (d) Irradiance profile from the solar spot. The horizontal axis is cm and the vertical should be multiplied by 100 W.
The images from CCD camera were analyzed, and we compared the profiles of irradiance in two orthogonal directions (horizontal and vertical) against the theoretical profile obtained for the global optical error, which gave the best fit with the experimental curve.
Estimated optical error from different experimental images
Figure 11.
Comparison of experimental and theoretical irradiance profiles for image 1. (a) Vertical profile. (b) Horizontal profile.
Figure 11 shows an example of graphs obtained for the optimal adjustment in the horizontal and vertical image for first image as an example. Table 2 shows the summary of the results obtained with four images captured at different times. As you can see from the values in Table 2, the optical errors are consistent and repeatable; therefore, we can conclude that the global optical error is approximately 2.7 ± 0.2 mrad. It is important to note that this error does not include the tracking error of the heliostat along the solar day.
Figure 11 only presents the adjustment in particular directions from the images, but they cannot show the symmetry of the image compared to those expected theoretically. Figure 12 shows theoretical and experimental comparison of the contours of the irradiance distributions at the receiver for image 1. To construct Figure 12, a particular level of irradiance is set in the experimental and the theoretical image, the curve formed by points with the same irradiance value is a contour. Each color in Figure 12 corresponds to a different level of irradiance in the image. There are two curves with the same color, corresponding to the experimental and theoretical images. The experimental and theoretical distributions were normalized with respect to the peak.
Figure 12 shows a relative good correspondence with experimental results except in the lower contour in which there is a deviation from the circular shape of the image.
Figure 12.
Comparison of experimental and theoretical contours, for image 1. The color scale units are Watts and is normalized.
4. Alignment tolerances of the method
Although the method has only geometric bases and their implementation requires fewer optical elements and sophisticated software is not required to process data as if it require other techniques, the results of the Section 3 shows that the alignment is within specified tolerances. To understand why the proposed method gives such good results, the following analysis was performed.
The optical concentrator design considers that the light source is at infinity and has the angular size of the sun, with these considerations the positions of each of the segments were defined for maximum concentration. However, in the alignment method the light source is near the center of curvature of each group of mirrors. Therefore, it is necessary to know as alignment errors are transformed into errors in the image.
In the mirror set of 850 cm of radius of curvature, we select one of them and will apply rotations around the X-axis in the range of –0.25 degrees to 0.25 degrees, and we calculate changes in image position for each angle. Figure 13 shows a graph of the results, the behavior is almost linear, and follows the following equation:
y=22.737x+0.116,E1
where the variable x represents the rotation angle of the mirror and variable y represents the displacement of the image position.
As the diameter of the spot generated by the mirror is 4 mm, the maximum possible error in the alignment process corresponds to a displacement of 4 mm and this corresponds to a mirror rotation 0.012 degrees.
Figure 13.
Image shift as a function of rotation of the mirror in the process of alignment. The dots (black) are the measured data and the solid line (red) corresponds to the fit of the data.
Figure 14 shows the ideal spot position without rotation and the spot position generated by applying a 0.01 degree rotation, during the alignment process. It is clear that this could be the maximum possible error.
Using the same mirror, but considering the sun as light source, we apply rotations of the mirror in a range of 0.01 degrees to 0.1 degrees, and we calculate the displacement of the image, the results are shown in the graph of Figure 15. As you can see, the behavior is almost linear and follows the following equation:
y=32.757x−0.0006,E2
where the variable x represents the rotation angle of the mirror and variable y represents the displacement of the image position.
Figure 14.
The ideal spot position and spot displaced by a rotation of 0.01 degrees.
Figure 15.
Image shift as a function of rotation of the mirror with the sun as a light source. The dots are the measured data and the solid line corresponds to the fit of the data.
Therefore, a rotation of 0.12 degrees involves a displacement of 0.39 cm. As the sun’s image generated by the mirror is 6 cm, this displacement would generate a maximum error of 13% and the image would have a diameter of 6.78 cm corresponding to the specifications as an 8 cm in diameter is desired. Similar results are obtained with rotations about the Y-axis and mirror displacements along the three axes.
5. Conclusions
We have presented a novel method for aligning facets of segmented mirrors for applications of concentrating solar power. This is a method that requires only three optical components: it is cheap and easy to implement and can be used during day and night because the light source is a laser.
We showed that the proposed method allows the alignment of the segments and obtained the specifications with relative simplicity. We obtained the maximum errors that can occur in the alignment process and we find that the method generates errors tolerable without complicated computer programs.
After the alignment process, we used different tests to verify the actual operation of the concentrator and all tests showed a performance that exceeds expectations, demonstrating the viability of the proposed method.
Finally, if CCD cameras and image processing software are used, this method could be used to align the segmented mirror facets as used in large telescopes.
\n',keywords:"Optical alignment, radiative flux, segmented concentrator, solar concentration, solar furnace",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/50271.pdf",chapterXML:"https://mts.intechopen.com/source/xml/50271.xml",downloadPdfUrl:"/chapter/pdf-download/50271",previewPdfUrl:"/chapter/pdf-preview/50271",totalDownloads:866,totalViews:108,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"October 17th 2014",dateReviewed:"April 5th 2016",datePrePublished:null,datePublished:"May 11th 2016",readingETA:"0",abstract:"The high radiative flux solar furnaces already in operation, and the furnaces to be built in the future, have large concentrators consisting of multiple facets. It is, therefore, necessary to have an alignment procedure of the facets that guarantee the accuracy of alignment, allowing an alignment in a short time. This chapter presents a novel method for aligning the facets of a large concentrator, which uses a single optical system to achieve the required precision and the desired energy distribution in the focal plane. Simulation and experimental results obtained with our procedure show that the proposed alignment satisfactorily meets the specifications.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/50271",risUrl:"/chapter/ris/50271",book:{slug:"renewable-energy-utilisation-and-system-integration"},signatures:"Sergio Vázquez y Montiel, Fermín Granados Agustín and Lizbeth\nCastañeda Escobar",authors:[{id:"165219",title:"Dr.",name:"Lizbeth",middleName:null,surname:"Castañeda Escobar",fullName:"Lizbeth Castañeda Escobar",slug:"lizbeth-castaneda-escobar",email:"janali20000@yahoo.com.mx",position:"Docente - Investigador",institution:null},{id:"165220",title:"Dr.",name:"Fermin",middleName:null,surname:"Granados Agustin",fullName:"Fermin Granados Agustin",slug:"fermin-granados-agustin",email:"fermin@inaoep.mx",position:null,institution:null},{id:"173771",title:"Dr.",name:"Sergio",middleName:null,surname:"Vazquez Y Montiel",fullName:"Sergio Vazquez Y Montiel",slug:"sergio-vazquez-y-montiel",email:"gatoangora2000@yahoo.com.mx",position:null,institution:{name:"Universidad Politécnica de Tulancingo",institutionURL:null,country:{name:"Mexico"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Alignment procedure facets",level:"1"},{id:"sec_3",title:"3. Experimental results",level:"1"},{id:"sec_4",title:"4. Alignment tolerances of the method",level:"1"},{id:"sec_5",title:"5. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Kevane, C.J., 1957. Construction and operation of the Arizona State College solar furnace. Solar Energy 1, 99–101.'},{id:"B2",body:'Hisada, T., Mii, H., Noguchi, C., Noguchi, T., Hukuo, N., Mizuno, M., 1957. Concentration of the solar radiation in a solar furnace. Solar Energy 1, 14–18.'},{id:"B3",body:'Brenden, B.B., Newkirk, H.W., S.H., 1958. A study of temperature measurement in a solar furnace. Solar Energy 2, 13–17.'},{id:"B4",body:'Loh, E., Hiester, N.K., Tietz, T.E., 1957. Heat flux measurements at the sun image of the California institute of technology lens-type solar furnace. Solar Energy 1, 23–26.'},{id:"B5",body:'Pérez-Rábago, C.A., Marcos, M.J., Romero, M., Estrada, C.A., 2006. Heat transfer in a conical cavity calorimeter for measuring thermal power of a point focus concentrator. Solar Energy 80, 1434–1442.'},{id:"B6",body:'Estrada, C.A., Jaramillo, O.A., Acosta, R., Arancibia-Bulnes, C.A., 2007. Heat transfer analysis in a calorimeter for concentrated solar radiation measurements. Solar Energy 81, 1306–1313.'},{id:"B7",body:'http://lacyqs.cie.unam.mx/es/index.php/instalaciones/horno-solar-de-alto-flujo-radiativo.'},{id:"B8",body:'Rivero-Rosas, D., Herrera-Vázquez, J., Pérez-Rabago, C. A., Arancibia-Bulnes, C.A., Vázquez-Montiel, S., Sanchez-González, M., Granados-Agustín, F., Jaramillo, O.A., Estrada, C.A. 2010. Optical design of a high radiative flux solar furnace for Mexico. Solar Energy 84, 792–800.'},{id:"B9",body:'Vázquez-Montiel, S., Pérez-Rabago C.A., Pérez-Enciso, R., Rivero-Rosas, D., Granados-Agustín, F., Arancibia-Bulnes, C.A., Estrada, C.A. 2011. Method for facets alignment for the high flux solar furnace at CIE-UNAM in Temixco, Mexico, First Stage. In: SolarPaces September 2011; September 2011; Granada Spain. 2011.'},{id:"B10",body:'Rivero-Rosas D., Pérez-Rabago C. A., Arancibia-Bulnes C. A., Pérez-Enciso R., Estrada C. A.. Concentration Images Profiles of the High-Flux Solar Furnace of CIE-UNAM in Temixco, Mexico, First Stage. In: SolarPaces September 2011 symposium; Granada Spain. 2011.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Sergio Vázquez y Montiel",address:"gatoangora2000@yahoo.com.mx",affiliation:'
'}],corrections:null},book:{id:"4623",title:"Renewable Energy",subtitle:"Utilisation and System Integration",fullTitle:"Renewable Energy - Utilisation and System Integration",slug:"renewable-energy-utilisation-and-system-integration",publishedDate:"May 11th 2016",bookSignature:"Wenping Cao and Yihua Hu",coverURL:"https://cdn.intechopen.com/books/images_new/4623.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"174154",title:"Prof.",name:"Wenping",middleName:null,surname:"Cao",slug:"wenping-cao",fullName:"Wenping Cao"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"50334",title:"Wind Power Development and Landscape – Social Participation, Opportunities and Challenges",slug:"wind-power-development-and-landscape-social-participation-opportunities-and-challenges",totalDownloads:1009,totalCrossrefCites:1,signatures:"Karin Hammarlund, Marina Frolova and Anna Brånhult",authors:[{id:"174792",title:"Ph.D. Student",name:"Karin",middleName:null,surname:"Hammarlund Kramer",fullName:"Karin Hammarlund Kramer",slug:"karin-hammarlund-kramer"},{id:"174849",title:"Dr.",name:"Marina",middleName:null,surname:"Frolova",fullName:"Marina Frolova",slug:"marina-frolova"},{id:"174850",title:"Dr.",name:"Anna",middleName:null,surname:"Branhult",fullName:"Anna Branhult",slug:"anna-branhult"}]},{id:"50004",title:"Study of Novel Power Electronic Converters for Small Scale Wind Energy Conversion Systems",slug:"study-of-novel-power-electronic-converters-for-small-scale-wind-energy-conversion-systems",totalDownloads:1615,totalCrossrefCites:1,signatures:"Mostafa Abarzadeh, Hossein Madadi Kojabadi and Liuchen Chang",authors:[{id:"19466",title:"Dr.",name:"Hossein Madadi",middleName:null,surname:"Kojabadi",fullName:"Hossein Madadi Kojabadi",slug:"hossein-madadi-kojabadi"},{id:"22279",title:"Prof.",name:"Liuchen",middleName:null,surname:"Chang",fullName:"Liuchen Chang",slug:"liuchen-chang"},{id:"22578",title:"Ph.D.",name:"Mostafa",middleName:null,surname:"Abarzadeh",fullName:"Mostafa Abarzadeh",slug:"mostafa-abarzadeh"}]},{id:"50017",title:"Modelling and Control of Grid-connected Solar Photovoltaic Systems",slug:"modelling-and-control-of-grid-connected-solar-photovoltaic-systems",totalDownloads:3490,totalCrossrefCites:2,signatures:"Marcelo Gustavo Molina",authors:[{id:"7483",title:"Dr.",name:"Marcelo",middleName:"Gustavo",surname:"Molina",fullName:"Marcelo Molina",slug:"marcelo-molina"}]},{id:"50271",title:"Method for Aligning Facets in Large Concentrators That Have Segmented Mirrors for Solar Thermal Applications",slug:"method-for-aligning-facets-in-large-concentrators-that-have-segmented-mirrors-for-solar-thermal-appl",totalDownloads:866,totalCrossrefCites:0,signatures:"Sergio Vázquez y Montiel, Fermín Granados Agustín and Lizbeth\nCastañeda Escobar",authors:[{id:"165219",title:"Dr.",name:"Lizbeth",middleName:null,surname:"Castañeda Escobar",fullName:"Lizbeth Castañeda Escobar",slug:"lizbeth-castaneda-escobar"},{id:"165220",title:"Dr.",name:"Fermin",middleName:null,surname:"Granados Agustin",fullName:"Fermin Granados Agustin",slug:"fermin-granados-agustin"},{id:"173771",title:"Dr.",name:"Sergio",middleName:null,surname:"Vazquez Y Montiel",fullName:"Sergio Vazquez Y Montiel",slug:"sergio-vazquez-y-montiel"}]},{id:"49793",title:"Theoretical Analysis and Implementation of Photovoltaic Fault Diagnosis",slug:"theoretical-analysis-and-implementation-of-photovoltaic-fault-diagnosis",totalDownloads:1650,totalCrossrefCites:0,signatures:"Yihua Hu and Wenping Cao",authors:[{id:"174154",title:"Prof.",name:"Wenping",middleName:null,surname:"Cao",fullName:"Wenping Cao",slug:"wenping-cao"},{id:"174197",title:"Dr.",name:"Yihua",middleName:null,surname:"Hu",fullName:"Yihua Hu",slug:"yihua-hu"}]},{id:"50022",title:"Genset Optimization for Biomass Syngas Operation",slug:"genset-optimization-for-biomass-syngas-operation",totalDownloads:1052,totalCrossrefCites:0,signatures:"Horizon Walker Gitano-Briggs and Koay Loke Kean",authors:[{id:"9153",title:"Professor",name:"Horizon",middleName:null,surname:"Gitano",fullName:"Horizon Gitano",slug:"horizon-gitano"}]},{id:"49376",title:"Radio Frequency Energy Harvesting - Sources and Techniques",slug:"radio-frequency-energy-harvesting-sources-and-techniques",totalDownloads:2988,totalCrossrefCites:2,signatures:"M. 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\n
1. Introduction
\n
ECMO is a cardiopulmonary bypass circuit to support patients in severe cardiac and/or respiratory failure. It is an advanced life support therapy for patients at high risk of dying from their respiratory or cardiac disease. Extracorporeal life support, while life-saving in many instances, can pose serious risks and is associated with several neurologic complications. In this chapter, we will review some of the more common neurologic adverse events seen in patients on extracorporeal membrane oxygenation (ECMO), as well as review some of the neuromonitoring modalities available for early recognition of neurologic morbidity. Based on a recent report from the Extracorporeal Life Support Organization (ELSO), the current survival to discharge after ECMO ranges from 28% for adult ECPR patients to 73% for neonatal respiratory ECMO [1]. As survival after ECMO improves with advances in technologies and patient care, there is ever increasing emphasis placed on reducing morbidity experience by survivors.
\n
Majority of the literature on neurologic injuries come from analyses of the ELSO Registry and single center experiences. The ELSO registry currently collects limited information on presence of seizures (clinical or EEG confirmed), central nervous system (CNS) hemorrhages (intraventricular or parenchymal) as determined by ultrasound (US), Computed tomography (CT) or Magnetic Resonance Imaging (MRI); diffuse ischemia or CNS infarction; need for neurosurgical intervention, and brain death on ECMO [2]. In spite of advances in ECMO circuitry, anticoagulation, and clinical management, the rate of occurrence of neurologic injury has not changed in recent times [3].
\n
ECMO was first trialed on a neonate and the success with that patient gradually spread its popularity among the neonatal and eventually pediatric patient populations [4]. The H1N1 influenza pandemic in 2009 is primarily credited for the adoption of ECMO in many adult centers and its use in adults has grown exponentially since. While most of the early data came from neonates, more recent studies on neurologic injuries in adults are informing care of the ECMO patient. As ECMO is becoming more ubiquitously used, this chapter discusses neurologic complications noted across the age spectrum. However risk factors, types of complications and management often vary by patient population, from neonates to adults. Effort has been made to specify if certain descriptions are only applicable to a certain age group, and information may not be relevant for all ages.
\n
\n
\n
2. Epidemiology
\n
Quantification of the burden of neurologic complications has been difficult due to voluntary and retrospective nature of reporting, variability and lack of consensus on neuromonitoring and heterogeneous populations.
\n
An ELSO registry analysis of neonates on ECMO from 2005 to 2010 showed that 20% had some neurologic complications [5]. Non hemorrhagic complications such as cerebral infarction, brain death and seizures were far less common than intracranial hemorrhage. A look at the subgroup of neonates with congenital heart disease failed to show an association between type of cardiac lesion and CNS injury [6]. The pediatric patient population is more heterogeneous than the neonatal group. A study by Hervey-Jumper et al. looked at children on ECMO from 1990 to 2009 and found that intracranial hemorrhage occurred in 7.4%, cerebral infarction in 5.7% and clinical seizures in 8.4% of all patients [7].
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A systematic review of studies from 1990 to 2017 found that intracranial hemorrhage was the most common type of neurologic injury in adults, followed by acute ischemic stroke [8]. Incidence reported varies widely with a range of 2–21% for intracranial hemorrhage and 1–33% for acute ischemic stroke, with a median proportion of 5% of patients experiencing hemorrhages and another 5% with stroke. Seizures had the lowest incidence of about 2%. The study did find that neurologic injury was overall more commonly reported in VA ECMO than VV ECMO. The occurrence of neurologic injury significantly increases the in-hospital mortality with median mortality of 96% for hemorrhages, 84% for ischemic strokes 84, and 40% for seizures.
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An analysis of the ELSO registry of almost 5000 adult patients on VV ECMO found an overall incidence of neurologic complications in 7.1% of patients [3]. Injuries included hemorrhage in 42.5%, brain death in 23.5%, stroke in 19.9%, and seizures in 14.1%. This study also found that in-hospital mortality was much higher (75.8% versus 37.8%) for patients with neurological injuries. An analysis of the ELSO registry for adult patients on VA ECMO, by the same group, found similar findings in the venoarterial cohort [9]. A decade’s review of the Nationwide Inpatient Sample, that included over 23,000 patients, found that adult patients with acute ischemic stroke and intracranial hemorrhage on ECMO had higher rates of discharge to a long term facility and longer length of stay when compared to patients without neurologic injury [10].
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A recent international randomized controlled trial, comparing ECMO to conventional mechanical ventilation for severe ARDS, showed a very low rate of ischemic stroke in the ECMO population [11]. Out of 124 patients randomized to receive ECMO, none had ischemic strokes compared to 5% of the patients initially randomized to conventional therapy, although there was the option of crossover to ECMO for refractory ARDS. It is unclear if this is due to a restrictive inclusion criteria of less than 7 days of mechanical ventilation combined with less severe hypoxemia and acidosis from early ECMO cannulation. However, the rates of hemorrhagic stroke were similar in the two groups.
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3. Cerebral blood flow and oxygenation on ECMO
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Cerebral autoregulation is the term used to describe the ability of cerebral arterioles to maintain steady cerebral blood flow across a wide range of cerebral blood pressure. This is achieved through dilation and constriction of cerebral blood vessels in response to fluctuations in mean arterial pressure. This is a complex process mediated through neurogenic regulation, involving sympathetic and cholinergic mechanisms, myogenic regulation involving smooth muscle tone, and metabolic regulation influenced by local concentration of metabolites [12]. Cerebral autoregulation can become disrupted focally or globally in pathological conditions leading to cerebral ischemia, hemorrhage or edema. These conditions associated with ECMO include vasospasm, severe acidosis, low cardiac output states, hypotension and hypertension, reperfusion injury and absence of pulsatile flow in VA ECMO. Hypercapnia is associated with cerebral vasodilation while hypocapnia causes cerebral vasoconstriction. A rapid decline in paCO2 after initiation of VV ECMO has been associated with central nervous system (CNS) injury [13].
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A study by O’Brien using transcranial Doppler (TCD) showed that in patients that did not have neurologic injury, cerebral blood flow velocities on ECMO were much lower than predicted and returned closer to baseline after decannulation. However in patients that did have cerebral hemorrhage on ECMO, supranormal flows were noted in the days preceding the event [14]. A more recent multicenter study by the same author confirmed lower flow velocities on ECMO but did not show a difference in flow velocities in children with cerebral ischemia compared to those without. No patients in this study had cerebral hemorrhage [15].
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Cannulation of cervical vessels relies on a competent Circle of Willis to allow for cerebral perfusion of both hemispheres. Occlusion of vessels can cause ipsilateral venous stasis and this venous congestion can lead to venous hypertension and decreased cerebral perfusion. Changes in cerebral blood flow rate and volume can contribute to altered cerebral oxygenation as demonstrated by cerebral oximetry [12]. Impairments in cerebral autoregulation, based on wavelet transform coherence, are associated with findings on neuroimaging and neurologic outcomes [16].
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4. Risk factors for neurologic injury
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These can be divided into factors prior to initiation of ECMO and factors inherent to ECMO therapy [17]. There are also risk factors for neurological injury after ECMO such as ligation or anastomosis of cervical blood vessels. Because CNS injury is often multifactorial, and lesions are often detected retrospectively on imaging after ECMO, the exact timing of injury can be difficult to determine.
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4.1 Pre-ECMO
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The underlying physiologic conditions that necessitate ECMO cannulation, such as labile hemodynamics, severe hypoxemia and acidosis, refractory hypotension, etc., leave the patient vulnerable to neurologic insults. These can alter the mechanisms responsible for maintaining cerebral autoregulation and make the vasculature more susceptible to alterations in systemic blood pressure. Prematurity is associated with an increase in intraventricular and intracranial hemorrhage and can be a contraindication for ECMO cannulation. A prior history of neurologic injury puts one at further risk of adverse cerebrovascular events.
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4.2 ECMO-related
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Animal models have demonstrated the effects of carotid artery and jugular vein cannulation and ligation on cerebral blood flow [18, 19]. Adults with atherosclerosis may develop emboli during arterial cannulation. ECMO cannulae and circuits expose a patient to prothrombotic surfaces and the foreign materials often incite an inflammatory response. Platelets are consumed in the circuit components leading to thrombocytopenia, putting a patient at increased risk of bleeding. Maintaining patency of the circuits requires the use of anticoagulation, which needs to be closely monitored to avoid complications such as bleeding, or thrombosis and embolism. Reperfusion injury is another risk factor after adequate oxygenation and blood flow delivery have been ensured following a period of severe hypoxemia. VA ECMO cannulation for cardiogenic shock is also associated with non-pulsatile flow which is not physiologic. Neurologic exams are often limited for patients on ECMO, confounded by sedation and limited mobility, which can lead to delayed diagnosis and recognition. A precannulation lactate greater than 10 mmol/L was found to be associated with increased odds for ischemic strokes in adults [8]. A history of pre ECMO cardiac arrest, need for renal replacement therapy and elevated bilirubin levels were associated with increased odds of neurologic injury [3]. A study of neonates found that birth weight less than 3 kg, gestational age less than 34 weeks, a history of prior ECMO cannulation and severe acidosis were risk factors for neurologic injury [5].
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4.3 Veno-arterial (VA) versus veno-venous (VV)
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VA ECMO carries with it the increased risk of embolization as blood is directly pumped into the arterial system, unlike in VV ECMO where the oxygenated blood is returned to the venous system where the lungs can filter thrombi. However, a study by Zahraa found that there was no difference in central nervous system complications between pediatric respiratory failure patients supported on VA versus VV ECMO [20]. Differential hypoxia, where the arterial oxygen tension is lower in the upper half of the body than in the lower half, is a phenomenon occasionally seen in patients supported on peripheral VA ECMO that causes cerebral ischemia [21]. For pediatric patients on VA ECMO, the incidence of stroke was much lower for transthoracic or central cannulation compared to peripheral cannulation [22]. VA ECMO is also unique in that poor cardiac function results in absence of pulsatile flow, with potential implications for cerebral autoregulation and vascular reactivity.
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4.4 Carotid repair
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The right carotid artery and internal jugular vein are commonly sacrificed during ECMO cannulation. Taylor et al. showed the feasibility of vascular repair with antegrade flow, without increasing the incidence of embolic phenomenon [23]. A larger, more recent study of neonates on VA ECMO, showed over 84% patency of repaired vessels. While 43% of all patients had a severe brain lesion after ECMO, there was no difference in early neurologic outcomes between the groups that underwent carotid repair versus carotid ligation [24].
ECPR is the rapid deployment of VA ECMO for a patient in cardiac arrest, with ongoing CPR, prior to the return of spontaneous circulation. A systematic review of adult ECPR data showed that a shockable rhythm and duration of CPR were significantly associated with a favorable neurologic outcome [25]. A study of the ELSO registry looking at pediatric patients that received ECPR found an overall incidence of acute neurologic injury in 22% of patients [26]. The in-hospital mortality was high for these patients at 89%. An analysis of neonatal and pediatric ECPR events from a multicenter, national registry showed that while only 43.7% of patients survived to hospital discharge, the majority of survivors had favorable neurologic outcomes [27]. Another study comparing survivors of ECPR and those with return of circulation after conventional CPR found comparable neurologic outcomes between the two groups, with total duration of cardiac arrest being the only predictor of survival [28].
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5. Types of neurological complications and their management
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There is a wide variety of neurological injuries that are noted after ECMO including embolic strokes, hypoxic-ischemic encephalopathy, cerebral infarction, intracranial and subarachnoid hemorrhages, seizures, cerebral edema and even brain death. Other complications, such as critical illness myopathy, neuropathies, delirium, hearing loss, vocal cord paralysis etc. are related to prolonged hospitalization and ICU stays, need for prolonged mechanical ventilation or tracheostomy, prolonged exposure to sedation, and limited mobility that often accompany ECMO runs. In this section of the chapter, we will look at some of the more common neurologic complications experienced by patients treated with ECMO.
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5.1 Hemorrhagic complications
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Intracranial hemorrhage (ICH) is one of the most common adverse neurologic events on ECMO, carrying a high mortality rate. It can occur as intraparenchymal, intraventricular or subarachnoid hemorrhages. Gestational age at time of ECMO cannulation, severe acidosis needing correction, sepsis, need for epinephrine, therapeutic hypothermia and need for cardiopulmonary resuscitation (CPR) have been associated with intracranial hemorrhage in neonates [29, 30, 31]. A longer duration of ECMO, higher activated clotting times (ACTs), presence of bleeding at other sites, pre-admission antithrombotic therapy, and low platelet counts were associated with hemorrhage in adults [32, 33]. Rapid PaCO2 decrease/correction of hypercapnia and renal failure at ICU admission were associated with increased intracranial hemorrhage in one adult study [13]. In order to detect intracranial hemorrhage while on ECMO, cranial ultrasounds are used in neonates while CT imaging is used in children and adults. In one observational study, 42% of the cohort underwent withdrawal of life sustaining therapy, 18% did not require any intervention and 40% were treated. Treatments included hemostatic interventions, ICP management and surgical interventions with 14% of the cohort uneventfully decannulated [34]. Patients that have clinically significant bleeds, with progression of brain injury and little to no improvement on ECMO ultimately end up with withdrawal of life sustaining therapies due to poor prognosis and risk of progression of the bleed. Patients with very small or clinically insignificant hemorrhages can continue their ECMO courses with close neurological monitoring, decannulation at the earliest feasible time and possibly lowering of anticoagulation parameters while balancing thrombotic risks. Platelets and anti-fibrinolytics may need to be administered. Occasionally ECMO circuits can be trialed without any anticoagulation keeping a close eye on the circuit for clots and fibrin deposition. Life-threatening hemorrhage can be severe enough to warrant a craniotomy [7, 35]. Hematoma evacuation on ECMO is high risk and carries a high mortality although there are reports of patients who survived [34]. There is heterogeneity in practice with drugs used for anticoagulation (heparin versus bivalirudin), tests to assess for anticoagulation (TEG, ROTEM, activated clotting time, PT/PTT, heparin assays) and therapeutic targets for titration. Further research is needed to help develop guidelines and consensus on best practice to minimize and treat bleeding complications on ECMO.
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5.2 Ischemic complications
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It occurs in about 5–6% of children and adults [8, 36], and is best identified on MR imaging. Due to multifactorial etiology for ischemic strokes such as hypotension, large vessel occlusion, thromboembolism, septic embolism, etc. it is difficult to characterize lesions anatomically or to prognosticate based on imaging. Timing of injury is also difficult to ascertain. There are conflicting reports on laterality of lesions [37] but seem to occur in the middle cerebral artery vascular territory. A single center pediatric study found that majority of strokes were bilateral, a few were unilateral right sided lesions and no patients had unilateral left sided strokes; majority of the lesions were in the anterior cerebral circulation distribution [22]. Ischemic lesions are associated with electrographic seizures and decreased survival [38]. Asymmetry in regional cerebral saturation or on continuous EEG monitoring might be suggestive of focal ischemia. Once detected, hemodynamics should be optimized through adequate pump flows on VA ECMO, vasoactives can be used if needed, and further neurologic injury should be minimized by avoiding hyperoxia and treating seizures.
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5.3 Seizures
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Although less common than intracranial hemorrhage and stroke, seizures can be difficult to recognize if they are nonconvulsive or subclinical. A study of children and neonates undergoing ECMO revealed that 18% of patients had electrographic seizures, with 61% of those patients having electrographic status epilepticus and 83% having exclusively electrographic seizures [39]. Another recent study of neonatal and pediatric patients found electrographic seizures in 23% of their patients, especially within the first 24 hours of ECMO [40]. Patients with seizures had decreased survival to discharge (44% versus 74%). Older studies that reported lower incidence of seizures may have missed patients if only clinical seizures were reported, as the routine use of continuous EEG monitoring for patients is not yet a widespread practice, although recent recommendations advocate for its use in ECMO. Given that patients on ECMO are a high risk population, seizures should be treated with the help of neurologists.
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5.4 Sensorineural hearing loss
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Sensorineural hearing loss has been reported in neonatal ECMO graduates with a frequency of 3–21% [41]. Diagnosis of congenital diaphragmatic hernia, duration of ECMO, and aminoglycoside antibiotic use were associated with hearing loss [42]. A follow-up study found that even children diagnosed with hearing loss after ECMO can go on to have normal language development [43].
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5.5 Myopathy
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Prolonged immobilization, sedation and paralytics, hemodynamic instability, all contribute to neuromuscular weakness in ECMO patients. Studies have proved that active physiotherapy, with early mobilization, is feasible and safe in ECMO patients when performed with an experienced, multidisciplinary team [44, 45]. It may also shorten hospital duration and improve functional outcomes for patients [46].
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5.6 Delirium
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A small study of pediatric cardiac ECMO patients diagnosed delirium in all their patients, in 21% of coma-free ECMO days [47]. Use of validated delirium screening tools can aid in early recognition and management of delirium. The move to liberate ICU patients should include patients on ECMO whenever feasible, with an emphasis on delirium prevention.
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5.7 Brain death on ECMO
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Progressive cerebral edema and large hemorrhages, whether from insults prior to cannulation or secondary to complications from ECMO, can ultimately lead to brain death in patients supported on ECMO. Diagnosis of brain death can be challenging on ECMO, but is important to determine as it is medically and ethically unreasonable to continue ECMO for a patient who has met criteria for brain death.
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5.7.1 Determination of brain death
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The American Academy of Neurology issued guidelines on the determination of brain death in adults, most recently revised in 2010 [48]. Similarly the Society of Critical care Medicine, American Academy of pediatrics and the Child Neurology Society jointly published guidelines for the determination of brain death in children and infants in 2011 [49]. The following general criteria apply to all patients undergoing brain death testing, although the specifics may vary by institutional policies. Patients should be relatively normothermic, and electrolytes and glucose should be within acceptable ranges. Any medications that may interfere with respiratory drive and neurologic function must be discontinued, with drug levels obtained if needed. The patient must demonstrate absence of all motor function and lack of responsiveness to stimuli, except spinal reflexes. Cranial nerve testing should reveal absence of pupillary reflexes, corneal reflexes, oculovestibular and oculocephalic reflexes, absence of cough and gag reflexes and absent brain stem reflexes.
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The apnea test is an important component of brain death testing without which ancillary studies such as cerebral angiography, nuclear scanning for cerebral blood flow, electroencephalography, transcranial Doppler etc. are required to demonstrate absence of blood flow to the brain. The apnea test is performed to demonstrate absence of spontaneous respiratory drive in the presence of rising paCO2 levels in the blood. The patient is pre-oxygenated with 100% FiO2 and ventilated to achieve normocarbia, if possible. A baseline blood gas analysis is obtained. The patient is then disconnected from the ventilator and oxygenated via a T-piece or flow-inflating anesthesia bag. The patient is closely observed for signs of spontaneous respiration or chest rise. Serial blood gases are obtained at every few minute intervals. A rise in paCO2 > 60 mmHg and > 20 mmHg above baseline is conclusive of absence of respiratory drive. If the patient were to become hypoxic or hemodynamically unstable the apnea test should be discontinued and ancillary studies obtained.
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5.7.2 Apnea testing on ECMO
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While clinical criteria of absence of cortical function and brain stem reflexes can be assessed in the usual manner, apnea testing can be difficult on ECMO. A proposed method for apnea testing is oxygenating the patient by use of continuous positive airway pressure (CPAP) or T-piece or by placing the patient on a self-inflating anesthesia bag with a PEEP valve, while watching for spontaneous respirations. The oxygenator on the circuit can then be capped. Alternatively, the sweep gas is decreased to 0.5 –1 L/minute and oxygen increased to 100% FiO2 through the circuit, without any changes to extracorporeal blood flow [50, 51]. In-line gas monitoring on the ECMO circuit can be used to trend venous paCO2, but serial arterial blood gas analysis should be used to confirm the lack of ventilation secondary to central apnea. For patients on VA ECMO, hemodynamics should be maintained through circuit flows and use of vasoactive medications as needed. Patients found to be brain dead on ECMO can be considered as candidates for organ donation.
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6. Neurological monitoring
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There are currently no consensus guidelines for neuromonitoring on ECMO, with variations in practice at different institutions. Neuromonitoring may include assessment of brain structure or morphology via imaging, assessment of brain function via EEG or SSEPs, assessment of cerebral perfusion via cerebral oximetry or transcranial doppler, and assessment for neurological injury via biomarkers. Bembea and colleagues performed a systematic review of the literature; 39 observational and case-control studies met inclusion criteria, with most of the literature coming from neonatal studies [52]. There was very little data in pediatric and adult cohorts, and the study found limited data on the use and effectiveness of monitoring technologies. A recent review by Lin et al. discusses neuromonitoring in the neonatal ECMO patient [53].
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6.1 Exam
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Neuromonitoring of the ECMO patient should begin with daily neurologic assessments that are documented in the patients chart. These are limited by reliability when performed by multiple providers from different disciplines, however are useful for obtaining a daily baseline that can be suggestive of injury when a change is noted. This would also require daily sedation holidays for accurate assessments as well as using the least amount of sedation to keep the patient safe and comfortable. Use of neuromuscular blockade should be reserved for extremely ill patients and those whose movement limits ECMO flows. A change in neurologic exam is often the trigger for seeking additional information such as through neuroimaging.
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6.2 Neuroimaging
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Cranial or head ultrasound (HUS) is a mode of imaging limited to neonates and infants with open fontanelles. Ultrasound uses high frequency sound waves transmitted via a probe that are reflected back based on the tissue’s composition as well as distance from the probe. Changes in tissue density from hemorrhage or ischemia will reflect back sound waves differently from surrounding tissue. Cranial ultrasounds are portable, easy to use, relatively inexpensive, and do not carry radiation risks. Most neonatal ECMO programs will obtain a HUS prior to ECMO cannulation as well as daily HUS for the 1st few days on ECMO. While it is best for detecting hemorrhages, ischemic changes are harder to interpret on HUS [54]. HUS can also give information on changes in ventricular size that would be seen in hydrocephalus. It is not as sensitive as other imaging techniques and a study showed that MRI was significantly more sensitive for detection of CNS lesions than HUS alone [55, 56]. The quality of images depends on the skill level of the ultrasound technician and interpretation of acquired images can be subjective and variable. HUS findings have not consistently correlated with neurodevelopmental outcomes and should not be used for predicting outcomes in neonatal ECMO survivors [37, 56].
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Computed tomography (CT) is a diagnostic imaging modality that utilizes X-Rays directed at the patient that are picked up by a detector and sent to a computer to create thin 2D image slices, at different tissue depths. Multiple images can then be stacked to create a 3D picture. It is the most frequently used imaging modality for diagnosis of acute intracranial injury for patients on ECMO. A CT scan can be quickly obtained and has better sensitivity and specificity for detecting intracranial hemorrhage that might lead to clinical changes in management [53]. A disadvantage is exposure to radiation and its associated risks. Transporting a patient on ECMO to a CT scanner in the radiology department can be challenging in the absence of a portable scanner that can be brought to bedside. ELSO currently recommends a CT scan prior to hospital discharge for patients less than 4 years of age and if there is an abnormal neurologic exam for patients older than 4 years of age as part of post-ECMO follow up [57].
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Magnetic Resonance Imaging (MRI) is a non-invasive technology that creates 3D anatomic images without exposing the patient to radiation. A strong magnetic field is used to force protons in the body into alignment. Then a brief radiofrequency pulse stimulates protons causing a change in alignment. The scanner can detect electromagnetic energy transmitted as the protons realign. It is reserved for patients after decannulation from ECMO, due to MRI incompatible materials in the cannulae and circuits. MRI is the most sensitive and specific imaging technique available. However it takes much longer time to obtain the study compared to a CT and is more expensive. While diffusion-restriction can be seen up to 10 days after acute ischemic injury, the optimal timing for obtaining an MRI after ECMO remains unclear [53].
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6.3 Electroencephalography (EEG)
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While neuroimaging provides information on the structure of the brain, EEG provides real-time information on the electrical activity of the brain. Information is obtained via electrodes placed on the scalp, connected to a monitor, with very little burden to the patient that would include scalp abrasions. Continuous EEG (cEEG) monitoring requires technicians to set up the electrodes as well as neurologists to read the EEGs, which can be time consuming. Amplitude-integrated EEG (aEEG) compresses the raw EEG data from 1 to 2 leads, is easier to set up and interpret, but due to lower sensitivity, can be used as a screening tool or in resource limited settings [53]. Ischemic and hemorrhagic injuries can predispose a patient to seizures that require prompt treatment. Continuous EEG monitoring is important for early identification and treatment of subclinical seizures or electrical status epilepticus that may not be otherwise detected, although studies are needed to show its benefit in improving long term outcomes. EEG monitoring is especially useful in paralyzed patients in whom a neurological exam cannot be elicited. EEG can be used to detect early cerebral ischemia through loss of fast alpha and beta frequencies to slowing and even suppression of all electrical activity as might be seen in an infarct. In 2011, the American Clinical Neurophysiology Society deemed ECMO as a high risk clinical scenario in neonates that would warrant long term EEG monitoring due to cardiac or pulmonary risks for acute brain injury and clinical encephalopathy [58]. This recommendation is supported by ELSO in their guidelines for management of neonatal respiratory failure [59]. In their 2015 consensus statement on continuous EEG in critically ill adults and children, the American Clinical Neurophysiology Society recommended continuous EEG monitoring for patients treated with pharmacologic paralysis, including patients on ECMO [60].
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6.4 Transcranial doppler ultrasound (TCD)
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This is a non-invasive, portable test that is based on the Doppler effect. A Doppler probe is used to emit high frequency sound waves through the cranium that are reflected back by moving red blood cells in the blood vessels. The difference in frequencies of emitted and reflected waves is proportional to the cerebral blood flow. Studies have found that TCD velocities (TCDV) are much lower for pediatric patients on ECMO when compared to normative values for healthy and critically-ill children [15, 61]. While there was no significant association between global TCDV (systolic flow velocity, diastolic flow velocity, mean flow velocity) and neurologic injury, increased pulsatility index and regional increases in velocities or asymmetries might be predictive of neurologic injury.
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6.5 Cerebral near infra-red spectroscopy (NIRS)
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NIRS monitoring is a non-invasive technology that uses near-infrared wavelength of light that penetrates brain tissue via a scalp electrode. It provides a continuous measurement of regional tissue oxygen saturation (rSO2), which is a marker of the balance between oxygen delivery and demand in the tissues. When the probe is placed on the forehead, it measures cerebral oximetry. An analysis of adult patients on VA ECMO showed that cerebral desaturation was common and mortality higher for patients with cerebral desaturation compared to those without [21]. A sudden decrease in cerebral saturation can be associated with an acute neurological event, prompting further investigation. It can also serve as an early predictor of inadequate oxygenation and cardiac output especially peri-cannulation [62]. It can influence management by prompting a need for increased flows in VA ECMO or alternate cannulation strategies if there is differential hypoxia. A very high rSO2 could also be suggestive of very poor oxygen extraction and poor neurologic outcomes.
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6.6 Biomarkers
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Several plasma proteins have been evaluated as potential markers for brain injury [63]. These biomarkers include substances associated with glial injury (glial fibrillary acidic protein and s-100b), neuronal injury (neuron-specific enolase and brain-derived neurotrophic factor) and neuro-inflammation (intercellular adhesion molecue-5). Unfavorable neurologic outcomes have been associated with higher biomarker concentrations [64], with combinations of biomarkers providing higher sensitivities and specificities for detection of neurologic injury. These tests are more expensive and require laboratory equipment and processing availability. While not currently a routine component of neuromonitoring on ECMO in most institutions, there is potential for further research and applicability if these results can be obtained in real time to influence management.
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6.7 Somato-sensory evoked potentials (SSEPs)
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SSEPs measure electrical signals in the somatosensory cortex after a peripheral stimulus, assessing the pathway of neuronal conduction from the peripheral nerve to the cortex. They are assessed as normal, abnormal (increased latency) or absent. ECMO cannulation is not thought to alter the ability to assess SSEPs from the hemispheres [65]. Small studies have shown an association between abnormal SSEPs and poor neurologic outcome after ECMO [66], but the predictive value of evoked potentials remains to be determined. In one study, absence of bilateral SSEPs was associated with progression to brain death for patients treated with ECPR [67].
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6.8 Optic nerve sheath diameter (ONSD)
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It is a simple bedside test used to detect elevated intracranial pressure. A cut-off of 5.2 mm is sensitive and specific for intracranial hypertension [68]. Its use in ECMO management is still in its infancy, although a study showed that higher ONSD was associated with poor neurological outcome after ECPR [69].
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7. Therapeutic hypothermia
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Therapeutic hypothermia has been shown to be neuroprotective for term neonates at risk of hypoxic ischemic encephalopathy secondary to perinatal asphyxia. However a randomized controlled study out of the United Kingdom did not show an improvement in outcomes for neonates on ECMO treated with mild hypothermia [70]. On the other hand, therapeutic hypothermia has been associated as a risk factor for intracranial hemorrhage and should be avoided [30]. In 2015, the American Heart Association recommended targeted temperature management of 32–36°C for comatose patients with return of spontaneous circulation after cardiac arrest [71]. This was also applied to patients who suffered in- hospital cardiac arrest leading to ECPR. A more recent large, multicenter, randomized control trial failed to show a benefit in survival with favorable neurological outcome for children with in-hospital cardiac arrest. There is no data to support routine therapeutic hypothermia for children undergoing ECPR although maintaining normothermia is still encouraged.
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8. Conclusion
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Neurologic complications contribute to significant morbidity and mortality for patients on ECMO, who constitute a high risk population. There are many modalities currently available for neuromonitoring, and as we gain more experience and information through more frequent use, we will be able to develop consensus guidelines and protocols to provide better care. A multimodal approach to active surveillance, early recognition and prompt management of neurologic injuries as they arise, may improve outcomes for patients on ECMO.
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Conflict of interest
The author has no “conflict of interest” to disclose.
\n',keywords:"stroke, hemorrhage, MRI, neuromonitoring, neuroimaging, ECMO",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/66143.pdf",chapterXML:"https://mts.intechopen.com/source/xml/66143.xml",downloadPdfUrl:"/chapter/pdf-download/66143",previewPdfUrl:"/chapter/pdf-preview/66143",totalDownloads:390,totalViews:0,totalCrossrefCites:0,dateSubmitted:"September 5th 2018",dateReviewed:"February 11th 2019",datePrePublished:"March 14th 2019",datePublished:"December 4th 2019",readingETA:"0",abstract:"Extracorporeal membrane oxygenation is challenged by several potential complications. Adverse neurologic events such as intracranial hemorrhages, strokes, seizures, and brain death are among the most detrimental and even catastrophic of ECMO complications. There are several risk factors related to the patients, their underlying conditions and the therapy itself that predispose these patients to neurologic injuries. In this chapter, we review different types of neurological complications, the identification and management of which can be difficult. We will also discuss some of the currently available technologies for multimodal neurological monitoring as a complement to clinical exam.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/66143",risUrl:"/chapter/ris/66143",signatures:"Venessa Lynn Pinto",book:{id:"7878",title:"Advances in Extracorporeal Membrane Oxygenation",subtitle:"Volume 3",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",publishedDate:"December 4th 2019",bookSignature:"Michael S. Firstenberg",coverURL:"https://cdn.intechopen.com/books/images_new/7878.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"64343",title:null,name:"Michael S.",middleName:"S",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"273067",title:"Dr.",name:"Venessa",middleName:null,surname:"Pinto",fullName:"Venessa Pinto",slug:"venessa-pinto",email:"vlpinto@bcm.edu",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Epidemiology",level:"1"},{id:"sec_3",title:"3. Cerebral blood flow and oxygenation on ECMO",level:"1"},{id:"sec_4",title:"4. Risk factors for neurologic injury",level:"1"},{id:"sec_4_2",title:"4.1 Pre-ECMO",level:"2"},{id:"sec_5_2",title:"4.2 ECMO-related",level:"2"},{id:"sec_6_2",title:"4.3 Veno-arterial (VA) versus veno-venous (VV)",level:"2"},{id:"sec_7_2",title:"4.4 Carotid repair",level:"2"},{id:"sec_8_2",title:"4.5 Extracorporeal cardiopulmonary resuscitation (ECPR)",level:"2"},{id:"sec_10",title:"5. Types of neurological complications and their management",level:"1"},{id:"sec_10_2",title:"5.1 Hemorrhagic complications",level:"2"},{id:"sec_11_2",title:"5.2 Ischemic complications",level:"2"},{id:"sec_12_2",title:"5.3 Seizures",level:"2"},{id:"sec_13_2",title:"5.4 Sensorineural hearing loss",level:"2"},{id:"sec_14_2",title:"5.5 Myopathy",level:"2"},{id:"sec_15_2",title:"5.6 Delirium",level:"2"},{id:"sec_16_2",title:"5.7 Brain death on ECMO",level:"2"},{id:"sec_16_3",title:"5.7.1 Determination of brain death",level:"3"},{id:"sec_17_3",title:"5.7.2 Apnea testing on ECMO",level:"3"},{id:"sec_20",title:"6. Neurological monitoring",level:"1"},{id:"sec_20_2",title:"6.1 Exam",level:"2"},{id:"sec_21_2",title:"6.2 Neuroimaging",level:"2"},{id:"sec_22_2",title:"6.3 Electroencephalography (EEG)",level:"2"},{id:"sec_23_2",title:"6.4 Transcranial doppler ultrasound (TCD)",level:"2"},{id:"sec_24_2",title:"6.5 Cerebral near infra-red spectroscopy (NIRS)",level:"2"},{id:"sec_25_2",title:"6.6 Biomarkers",level:"2"},{id:"sec_26_2",title:"6.7 Somato-sensory evoked potentials (SSEPs)",level:"2"},{id:"sec_27_2",title:"6.8 Optic nerve sheath diameter (ONSD)",level:"2"},{id:"sec_29",title:"7. Therapeutic hypothermia",level:"1"},{id:"sec_30",title:"8. Conclusion",level:"1"},{id:"sec_34",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'ECLS Registry Report. Extracorporeal Life Support Organization. 2017. Available from: https://www.elso.org/Portals/0/Files/Reports/2017/International%20Summary%20January%202017.pdf [Accessed: 30-01-2019]\n'},{id:"B2",body:'ECLS Registry Form. ELSO. 2018. Available from: https://www.elso.org/Portals/0/ELSOECLSRegistryForm5_0%202018-03-01.pdf [Accessed: 05-12-2018]\n'},{id:"B3",body:'Lorusso R, Gelsomino S, Parise O, Di Mauro M, Barili F, Geskes G, et al. Neurologic injury in adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure: Findings from the extracorporeal life support organization database. Critical Care Medicine. 2017;45(8):1389-1397\n'},{id:"B4",body:'Bartlett RH. Esperanza: The first neonatal ECMO patient. American Society for Artificial Internal Organs: 1992. 2017;63(6):832-843\n'},{id:"B5",body:'Polito A, Barrett CS, Wypij D, Rycus PT, Netto R, Cogo PE, et al. Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data. Intensive Care Medicine. 2013;39(9):1594-1601\n'},{id:"B6",body:'Polito A, Barrett CS, Rycus PT, Favia I, Cogo PE, Thiagarajan RR. Neurologic injury in neonates with congenital heart disease during extracorporeal membrane oxygenation: An analysis of extracorporeal life support organization registry data. American Society for Artificial Internal Organs: 1992. 2015;61(1):43-48\n'},{id:"B7",body:'Hervey-Jumper SL, Annich GM, Yancon AR, Garton HJL, Muraszko KM, Maher CO. Neurological complications of extracorporeal membrane oxygenation in children. Journal of Neurosurgery. Pediatrics. 2011;7(4):338-344\n'},{id:"B8",body:'Sutter R, Tisljar K, Marsch S. Acute neurologic complications during extracorporeal membrane oxygenation: A systematic review. Critical Care Medicine. 2018;46(9):1506-1513\n'},{id:"B9",body:'Lorusso R, Barili F, Mauro MD, Gelsomino S, Parise O, Rycus PT, et al. In-hospital neurologic complications in adult patients undergoing venoarterial extracorporeal membrane oxygenation: Results from the extracorporeal life support organization registry. Critical Care Medicine. 2016;44(10):e964-e972\n'},{id:"B10",body:'Nasr DM, Rabinstein AA. Neurologic complications of extracorporeal membrane oxygenation. Journal of Clinical Neurology. 2015;11(4):383-389\n'},{id:"B11",body:'Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. The New England Journal of Medicine. 2018;378(21):1965-1975\n'},{id:"B12",body:'Kazmi SO, Sivakumar S, Karakitsos D, Alharthy A, Lazaridis C. Cerebral pathophysiology in extracorporeal membrane oxygenation: Pitfalls in daily clinical management. Critical Care Research and Practice. 2018;2018:3237810\n'},{id:"B13",body:'Luyt C-E, Bréchot N, Demondion P, Jovanovic T, Hékimian G, Lebreton G, et al. Brain injury during venovenous extracorporeal membrane oxygenation. Intensive Care Medicine. 2016;42(5):897-907\n'},{id:"B14",body:'O’Brien NF, Hall MW. Extracorporeal membrane oxygenation and cerebral blood flow velocity in children. Pediatric Critical Care Medicine. 2013;14(3):e126-e134\n'},{id:"B15",body:'O’Brien NF, Buttram SDW, Maa T, Lovett ME, Reuter-Rice K, LaRovere KL, et al. Cerebrovascular physiology during pediatric extracorporeal membrane oxygenation: A multicenter study using transcranial doppler ultrasonography. Pediatric Critical Care Medicine. 2018;20(2):178-186\n'},{id:"B16",body:'Tian F, Morriss MC, Chalak L, Venkataraman R, Ahn C, Liu H, et al. Impairment of cerebral autoregulation in pediatric extracorporeal membrane oxygenation associated with neuroimaging abnormalities. Neurophotonics. 2017;4(4):041410\n'},{id:"B17",body:'Xie A, Lo P, Yan TD, Forrest P. Neurologic Complications of Extracorporeal Membrane Oxygenation: A Review. Journal of Cardiothoracic and Vascular Anesthesia. 2017;31(5):1836-1846\n'},{id:"B18",body:'Short BL. The effect of extracorporeal life support on the brain: A focus on ECMO. Seminars in Perinatology. 2005;29(1):45-50\n'},{id:"B19",body:'Graziani LJ, Gringlas M, Baumgart S. Cerebrovascular complications and neurodevelopmental sequelae of neonatal ECMO. Clinics in Perinatology. 1997;24(3):655-675\n'},{id:"B20",body:'Zahraa JN, Moler FW, Annich GM, Maxvold NJ, Bartlett RH, Custer JR. Venovenous versus venoarterial extracorporeal life support for pediatric respiratory failure: Are there differences in survival and acute complications? Critical Care Medicine. 2000;28(2):521-525\n'},{id:"B21",body:'Pozzebon S, Blandino Ortiz A, Franchi F, Cristallini S, Belliato M, Lheureux O, et al. Cerebral near-infrared spectroscopy in adult patients undergoing veno-arterial extracorporeal membrane oxygenation. Neurocritical Care. 2018;29(1):94-104\n'},{id:"B22",body:'Pinto VL, Pruthi S, Westrick AC, Shannon CN, Bridges BC, Le TM. Brain magnetic resonance imaging findings in pediatric patients post extracorporeal membrane oxygenation. American Society for Artificial Internal Organs: 1992. 2017;63(6):810-814\n'},{id:"B23",body:'Taylor GA, Short BL, Glass P, Ichord R. Cerebral hemodynamics in infants undergoing extracorporeal membrane oxygenation: Further observations. Radiology. 1988 Jul;168(1):163-167\n'},{id:"B24",body:'Duggan EM, Maitre N, Zhai A, Krishnamoorthi H, Voskresensky I, Hardison D, et al. Neonatal carotid repair at ECMO decannulation: Patency rates and early neurologic outcomes. Journal of Pediatric Surgery. 2015;50(1):64-68\n'},{id:"B25",body:'Wang J, Ma Q , Zhang H, Liu S, Zheng Y. Predictors of survival and neurologic outcome for adults with extracorporeal cardiopulmonary resuscitation: A systemic review and meta-analysis. Medicine (Baltimore). 2018;97(48):e13257\n'},{id:"B26",body:'Barrett CS, Bratton SL, Salvin JW, Laussen PC, Rycus PT, Thiagarajan RR. Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatric Critical Care Medicine. 2009;10(4):445-451\n'},{id:"B27",body:'Raymond TT, Cunnyngham CB, Thompson MT, Thomas JA, Dalton HJ, Nadkarni VM, et al. Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory inhospital pediatric cardiac arrest: A report from the National Registry of Cardiopulmonary Resuscitation. Pediatric Critical Care Medicine. 2010;11(3):362-371\n'},{id:"B28",body:'Cesana F, Avalli L, Garatti L, Coppo A, Righetti S, Calchera I, et al. Effects of extracorporeal cardiopulmonary resuscitation on neurological and cardiac outcome after ischaemic refractory cardiac arrest. European Heart Journal Acute Cardiovascular Care. 2018;7(5):432-441\n'},{id:"B29",body:'Dela Cruz TV, Stewart DL, Winston SJ, Weatherman KS, Phelps JL, Mendoza JC. Risk factors for intracranial hemorrhage in the extracorporeal membrane oxygenation patient. Journal of Perinatology. 1997;17(1):18-23\n'},{id:"B30",body:'Cashen K, Reeder RW, Shanti C, Dalton HJ, Dean JM, Meert KL, et al. Is therapeutic hypothermia during neonatal extracorporeal membrane oxygenation associated with intracranial hemorrhage? Perfusion. 2018;33(5):354-362\n'},{id:"B31",body:'Hardart GE, Fackler JC. Predictors of intracranial hemorrhage during neonatal extracorporeal membrane oxygenation. The Journal of Pediatrics. 1999;134(2):156-159\n'},{id:"B32",body:'Omar HR, Mirsaeidi M, Mangar D, Camporesi EM. Duration of ECMO is an independent predictor of intracranial hemorrhage occurring during ECMO support. American Society for Artificial Internal Organs: 1992. 2016;62(5):634-636\n'},{id:"B33",body:'Fletcher Sandersjöö A, Bartek J, Thelin EP, Eriksson A, Elmi-Terander A, Broman M, et al. Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: An observational cohort study. Journal of Intensive Care. 2017;5:27\n'},{id:"B34",body:'Fletcher-Sandersjöö A, Thelin EP, Bartek J, Elmi-Terander A, Broman M, Bellander B-M. Management of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation (ECMO): An observational cohort study. PLoS One. 2017;12(12):e0190365\n'},{id:"B35",body:'Fletcher-Sandersjöö A, Thelin EP, Bartek J, Broman M, Sallisalmi M, Elmi-Terander A, et al. Incidence, outcome, and predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: A systematic and narrative review. Frontiers in Neurology. 2018;9:548\n'},{id:"B36",body:'Wien MA, Whitehead MT, Bulas D, Ridore M, Melbourne L, Oldenburg G, et al. Patterns of brain injury in newborns treated with extracorporeal membrane oxygenation. AJNR. American Journal of Neuroradiology. 2017;38(4):820-826\n'},{id:"B37",body:'Bulas D, Glass P. Neonatal ECMO: Neuroimaging and neurodevelopmental outcome. Seminars in Perinatology. 2005;29(1):58-65\n'},{id:"B38",body:'LaRovere KL, Vonberg FW, Prabhu SP, Kapur K, Harini C, Garcia-Jacques R, et al. Patterns of head computed tomography abnormalities during pediatric extracorporeal membrane oxygenation and association with outcomes. Pediatric Neurology. 2017;73:64-70\n'},{id:"B39",body:'Lin J-J, Banwell BL, Berg RA, Dlugos DJ, Ichord RN, Kilbaugh TJ, et al. Electrographic seizures in children and neonates undergoing extracorporeal membrane oxygenation. Pediatric Critical Care Medicine. 2017;18(3):249-257\n'},{id:"B40",body:'Okochi S, Shakoor A, Barton S, Zenilman AR, Street C, Streltsova S, et al. Prevalence of seizures in pediatric extracorporeal membrane oxygenation patients as measured by continuous electroencephalography. Pediatric Critical Care Medicine. 2018;19:1162-1167\n'},{id:"B41",body:'Cheung PY, Robertson CM. Sensorineural hearing loss in survivors of neonatal extracorporeal membrane oxygenation. Pediatric Rehabilitation. 1997;1(2):127-130\n'},{id:"B42",body:'Fligor BJ, Neault MW, Mullen CH, Feldman HA, Jones DT. Factors associated with sensorineural hearing loss among survivors of extracorporeal membrane oxygenation therapy. Pediatrics. 2005;115(6):1519-1528\n'},{id:"B43",body:'van den Hondel D, Madderom MJ, Goedegebure A, Gischler SJ, Mazer P, Tibboel D, et al. Sensorineural hearing loss and language development following neonatal extracorporeal membrane oxygenation. Pediatric Critical Care Medicine. 2013;14(1):62-69\n'},{id:"B44",body:'Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Critical Care (London, England). 2014;18(1):R38\n'},{id:"B45",body:'Munshi L, Kobayashi T, DeBacker J, Doobay R, Telesnicki T, Lo V, et al. Intensive care physiotherapy during extracorporeal membrane oxygenation for acute respiratory distress syndrome. Annals of the American Thoracic Society. 2017;14(2):246-253\n'},{id:"B46",body:'Thiagarajan RR, Teele SA, Teele KP, Beke DM. Physical therapy and rehabilitation issues for patients supported with extracorporeal membrane oxygenation. Journal of Pediatric Rehabilitation Medicine. 2012;5(1):47-52\n'},{id:"B47",body:'Patel AK, Biagas KV, Clark EC, Traube C. Delirium in the pediatric cardiac extracorporeal membrane oxygenation patient population: A case series. Pediatric Critical Care Medicine. 2017;18(12):e621-e624\n'},{id:"B48",body:'Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. American Academy of Neurology. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010 8;74(23):1911-1918\n'},{id:"B49",body:'Nakagawa TA, Ashwal S, Mathur M, Mysore M. Society of critical care medicine, section on critical care and section on neurology of American Academy of Pediatrics, Child Neurology Society. Clinical report—guidelines for the determination of brain death in infants and children: An update of the 1987 task force recommendations. Pediatrics. 2011;128(3):e720-e740\n'},{id:"B50",body:'Giani M, Scaravilli V, Colombo SM, Confalonieri A, Leo R, Maggioni E, et al. Apnea test during brain death assessment in mechanically ventilated and ECMO patients. Intensive Care Medicine. 2016;42(1):72-81\n'},{id:"B51",body:'Muralidharan R, Mateen FJ, Shinohara RT, Schears GJ, Wijdicks EFM. The challenges with brain death determination in adult patients on extracorporeal membrane oxygenation. Neurocritical Care. 2011;14(3):423-426\n'},{id:"B52",body:'Bembea MM, Felling R, Anton B, Salorio CF, Johnston MV. Neuromonitoring during extracorporeal membrane oxygenation: A systematic review of the literature. Pediatric Critical Care Medicine. 2015;16(6):558-564\n'},{id:"B53",body:'Lin N, Flibotte J, Licht DJ. Neuromonitoring in the neonatal ECMO patient. Seminars in Perinatology. 2018;42(2):111-121\n'},{id:"B54",body:'van Heijst AFJ, de Mol AC, Ijsselstijn H. ECMO in neonates: Neuroimaging findings and outcome. Seminars in Perinatology. 2014;38(2):104-113\n'},{id:"B55",body:'Rollins MD, Yoder BA, Moore KR, Barnhart DC, Jones C, Null DM, et al. Utility of neuroradiographic imaging in predicting outcomes after neonatal extracorporeal membrane oxygenation. Journal of Pediatric Surgery. 2012;47(1):76-80\n'},{id:"B56",body:'Lazar EL, Abramson SJ, Weinstein S, Stolar CJ. Neuroimaging of brain injury in neonates treated with extracorporeal membrane oxygenation: Lessons learned from serial examinations. Journal of Pediatric Surgery. 1994;29(2):186-190; discussion 190-191\n'},{id:"B57",body:'ELSO Recommendations for Follow-up for ECMO Patients. 1997. Available from: https://www.elso.org/Portals/0/IGD/Archive/FileManager/2440a82ecdcusersshyerdocumentselsorecommendationsforneonatalpediatricecmopatientfollowup.pdf [Accessed: 07-12-2018]\n'},{id:"B58",body:'Shellhaas RA, Chang T, Tsuchida T, Scher MS, Riviello JJ, Abend NS, et al. The American Clinical Neurophysiology Society’s Guideline on continuous electroencephalography monitoring in neonates. Journal of Clinical Neurophysiology. 2011;28(6):611-617\n'},{id:"B59",body:'ELSO. Guidelines for Neonatal Respiratory Failure. Ann Arbor, MI, USA: ELSO; 2017. Available from: https://www.elso.org/Portals/0/ELSOGuidelinesNeonatalRespiratoryFailurev1_4_1.pdf\n\n'},{id:"B60",body:'Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, et al. Consensus statement on continuous EEG in critically ill adults and children, part I: Indications. Journal of Clinical Neurophysiology. 2015;32(2):87-95\n'},{id:"B61",body:'Rilinger JF, Smith CM, deRegnier RAO, Goldstein JL, Mills MG, Reynolds M, et al. Transcranial doppler identification of neurologic injury during pediatric extracorporeal membrane oxygenation therapy. Journal of Stroke and Cerebrovascular Diseases. 2017;26(10):2336-2345\n'},{id:"B62",body:'Maldonado Y, Singh S, Taylor MA. Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients. Current Opinion in Anaesthesiology. 2014;27(1):81-88\n'},{id:"B63",body:'Bembea MM, Rizkalla N, Freedy J, Barasch N, Vaidya D, Pronovost PJ, et al. Plasma biomarkers of brain injury as diagnostic tools and outcome predictors after extracorporeal membrane oxygenation. Critical Care Medicine. 2015;43(10):2202-2211\n'},{id:"B64",body:'Nguyen DN, Huyghens L, Wellens F, Schiettecatte J, Smitz J, Vincent J-L. Serum S100B protein could help to detect cerebral complications associated with extracorporeal membrane oxygenation (ECMO). Neurocritical Care. 2014;20(3):367-374\n'},{id:"B65",body:'Carter BG, Butt WW. Median nerve somatosensory evoked potentials in children receiving ECMO. Pediatric Neurology. 1995;12(1):42-46\n'},{id:"B66",body:'Amigoni A, Pettenazzo A, Biban P, Suppiej A, Freato F, Zaramella P, et al. Neurologic outcome in children after extracorporeal membrane oxygenation: Prognostic value of diagnostic tests. Pediatric Neurology. 2005;32(3):173-179\n'},{id:"B67",body:'Casadio MC, Coppo A, Vargiolu A, Villa J, Rota M, Avalli L, et al. Organ donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study. Resuscitation. 2017;118:133-139\n'},{id:"B68",body:'Raffiz M, Abdullah JM. Optic nerve sheath diameter measurement: A means of detecting raised ICP in adult traumatic and non-traumatic neurosurgical patients. The American Journal of Emergency Medicine. 2017;35(1):150-153\n'},{id:"B69",body:'Ryu J-A, Chung CR, Cho YH, Sung K, Suh GY, Park TK, et al. The association of findings on brain computed tomography with neurologic outcomes following extracorporeal cardiopulmonary resuscitation. Critical Care (London, England). 2017;21(1):15\n'},{id:"B70",body:'Field D, Juszczak E, Linsell L, Azzopardi D, Cowan F, Marlow N, et al. Neonatal ECMO study of temperature (NEST): A randomized controlled trial. Pediatrics. 2013;132(5):e1247-e1256\n'},{id:"B71",body:'Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: Post-cardiac arrest care: 2015 American Heart Association Guidelines Update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S465-S482\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Venessa Lynn Pinto",address:"vlpinto@bcm.edu",affiliation:'
Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
'}],corrections:null},book:{id:"7878",title:"Advances in Extracorporeal Membrane Oxygenation",subtitle:"Volume 3",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",publishedDate:"December 4th 2019",bookSignature:"Michael S. Firstenberg",coverURL:"https://cdn.intechopen.com/books/images_new/7878.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"64343",title:null,name:"Michael S.",middleName:"S",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"206096",title:"Dr.",name:"Andrew",middleName:null,surname:"McGlone",email:"andrew.mcglone@plantandfood.co.nz",fullName:"Andrew McGlone",slug:"andrew-mcglone",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"Optical Methods for Firmness Assessment of Fresh Produce: A Review",slug:"optical-methods-for-firmness-assessment-of-fresh-produce-a-review",abstract:"This chapter is devoted to a review of optical techniques to measure the firmness of fresh produce. Emphasis is placed on the techniques that have a potential for online high-speed grading. Near-infrared spectroscopy (NIRS) and spatially resolved reflectance spectroscopy (SRRS) are discussed in detail because of their advantages for online applications. For both techniques, this chapter reviews the fundamental principles as well as the measured performances for measuring the firmness of fresh produce, particularly fruit. For both techniques, there have been studies that show correlations with penetrometer firmness as high as r = 0.8 − 0.9. However, most studies appear to involve bespoke laboratory instruments measuring single produce types under static conditions. Therefore, accurate performance comparison of the two techniques is very difficult. We suggest more studies are now required on a wider variety of produce and particularly comparative studies between the NIRS and SRRS systems on the same samples. Further instrument developments are also likely to be required for the SRRS systems, especially with an online measurement where fruit speed and orientation are likely to be issues, before the technique can be considered advantageous compared to the commonly used NIRS systems.",signatures:"Jason Sun, Rainer Künnemeyer and Andrew McGlone",authors:[{id:"202132",title:"Ph.D. Student",name:"Jason",surname:"Sun",fullName:"Jason Sun",slug:"jason-sun",email:"zhesun89@gmail.com"},{id:"206093",title:"Prof.",name:"Rainer",surname:"Kunnemeyer",fullName:"Rainer Kunnemeyer",slug:"rainer-kunnemeyer",email:"r.kunnemeyer@ieee.org"},{id:"206096",title:"Dr.",name:"Andrew",surname:"McGlone",fullName:"Andrew McGlone",slug:"andrew-mcglone",email:"andrew.mcglone@plantandfood.co.nz"}],book:{title:"Postharvest Handling",slug:"postharvest-handling",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"169352",title:"Dr.",name:"Tonna",surname:"Anyasi",slug:"tonna-anyasi",fullName:"Tonna Anyasi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169352/images/7075_n.jpg",biography:"Tonna Anyasi obtained his doctoral degree in Agriculture (Food Science and Technology) from the University of Venda, South Africa and his Master’s degree (Food Technology) from the University of Ibadan, Nigeria. His research interests include studies on antioxidant activities, bionutrients, phytochemicals and in vitro digestibility of starch in fruits, vegetables, roots and tuber crops. He has published several journal articles and book chapters in international peer accredited journals and serves as a reviewer for Elsevier, Springer Nature, Wiley Online and American Chemical Society journals. He is involved in the supervision and mentoring of Ph.D., Masters and Honours students at the University of Venda and is a member of the Institute of Food Technologists Illinois, USA, as well as a professional member of the South African Association for Food Science and Technology. Tonna is currently a Postdoctoral Research Fellow at the Department of Food Science and Technology, University of Venda.",institutionString:null,institution:{name:"University of Venda",institutionURL:null,country:{name:"South Africa"}}},{id:"178185",title:"Ph.D.",name:"Ibrahim",surname:"Kahramanoglu",slug:"ibrahim-kahramanoglu",fullName:"Ibrahim Kahramanoglu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178185/images/system/178185.jpg",biography:"İbrahim Kahramanoğlu holds a PhD in Postharvest Biology and Technology and works as a lecturer at the European University of Lefke (Northern Cyprus). He received a BSc in Horticulture and MSc in Plant Protection. He previously worked in the alternative crops projects of USAID in Cyprus and was the managing director of Alnar Narcilik Ltd. for 8 years. He has practical experiences in fruit production (especially pomegranate, olive and citrus); control of pests, diseases and weeds; and Good Agricultural Practices. 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