101
|
Hood R, Budd A, Sorond FA, Hogue CW. Peri-operative neurological complications. Anaesthesia 2018; 73 Suppl 1:67-75. [DOI: 10.1111/anae.14142] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/27/2022]
Affiliation(s)
- R. Hood
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - A. Budd
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - F. A. Sorond
- Department of Neurology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - C. W. Hogue
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| |
Collapse
|
102
|
Rummel C, Basciani R, Nirkko A, Schroth G, Stucki M, Reineke D, Eberle B, Kaiser HA. Spatially extended versus frontal cerebral near-infrared spectroscopy during cardiac surgery: a case series identifying potential advantages. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-11. [PMID: 29359545 DOI: 10.1117/1.jbo.23.1.016012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 12/19/2017] [Indexed: 06/07/2023]
Abstract
Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.
Collapse
Affiliation(s)
- Christian Rummel
- University of Bern, Support Center for Advanced Neuroimaging, University Institute for Diagnostic an, Switzerland
| | - Reto Basciani
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - Arto Nirkko
- University of Bern, Department of Neurology, Schlaf-Wach-Epilepsie-Zentrum, Inselspital, Bern, Switzerland
| | - Gerhard Schroth
- University of Bern, Support Center for Advanced Neuroimaging, University Institute for Diagnostic an, Switzerland
| | - Monika Stucki
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - David Reineke
- University of Bern, Department of Cardiovascular Surgery, Inselspital, Bern, Switzerland
| | - Balthasar Eberle
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - Heiko A Kaiser
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| |
Collapse
|
103
|
|
104
|
Caldas JR, Haunton VJ, Panerai RB, Hajjar LA, Robinson TG. Cerebral autoregulation in cardiopulmonary bypass surgery: a systematic review. Interact Cardiovasc Thorac Surg 2017; 26:494-503. [DOI: 10.1093/icvts/ivx357] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/03/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Hospital Sao Rafael, Salvador, Bahia, Brazil
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Department of Cardiopneumology, Heart Institute, University of São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| |
Collapse
|
105
|
|
106
|
Lei L, Katznelson R, Fedorko L, Carroll J, Poonawala H, Machina M, Styra R, Rao V, Djaiani G. Cerebral oximetry and postoperative delirium after cardiac surgery: a randomised, controlled trial. Anaesthesia 2017; 72:1456-1466. [DOI: 10.1111/anae.14056] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 11/27/2022]
Affiliation(s)
- L. Lei
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - R. Katznelson
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - L. Fedorko
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - J. Carroll
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - H. Poonawala
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - M. Machina
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - R. Styra
- Department of Psychiatry; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - V. Rao
- Division of Cardiovascular Surgery; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| | - G. Djaiani
- Departments of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Ontario Canada
| |
Collapse
|
107
|
Vranken NP, Weerwind PW, Sutedja NA, Ševerdija EE, Barenbrug PJ, Maessen JG. Cerebral Oximetry and Autoregulation during Cardiopulmonary Bypass: A Review. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2017; 49:182-191. [PMID: 28979042 PMCID: PMC5621582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
Postoperative neurological complications (PNCs) following cardiac surgery with cardiopulmonary bypass (CPB) is a detrimental complication, contributing to increased mortality rates and health care costs. To prevent intraoperative cerebral desaturations associated with PNC, continuous brain monitoring using near-infrared spectroscopy has been advocated. However, clear evidence for a defined desaturation threshold requiring intervention during CPB is still lacking. Since cerebral oximetry readings are nonspecific, cerebral tissue oxygenation values need to be interpreted with caution and in the context of all available clinical information. Therefore, maintaining an intact autoregulatory activity during CPB rather than solely focusing on regional cerebral oxygen saturation measurements will collectively contribute to optimization of patient care during CPB.
Collapse
Affiliation(s)
| | | | - Nadia A. Sutedja
- Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | | |
Collapse
|
108
|
Lewis C, Hogue C. Lack of benefit of near-infrared spectroscopy monitoring for improving patient outcomes. Case closed? Br J Anaesth 2017; 119:347-349. [DOI: 10.1093/bja/aex214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
109
|
Moerman A, De Hert S. Recent advances in cerebral oximetry. Assessment of cerebral autoregulation with near-infrared spectroscopy: myth or reality? F1000Res 2017; 6:1615. [PMID: 29026526 PMCID: PMC5583743 DOI: 10.12688/f1000research.11351.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 01/12/2023] Open
Abstract
In recent years, the feasibility of near-infrared spectroscopy to continuously assess cerebral autoregulation has gained increasing interest. By plotting cerebral oxygen saturation over blood pressure, clinicians can generate an index of autoregulation: the cerebral oximetry index (COx). Successful integration of this monitoring ability in daily critical care may allow clinicians to tailor blood pressure management to the individual patient's need and might prove to be a major step forward in terms of patient outcome.
Collapse
Affiliation(s)
- Anneliese Moerman
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium
| | - Stefan De Hert
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
110
|
Hori D, Nomura Y, Ono M, Joshi B, Mandal K, Cameron D, Kocherginsky M, Hogue CW. Optimal blood pressure during cardiopulmonary bypass defined by cerebral autoregulation monitoring. J Thorac Cardiovasc Surg 2017; 154:1590-1598.e2. [PMID: 29042040 DOI: 10.1016/j.jtcvs.2017.04.091] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES We sought to define the lower and upper limits of cerebral blood flow autoregulation and the optimal blood pressure during cardiopulmonary bypass. We further sought to identify variables predictive of these autoregulation end points. METHODS Cerebral autoregulation was monitored continuously with transcranial Doppler in 614 patients during cardiopulmonary bypass enrolled in 3 investigations. A moving Pearson's correlation coefficient was calculated between cerebral blood flow velocity and mean arterial pressure to generate the variable mean velocity index. Optimal mean arterial pressure was defined as the mean arterial pressure with the lowest mean velocity index indicating the best autoregulation. The lower and upper limits of cerebral blood flow autoregulation were defined as the mean arterial pressure at which mean velocity index was increasingly pressure passive (ie, mean velocity index ≥0.4) with declining or increasing blood pressure, respectively. RESULTS The mean (± standard deviation) lower and upper limits of cerebral blood flow autoregulation, and optimal mean arterial pressure were 65 ± 12 mm Hg, 84 ± 11 mm Hg, and 78 ± 11 mm Hg, respectively, after adjusting for study enrollment. In 17% of patients, though, the lower limit of cerebral autoregulation was above this optimal mean arterial pressure, whereas in 29% of patients the upper limit of autoregulation was below the population optimal mean arterial pressure. Variables associated with optimal mean arterial pressure based on multivariate regression analysis were nonwhite race (increased 2.7 mm Hg; P = .034), diuretics use (decreased 1.9 mm Hg; P = .049), prior carotid endarterectomy (decreased 5.5 mm Hg; P = .019), and duration of cardiopulmonary bypass (decreased 1.28 per 60 minutes of cardiopulmonary bypass). The product of the duration and magnitude that mean arterial pressure during cardiopulmonary bypass was below the lower limit of cerebral autoregulation was associated with the risk for stroke (P = .02). CONCLUSIONS Real-time monitoring of autoregulation may improve individualizing mean arterial pressure during cardiopulmonary bypass and improving patient outcomes.
Collapse
Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Yohei Nomura
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Masahiro Ono
- Department of Cardiac Surgery, The Texas Heart Institute, Houston, Tex
| | - Brijen Joshi
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Masha Kocherginsky
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Charles W Hogue
- Department of Anesthesiology and the Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| |
Collapse
|
111
|
Goettel N, Burkhart CS, Rossi A, Cabella BCT, Berres M, Monsch AU, Czosnyka M, Steiner LA. Associations Between Impaired Cerebral Blood Flow Autoregulation, Cerebral Oxygenation, and Biomarkers of Brain Injury and Postoperative Cognitive Dysfunction in Elderly Patients After Major Noncardiac Surgery. Anesth Analg 2017; 124:934-942. [PMID: 28151820 DOI: 10.1213/ane.0000000000001803] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increasing evidence links postoperative cognitive dysfunction (POCD) to surgery and anesthesia. POCD is recognized as an important neuropsychological adverse outcome in surgical patients, particularly the elderly. This prospective cohort study aimed to investigate whether POCD is associated with impaired intraoperative cerebral autoregulation and oxygenation, and increased levels of biomarkers of brain injury. METHODS Study subjects were patients ≥65 years of age scheduled for major noncardiac surgery. Cognitive function was assessed before and 1 week after surgery. POCD was diagnosed if a decline of >1 standard deviation of z-scores was present in ≥2 variables of the test battery. The incidence of POCD 1 week after surgery was modeled as a multivariable function of the index of autoregulation (MxA) and tissue oxygenation index (TOI), adjusting for baseline neuropsychological assessment battery (Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery [CERAD-NAB]) total score and the maximum C-reactive protein (CRP) concentration. The biomarkers of brain injury neuron-specific enolase and S100β protein, age, and level of education were included in secondary multivariable logistic regression analyses. RESULTS Of the 82 patients who completed the study, 38 (46%) presented with POCD 1 week after surgery. In the multivariable regression analysis, higher intraoperative MxA (odds ratio [OR; 95% confidence interval (CI)], 1.39 [1.01-1.90] for an increase of 0.1 units, P = .08 after Bonferroni adjustment), signifying less effective autoregulation, was not associated with higher odds of POCD. The univariable logistic regression model for MxA yielded an association with POCD (OR [95% CI], 1.44 [1.06-1.95], P = .020). Tissue oxygenation index (1.12 [0.41-3.01] for an increase of 10%, P = 1.0 after Bonferroni adjustment) and baseline CERAD-NAB total score (0.80 [0.45-1.42] for an increase of 10 points, P = .45) did not affect the odds of POCD. POCD was associated with elevated CRP on postoperative day 2 (median [interquartile range]; 175 [81-294] vs 112 [62-142] mg/L, P = .033); however, the maximum CRP value (OR [95% CI], 1.35 [0.97-1.87] for a 2-fold increase, P = .07) had no distinct effect on POCD. CONCLUSIONS Impairment of intraoperative cerebral blood flow autoregulation is not predictive of early POCD in elderly patients, although secondary analyses indicate that an association probably exists.
Collapse
Affiliation(s)
- Nicolai Goettel
- From the *Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Switzerland; †Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland; ‡Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, Switzerland; §Brain Physics Lab, Division of Neurosurgery, University of Cambridge, United Kingdom; ‖Department of Mathematics and Technology, Koblenz University of Applied Sciences, Koblenz, Germany; and ¶Memory Clinic, University Center for Medicine of Aging Basel, Felix Platter Hospital, Basel, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
112
|
Perioperative hemodynamics and risk for delirium and new onset dementia in hip fracture patients; A prospective follow-up study. PLoS One 2017; 12:e0180641. [PMID: 28700610 PMCID: PMC5503267 DOI: 10.1371/journal.pone.0180641] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/19/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia. METHODS Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively. RESULTS Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively. CONCLUSION Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture.
Collapse
|
113
|
Caldas JR, Panerai RB, Bor-Seng-Shu E, Almeida JP, Ferreira GSR, Camara L, Nogueira RC, Oliveira ML, Jatene FB, Robinson TG, Hajjar LA. Cerebral hemodynamics with intra-aortic balloon pump: business as usual? Physiol Meas 2017; 38:1349-1361. [PMID: 28333037 DOI: 10.1088/1361-6579/aa68c4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Intra-aortic balloon pump (IABP) is commonly used as mechanical support after cardiac surgery or cardiac shock. Although its benefits for cardiac function have been well documented, its effects on cerebral circulation are still controversial. We hypothesized that transfer function analysis (TFA) and continuous estimates of dynamic cerebral autoregulation (CA) provide consistent results in the assessment of cerebral autoregulation in patients with IABP. APPROACH Continuous recordings of blood pressure (BP, intra-arterial line), end-tidal CO2, heart rate and cerebral blood flow velocity (CBFV, transcranial Doppler) were obtained (i) 5 min with IABP ratio 1:3, (ii) 5 min, starting 1 min with the IABP-ON, and continuing for another 4 min without pump assistance (IABP-OFF). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by TFA and as a function of time using an autoregressive moving-average model during removal of the device (ARI t ). Critical closing pressure and resistance area-product were also obtained. MAIN RESULTS ARI with IABP-ON (4.3 ± 1.2) were not different from corresponding values at IABP-OFF (4.7 ± 1.4, p = 0.42). Removal of the balloon had no effect on ARI t , CBFV, BP, cerebral critical closing pressure or resistance area-product. SIGNIFICANCE IABP does not disturb cerebral hemodynamics. TFA and continuous estimates of dynamic CA can be used to assess cerebral hemodynamics in patients with IABP. These findings have important implications for the design of studies of critically ill patients requiring the use of different invasive support devices.
Collapse
Affiliation(s)
- J R Caldas
- Department of Anesthesia, University of São Paulo, São Paulo, Brazil. Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
114
|
Haggstrom L, Welschinger R, Caplan GA. Functional neuroimaging offers insights into delirium pathophysiology: A systematic review. Australas J Ageing 2017; 36:186-192. [DOI: 10.1111/ajag.12417] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Lucy Haggstrom
- University of New South Wales; Sydney New South Wales Australia
| | - Robert Welschinger
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
| |
Collapse
|
115
|
Bartels UE. Delir in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-016-0123-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
116
|
Reduced Cerebral Perfusion Pressure during Lung Transplant Surgery Is Associated with Risk, Duration, and Severity of Postoperative Delirium. Ann Am Thorac Soc 2016; 13:180-7. [PMID: 26731642 DOI: 10.1513/annalsats.201507-454oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Delirium is common following lung transplant and is associated with poorer clinical outcomes. The extent to which intraoperative hemodynamic alterations may contribute to postoperative delirium among lung transplant recipients has not been examined. OBJECTIVES To examine the impact of intraoperative hemodynamic changes on neurobehavioral outcomes among lung transplant recipients. METHODS Intraoperative hemodynamic function during lung transplant was assessed in a consecutive series of patients between March and November 2013. Intraoperative cerebral perfusion pressure was assessed every minute in all patients. Following lung transplant, patients were monitored for the presence and severity of delirium using the Confusion Assessment Method and the Delirium Rating Scale until hospital discharge. MEASUREMENTS AND MAIN RESULTS Sixty-three patients received lung transplants, of whom 23 (37%) subsequently developed delirium. Lower cerebral perfusion pressure was associated with increased risk of delirium (odds ratio [OR], 2.08 per 10-mm Hg decrease; 95% confidence interval [CI], 1.02-4.24; P = 0.043), longer duration of delirium (OR, 1.7 d longer per 10-mm Hg decrease; 95% CI, 1.1-2.7; P = 0.022), and greater delirium severity (b = -0.81; 95% CI, -1.47 to -0.15; P = 0.017). CONCLUSIONS Poorer cerebral perfusion pressure during lung transplant is associated with greater risk for delirium following transplant, as well as greater duration and severity of delirium, independent of demographic and medical predictors.
Collapse
|
117
|
Goodson CM, Rosenblatt K, Rivera-Lara L, Nyquist P, Hogue CW. Cerebral Blood Flow Autoregulation in Sepsis for the Intensivist: Why Its Monitoring May Be the Future of Individualized Care. J Intensive Care Med 2016; 33:63-73. [PMID: 27798314 DOI: 10.1177/0885066616673973] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebral blood flow (CBF) autoregulation maintains consistent blood flow across a range of blood pressures (BPs). Sepsis is a common cause of systemic hypotension and cerebral dysfunction. Guidelines for BP management in sepsis are based on historical concepts of CBF autoregulation that have now evolved with the availability of more precise technology for its measurement. In this article, we provide a narrative review of methods of monitoring CBF autoregulation, the cerebral effects of sepsis, and the current knowledge of CBF autoregulation in sepsis. Current guidelines for BP management in sepsis are based on a goal of maintaining mean arterial pressure (MAP) above the lower limit of CBF autoregulation. Bedside tools are now available to monitor CBF autoregulation continuously. These data reveal that individual BP goals determined from CBF autoregulation monitoring are more variable than previously expected. In patients undergoing cardiac surgery with cardiopulmonary bypass, for example, the lower limit of autoregulation varied between a MAP of 40 to 90 mm Hg. Studies of CBF autoregulation in sepsis suggest patients frequently manifest impaired CBF autoregulation, possibly a result of BP below the lower limit of autoregulation, particularly in early sepsis or with sepsis-associated encephalopathy. This suggests that the present consensus guidelines for BP management in sepsis may expose some patients to both cerebral hypoperfusion and cerebral hyperperfusion, potentially resulting in damage to brain parenchyma. The future use of novel techniques to study and clinically monitor CBF autoregulation could provide insight into the cerebral pathophysiology of sepsis and offer more precise treatments that may improve functional and cognitive outcomes for survivors of sepsis.
Collapse
Affiliation(s)
- Carrie M Goodson
- 1 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn Rosenblatt
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Nyquist
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W Hogue
- 4 Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
118
|
Arora RC, Djaiani G, Rudolph JL. Detection, Prevention, and Management of Delirium in the Critically Ill Cardiac Patient and Patients Who Undergo Cardiac Procedures. Can J Cardiol 2016; 33:80-87. [PMID: 28024558 DOI: 10.1016/j.cjca.2016.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/06/2016] [Accepted: 08/25/2016] [Indexed: 02/08/2023] Open
Abstract
Delirium is an acute change in cognitive functioning, characterized by inattention and associated with alterations in awareness and fluctuation in arousal, disorganized thinking, or altered level that preferentially affects older adult patients. In the acutely ill cardiac patient, the incidence of delirium has been reported as high as 73%, depending on the type and sensitivity of delirium assessment. Cardiac patients with delirium experience higher rates of in-hospital and longer-term mortality and are at risk for progressive cognitive impairment, loss of functional independence, and increased hospitalization costs. As such, delirium represents an undesirable outcome in cardiac patients. Care improvements such as identifying risk of delirium at time of admission or in the preoperative setting; training cardiologist, surgeons, anaesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols might reduce the incidence of delirium and its associated morbidity.
Collapse
Affiliation(s)
- Rakesh C Arora
- Department of Surgery, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center; Center for Gerontology, Brown School of Public Health; and Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
119
|
|
120
|
Evans AS, Weiner MM, Arora RC, Chung I, Deshpande R, Varghese R, Augoustides J, Ramakrishna H. Current approach to diagnosis and treatment of delirium after cardiac surgery. Ann Card Anaesth 2016; 19:328-37. [PMID: 27052077 PMCID: PMC4900348 DOI: 10.4103/0971-9784.179634] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/09/2016] [Indexed: 01/12/2023] Open
Abstract
Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.
Collapse
Affiliation(s)
- Adam S. Evans
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Menachem M. Weiner
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Insung Chung
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Robin Varghese
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Augoustides
- Department of Anesthesiology, University of Pennsylvania, PA, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, United States
| |
Collapse
|
121
|
Cerebral Autoregulation Monitoring with Ultrasound-Tagged Near-Infrared Spectroscopy in Cardiac Surgery Patients. Anesth Analg 2016; 121:1187-93. [PMID: 26334746 DOI: 10.1213/ane.0000000000000930] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Individualizing mean arterial blood pressure (MAP) based on cerebral blood flow (CBF) autoregulation monitoring during cardiopulmonary bypass (CPB) holds promise as a strategy to optimize organ perfusion. The purpose of this study was to evaluate the accuracy of cerebral autoregulation monitoring using microcirculatory flow measured with innovative ultrasound-tagged near-infrared spectroscopy (UT-NIRS) noninvasive technology compared with transcranial Doppler (TCD). METHODS Sixty-four patients undergoing CPB were monitored with TCD and UT-NIRS (CerOx™). The mean velocity index (Mx) was calculated as a moving, linear correlation coefficient between slow waves of TCD-measured CBF velocity and MAP. The cerebral flow velocity index (CFVx) was calculated as a similar coefficient between slow waves of cerebral flow index measured using UT-NIRS and MAP. When MAP is outside the autoregulation range, Mx is progressively more positive. Optimal blood pressure was defined as the MAP with the lowest Mx and CFVx. The right- and left-sided optimal MAP values were averaged to define the individual optimal MAP and were the variables used for analysis. RESULTS The Mx for the left side was 0.31 ± 0.17 and for the right side was 0.32 ± 0.17. The mean CFVx for the left side was 0.33 ± 0.19 and for the right side was 0.35 ± 0.19. Time-averaged Mx and CFVx during CPB had a statistically significant "among-subject" correlation (r = 0.39; 95% confidence interval [CI], 0.22-0.53; P < 0.001) but had only a modest agreement within subjects (bias 0.03 ± 0.20; 95% prediction interval for the difference between Mx and CFVx, -0.37 to 0.42). The MAP with the lowest Mx and CFVx ("optimal blood pressure") was correlated (r = 0.71; 95% CI, 0.56-0.81; P < 0.0001) and was in modest within-subject agreement (bias -2.85 ± 8.54; 95% limits of agreement for MAP predicted by Mx and CFVx, -19.60 to 13.89). Coherence between ipsilateral middle CBF velocity and cerebral flow index values averaged 0.61 ± 0.07 (95% CI, 0.59-0.63). CONCLUSIONS There was a statistically significant correlation and agreement between CBF autoregulation monitored by CerOx compared with TCD-based Mx.
Collapse
|
122
|
Hori D, Hogue C, Adachi H, Max L, Price J, Sciortino C, Zehr K, Conte J, Cameron D, Mandal K. Perioperative optimal blood pressure as determined by ultrasound tagged near infrared spectroscopy and its association with postoperative acute kidney injury in cardiac surgery patients. Interact Cardiovasc Thorac Surg 2016; 22:445-51. [PMID: 26763042 DOI: 10.1093/icvts/ivv371] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative blood pressure management by targeting individualized optimal blood pressure, determined by cerebral blood flow autoregulation monitoring, may ensure sufficient renal perfusion. The purpose of this study was to evaluate changes in the optimal blood pressure for individual patients, determined during cardiopulmonary bypass (CPB) and during early postoperative period in intensive care unit (ICU). A secondary aim was to examine if excursions below optimal blood pressure in the ICU are associated with risk of cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS One hundred and ten patients undergoing cardiac surgery had cerebral blood flow monitored with a novel technology using ultrasound tagged near infrared spectroscopy (UT-NIRS) during CPB and in the first 3 h after surgery in the ICU. The correlation flow index (CFx) was calculated as a moving, linear correlation coefficient between cerebral flow index measured using UT-NIRS and mean arterial pressure (MAP). Optimal blood pressure was defined as the MAP with the lowest CFx. Changes in optimal blood pressure in the perioperative period were observed and the association of blood pressure excursions (magnitude and duration) below the optimal blood pressure [area under the curve (AUC) < OptMAP mmHgxh] with incidence of CSA-AKI (defined using Kidney Disease: Improving Global Outcomes criteria) was examined. RESULTS Optimal blood pressure during early ICU stay and CPB was correlated (r = 0.46, P < 0.0001), but was significantly higher in the ICU compared with during CPB (75 ± 8.7 vs 71 ± 10.3 mmHg, P = 0.0002). Thirty patients (27.3%) developed CSA-AKI within 48 h after the surgery. AUC < OptMAP was associated with CSA-AKI during CPB [median, 13.27 mmHgxh, interquartile range (IQR), 4.63-20.14 vs median, 6.05 mmHgxh, IQR 3.03-12.40, P = 0.008], and in the ICU (13.72 mmHgxh, IQR 5.09-25.54 vs 5.65 mmHgxh, IQR 1.71-13.07, P = 0.022). CONCLUSIONS Optimal blood pressure during CPB and in the ICU was correlated. Excursions below optimal blood pressure (AUC < OptMAP mmHgXh) during perioperative period are associated with CSA-AKI. Individualized blood pressure management based on cerebral autoregulation monitoring during the perioperative period may help improve CSA-AKI-related outcomes.
Collapse
Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joel Price
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Sciortino
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
123
|
Hori D, Max L, Laflam A, Brown C, Neufeld KJ, Adachi H, Sciortino C, Conte JV, Cameron DE, Hogue CW, Mandal K. Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study. J Cardiothorac Vasc Anesth 2016; 30:606-12. [PMID: 27321787 DOI: 10.1053/j.jvca.2016.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination. DESIGN Prospective, observational study. SETTING University hospital. PARTICIPANTS The study included 110 patients undergoing cardiac surgery. INTERVENTIONS Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit. MEASUREMENTS AND MAIN RESULTS The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean±SD, 33.2±26.51 mmHgxh v 23.4±16.13 mmHgxh; p = 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011). CONCLUSIONS Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.
Collapse
Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery
| | - Laura Max
- Department of Anesthesiology & Critical Care Medicine
| | - Andrew Laflam
- Department of Anesthesiology & Critical Care Medicine
| | - Charles Brown
- Department of Anesthesiology & Critical Care Medicine
| | - Karin J Neufeld
- Department of Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - John V Conte
- Division of Cardiac Surgery, Department of Surgery
| | | | | | | |
Collapse
|
124
|
|
125
|
Devinney M, Bauer R, Sanders R. Climbing the delirium mountain: is alpine anaesthesia the perioperative cause? Br J Anaesth 2015; 115:342-4. [DOI: 10.1093/bja/aev144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
126
|
Hypotension After Cardiac Operations Based on Autoregulation Monitoring Leads to Brain Cellular Injury. Ann Thorac Surg 2015; 100:487-93. [PMID: 26089226 DOI: 10.1016/j.athoracsur.2015.03.036] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/28/2015] [Accepted: 03/06/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Individualizing blood pressure targets could improve organ perfusion compared with current practices. In this study we assess whether hypotension defined by cerebral autoregulation monitoring vs standard definitions is associated with elevation in the brain-specific injury biomarker glial fibrillary acidic protein plasma levels (GFAP). METHODS Plasma GFAP levels were measured in 121 patients undergoing cardiac operations after anesthesia induction, at the conclusion of the operation, and on postoperative day 1. Cerebral autoregulation was monitored during the operation with the cerebral oximetry index, which correlates low-frequency changes in mean arterial pressure (MAP) and regional cerebral oxygen saturation. Blood pressure was recorded every 15 minutes in the intensive care unit. Hypotension was defined based on autoregulation data as an MAP below the optimal MAP (MAP at the lowest cerebral oximetry index) and based on standard definitions (systolic blood pressure decrement >20%, >30% from baseline, or <100 mm Hg, or both). RESULTS MAP (mean ± standard deviation) in the intensive care unit was 74 ± 7.3 mm Hg; optimal MAP was 78 ± 12.8 mm Hg (p = 0.008). The incidence of hypotension varied from 22% to 37% based on standard definitions but occurred in 54% of patients based on the cerebral oximetry index (p < 0.001). There was no relationship between standard definitions of hypotension and plasma GFAP levels, but MAP of less than optimal was positively related with postoperative day 1 GFAP levels (coefficient, 1.77; 95% confidence interval, 1.27 to 2.48; p = 0.001) after adjusting for GFAP levels at the conclusion of the operation and low cardiac output syndrome. CONCLUSIONS Individualizing blood pressure management using cerebral autoregulation monitoring may better ensure brain perfusion than current practice.
Collapse
|
127
|
Graber LC, Quillinan N, Marrotte EJ, McDonagh DL, Bartels K. Neurocognitive outcomes after extracorporeal membrane oxygenation. Best Pract Res Clin Anaesthesiol 2015; 29:125-35. [DOI: 10.1016/j.bpa.2015.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 01/05/2023]
|
128
|
Association between intraoperative blood pressure and postoperative delirium in elderly hip fracture patients. PLoS One 2015; 10:e0123892. [PMID: 25860338 PMCID: PMC4393126 DOI: 10.1371/journal.pone.0123892] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/27/2015] [Indexed: 01/22/2023] Open
Abstract
Background One possible area of intervention to prevent postoperative delirium (PD) is intraoperative blood pressure management. However, the relationship between intraoperative blood pressure and PD is unclear. A secondary analysis of a RCT study examining the PD risk over the range of absolute intraoperative mean arterial blood pressure (MAP) readings and the corresponding relative changes from preoperative baseline level was performed to determine the role of MAP on PD. Methods Nonparametric locally weighted quadratic polynomial smoothing (LOESS) regression explored the pattern of PD risk at postoperative day 2 as a function of mean surgery MAP (msMAP) and percent change of msMAP from baseline in 103 elderly hip fracture patients. Segment-linear logistic regression models were then constructed to determine the odds ratios (OR) of PD over the observed range of these msMAP measures, adjusting for potential confounds. Results Twenty-three patients (22%) developed PD on day 2. LOESS regression revealed a j-shaped association between absolute levels of msMAP and PD risk. When msMAP was ≥80 mmHg, higher msMAP imparted greater PD risk (OR = 2.28 per 10 mmHg msMAP increase; 95% CI: 1.11–4.70), while higher msMAP was associated with lower PD risk (OR = 0.19 per 10 mmHg increase; CI: 0.05–0.76) if msMAP was <80 mmHg. There was no statistically significant relationship between PD risk and average percent change from baseline in these msMAP measures. Conclusion In elderly hip fracture patients, both very high and very low levels of msMAP were associated with significantly increased risk of PD.
Collapse
|
129
|
Hori D, Ono M, Adachi H, Hogue CW. Effect of carotid revascularization on cerebral autoregulation in combined cardiac surgery†. Eur J Cardiothorac Surg 2015; 49:281-7. [PMID: 25646403 DOI: 10.1093/ejcts/ezv018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/22/2014] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Combined carotid artery endarterectomy (CEA) and coronary artery bypass grafting surgery is considered to reduce long-term stroke risk for patients with severe carotid artery stenosis. The benefits of CEA for improving cerebral perfusion during subsequent cardiopulmonary bypass (CPB) are unclear. The purpose of this pilot study was to assess cerebral autoregulation and cerebral oximetry in patients undergoing combined CEA and cardiac surgery with those undergoing cardiac surgery without significant carotid artery stenosis or with uncorrected stenosis. METHODS Cerebral autoregulation was monitored continuously in 257 patients with the cerebral oximetry index (COx). COx represents a moving Pearson's correlation coefficient between low-frequency changes in regional cerebral oxygen saturation (rScO2) and mean arterial pressure that has been validated in previous investigations. Impaired autoregulation was defined as a value of COx ≥0.3. RESULTS Nineteen patients had prior CEA, 8 underwent combined CEA and cardiac surgery, 8 had uncorrected stenosis >70% and 197 had stenosis <50%. Combined, patients with stenosis >70% had a higher COx before CPB compared with those with stenosis <50% (median, 0.26, 25th percentile and 75th percentile [p25-p75], 0.18-0.33 vs 0.18, p25-p75, 0.07-0.27, respectively, P = 0.054). Patients who underwent combined CEA and cardiac surgery had a higher COx before surgery compared with those with prior CEA (P = 0.027) and stenosis <50% (P = 0.026). There were no differences in average COx or rScO2 during CPB in patients undergoing combined CEA and cardiac surgery compared with those with prior CEA (P = 0.53, 0.27) and those with stenosis <50% (P = 0.71, 0.19), respectively. During CPB, patients with uncorrected stenosis had an average COx of 0.36 (p25-p75, 0.28-0.56) indicating cerebral autoregulation impairment, and lower rScO2 compared with patients with prior CEA (P = 0.006) and stenosis <50% (P = 0.005). CONCLUSIONS While higher at baseline, patients undergoing CEA immediately before cardiac surgery had COx and rScO2 measurements during CPB similar to those with non-significant stenosis in contrast to those patients with uncorrected stenosis who had evidence of impaired autoregulation and lower rScO2. These preliminary results suggest the potential utility of COx, possibly for complimenting patient selection for CEA as well as for individual patient management during surgery.
Collapse
Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Masahiro Ono
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|