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Jufar AH, May CN, Evans RG, Cochrane AD, Marino B, Hood SG, McCall PR, Bellomo R, Lankadeva YR. Influence of moderate-hypothermia on renal and cerebral haemodynamics and oxygenation during experimental cardiopulmonary bypass in sheep. Acta Physiol (Oxf) 2022; 236:e13860. [PMID: 35862484 DOI: 10.1111/apha.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
AIM Cardiac surgery requiring cardiopulmonary bypass (CPB) can result in renal and cerebral injury. Intra-operative tissue hypoxia could contribute to such organ injury. Hypothermia, however, may alleviate organ hypoxia. Therefore, we tested whether moderate-hypothermia (30o C) improves cerebral and renal tissue perfusion and oxygenation during ovine CPB. METHODS Ten sheep were studied while conscious, under stable anaesthesia and during 3 hours of CPB. In a randomised within-animal cross-over design, 5 sheep commenced CPB at a target body temperature of 30 o C (moderate-hypothermia). After 90 minutes, body temperature was increased to 36 o C (standard-procedure). The remaining 5 sheep were randomised to the opposite order of target body temperature. RESULTS Compared with the standard-procedure, moderately-hypothermic CPB reduced renal oxygen delivery (-34.8 ± 19.6%, P = 0.003) and renal oxygen consumption (-42.7 ± 35.2%, P = 0.04). Nevertheless, moderately-hypothermic CPB did not significantly alter either renal cortical or medullary tissue PO2 . Moderately-hypothermic CPB also did not significantly alter cerebral perfusion, cerebral tissue PO2 , or cerebral oxygen saturation compared with the standard-procedure. Compared with anaesthetised state, standard-procedure reduced renal medullary PO2 (-21.0 ± 13.8 mmHg, P = 0.014) and cerebral oxygen saturation (65.0 ± 7.0 to 55.4 ± 9.6%, P = 0.022) but did not significantly alter either renal cortical or cerebral PO2 . CONCLUSION Ovine experimental CPB leads to renal medullary tissue hypoxia. Moderately-hypothermic CPB did not improve cerebral or renal tissue oxygenation. In the kidney, this is probably because renal tissue oxygen consumption is matched by reduced renal oxygen delivery.
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Affiliation(s)
- Alemayehu H Jufar
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Roger G Evans
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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Prolonged postoperative cerebral oxygen desaturation after cardiac surgery: A prospective observational study. Eur J Anaesthesiol 2021; 38:966-974. [PMID: 33186311 DOI: 10.1097/eja.0000000000001391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is used routinely to monitor cerebral tissue oxygen saturation (SctO2) during cardiopulmonary bypass (CPB) but is rarely employed outside the operating room. Previous studies indicate that patients are at risk of postoperative cerebral oxygen desaturation after cardiac surgery. OBJECTIVES We aimed to assess perioperative and postoperative changes in NIRS-derived SctO2 in cardiac surgery patients. DESIGN Prospective observational study. SETTING The study was conducted in a tertiary referral university hospital in Australia from December 2017 to December 2018. PATIENTS We studied 34 adult patients (70.6% men) undergoing cardiac surgery requiring CPB and a reference group of 36 patients undergoing non-cardiac surgical procedures under general anaesthesia. MAIN OUTCOME MEASURES We measured SctO2 at baseline, during and after surgery, and then once daily until hospital discharge, for a maximum of 7 days. We used multivariate linear mixed-effects modelling to adjust for all relevant imbalances between the two groups. RESULTS In the cardiac surgery group, SctO2 was 63.7% [95% confidence interval (CI), 62.0 to 65.5] at baseline and 61.0% (95% CI, 59.1 to 62.9, P = 0.01) on arrival in the ICU. From day 2 to day 7 after cardiac surgery, SctO2 progressively declined. At hospital discharge, SctO2 was significantly lower than baseline, at 53.5% (95% CI, 51.8 to 55.2, P < 0.001). In the reference group, postoperative SctO2 was not significantly different from baseline. On multivariable analysis, cardiac surgery, peripheral vascular disease and time since the operation were associated with greater cerebral desaturation, whereas higher haemoglobin concentrations were associated with slightly better cerebral oxygenation. CONCLUSION After cardiac surgery on CPB, but not after non-cardiac surgery, most patients experience prolonged cerebral desaturation. Such postoperative desaturation remained unresolved 7 days after surgery. The underlying mechanisms and time to resolution of such cerebral desaturations require further investigation.
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Couture EJ, Deschamps A, Denault AY. Patient management algorithm combining processed electroencephalographic monitoring with cerebral and somatic near-infrared spectroscopy: a case series. Can J Anaesth 2019; 66:532-539. [DOI: 10.1007/s12630-019-01305-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/09/2018] [Accepted: 11/09/2018] [Indexed: 11/28/2022] Open
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Perioperative cerebral oxygenation in patients undergoing aortic valve replacement. Eur J Anaesthesiol 2017; 34:849-851. [PMID: 29087997 DOI: 10.1097/eja.0000000000000667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Scott JP, Hoffman GM. Near-infrared spectroscopy: exposing the dark (venous) side of the circulation. Paediatr Anaesth 2014; 24:74-88. [PMID: 24267637 DOI: 10.1111/pan.12301] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2013] [Indexed: 11/28/2022]
Abstract
The safety of anesthesia has improved greatly in the past three decades. Standard perioperative monitoring, including pulse oximetry, has practically eliminated unrecognized arterial hypoxia as a cause for perioperative injury. However, most anesthesia-related cardiac arrests in children are now cardiovascular in origin, and standard monitoring is unable to detect many circulatory abnormalities. Near-infrared spectroscopy provides noninvasive continuous access to the venous side of regional circulations that can approximate organ-specific and global measures to facilitate the detection of circulatory abnormalities and drive goal-directed interventions to reduce end-organ ischemic injury.
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Affiliation(s)
- John P Scott
- Departments of Anesthesiology and Pediatrics, Medical College of Wisconsin, Pediatric Anesthesiology and Critical Care Medicine, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Hogan AM, Shipolini A, Brown MM, Hurley R, Cormack F. Fixing hearts and protecting minds: a review of the multiple, interacting factors influencing cognitive function after coronary artery bypass graft surgery. Circulation 2013; 128:162-71. [PMID: 23836829 DOI: 10.1161/circulationaha.112.000701] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alexandra M Hogan
- MBBS, Developmental Cognitive Neuroscience Unit, UCL Institute of Child Health, 30 Guildford St, London, WC1E 6BT, United Kingdom.
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Roman PEF, Grigore AM. Pro: hypothermic cardiopulmonary bypass should be used routinely. J Cardiothorac Vasc Anesth 2012; 26:945-8. [PMID: 22790158 DOI: 10.1053/j.jvca.2012.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Philip E F Roman
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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9
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Pedersen LM, Nielsen J, Østergaard M, Nygård E, Nielsen HB. Increased intrathoracic pressure affects cerebral oxygenation following cardiac surgery. Clin Physiol Funct Imaging 2012; 32:367-71. [DOI: 10.1111/j.1475-097x.2012.01138.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 03/13/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - Jonas Nielsen
- Department of Anaesthesia; Rigshospitalet; University of Copenhagen; Copenhagen; Denmark
| | - Morten Østergaard
- Department of Anaesthesia; Rigshospitalet; University of Copenhagen; Copenhagen; Denmark
| | - Eigil Nygård
- Department of Thoracic Anaesthesia; Varde Heart Center; Varde; Denmark
| | - Henning B. Nielsen
- Department of Anaesthesia; Rigshospitalet; University of Copenhagen; Copenhagen; Denmark
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Sung TY, Kang WS, Han SJ, Kim JS, Chee HK, Shin JK, Kim SH. Does Near-Infrared Spectroscopy Provide an Early Warning of Low Haematocrit following the Initiation of Hypothermic Cardiopulmonary Bypass in Cardiac Surgery? J Int Med Res 2011; 39:1497-503. [DOI: 10.1177/147323001103900439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated 151 patients undergoing cardiac surgery to determine whether measurement of regional cerebral oxygen saturation (rScO2) using near-infrared spectroscopy (NIRS) can indicate a low haematocrit after initiation of hypothermic cardiopulmonary bypass (CPB). Haematocrit, rScO2, haemoglobin level, arterial partial pressures of carbon dioxide and oxygen, systemic blood pressure, and nasopharyngeal and rectal temperatures were determined 5 min after the initial administration of heparin for CPB and 90 s after completion of the first cardioplegic solution injection. Immediately after initiation of hypothermic CPB, rScO2, haemoglobin and haematocrit values were significantly lower than those before CPB. No significant correlations were found between the change in haematocrit and changes in left, right and mean rScO2; thus, changes in rScO2 before and after initiation of hypothermic CPB did not reflect changes in haematocrit values. This indicates that NIRS cannot provide early warning of a low haematocrit immediately after initiation of hypothermic CPB in cardiac surgery.
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Affiliation(s)
- TY Sung
- Department of Anaesthesiology and Pain Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - WS Kang
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - SJ Han
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - JS Kim
- Department of Cardiovascular and Thoracic Surgery, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - HK Chee
- Department of Cardiovascular and Thoracic Surgery, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - JK Shin
- Department of Cardiovascular and Thoracic Surgery, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - SH Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
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11
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Quarti A, Manfrini F, Oggianu A, D'Orfeo F, Genova S, Silvano R, Pozzi M. Non-invasive cerebral oximetry monitoring during cardiopulmonary bypass in congenital cardiac surgery: a starting point. Perfusion 2011; 26:289-93. [PMID: 21339245 DOI: 10.1177/0267659111399952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Non-invasive cerebral monitoring with the INVOS cerebral oximeter is an accepted good indicator of cerebral metabolism. In recent years, it has been used in the monitoring of patients who underwent cardiac surgery. Herein, we describe the INVOS trend during cardiopulmonary bypass (CPB) in a cohort of patients operated in our institution for congenital heart disease. PATIENTS AND METHODS Between December 2009 and March 2010, 40 patients (mean age 8.4 years; range 11 days-60 years) underwent cardiac surgical procedures using CPB. Values of INVOS cerebral parameter, pH, oxygen saturation, and CO(2) level were collected pre CPB, during cooling, re-warming and weaning, and post CPB. INVOS parameters were evaluated according to CPB priming, age and preoperative oxygen saturation. RESULTS Patients were divided according to CPB priming (haematic vs clear), age (≤1 vs >1 year of age) and oxygen saturation (≤92% vs >92%). During the operations, the trend demonstrated a reduction in INVOS value at the institution of CPB and a further reduction during the cooling phase in all groups.This has been correlated to the loss of pulsatile flow. However, the value recovered during re-warming, weaning and CPB discontinuation. Cyanotic patients presented a lower cerebral oximetry compared to acyanotic patients during the whole CPB period. Between age and priming groups, we noticed a statistical difference in cerebral oximetry, with a lower value in the younger patients and in the haematic priming group. This might be interrelated because all patients younger than 1 year old always received haematic CPB priming. CONCLUSIONS We demonstrated that cerebral oximetry decreases with the loss of pulsatile flow regardless of the mean arterial pressure and, furthermore, is not directly related to the haematocrit value in patients with reduced pulmonary blood flow.
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Affiliation(s)
- A Quarti
- Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliera Ospedali Riuniti, Ancona Via Conca 71, Ancona, Italy.
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Hoffman GM, Ghanayem NS. Perioperative neuromonitoring in pediatric cardiac surgery: Techniques and targets. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Song SY, Cho CB, Chung JY, Roh WS, Kim BI, Lee S. Total Intravenous Anesthesia for Open Heart Surgery in a Patient with a Moyamoya Disease - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.1.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seok Young Song
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Cheol Beom Cho
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Jin Yong Chung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Woon Seok Roh
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Bong Il Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Sub Lee
- Department of Cardiothoracic Surgery, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Ohmae E, Oda M, Suzuki T, Yamashita Y, Kakihana Y, Matsunaga A, Kanmura Y, Tamura M. Clinical evaluation of time-resolved spectroscopy by measuring cerebral hemodynamics during cardiopulmonary bypass surgery. JOURNAL OF BIOMEDICAL OPTICS 2007; 12:062112. [PMID: 18163815 DOI: 10.1117/1.2804931] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We developed a three-wavelength time-resolved spectroscopy (TRS) system, which allows quantitative measurement of hemodynamics within relatively large living tissue. We clinically evaluated this TRS system by monitoring cerebral circulation during cardiopulmonary bypass surgery. Oxyhemoglobin, deoxyhemoglobin, total hemoglobin and oxygen saturation (SO(2)) were determined by TRS on the left forehead attached with an optode spacing of 4 cm. We also simultaneously monitored jugular venous oxygen saturation (SjvO(2)) and arterial blood hematocrit (Hct) using conventional methods. The validity and usefulness of the TRS system were assessed by comparing parameters obtained with the TRS and conventional methods. Although the changes in SO(2) were lower than those in SjvO(2), SO(2) obtained by TRS paralleled the fluctuations in SjvO(2), and a good correlation between these values was observed. The only exceptions occurred during the perfusion period. Moreover, there was a good correlation between tHb and Hct values (r(2)=0.63). We concluded that time-resolved spectroscopy reflected the conditions of cerebral hemodynamics of patients during surgical operations.
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Affiliation(s)
- Etsuko Ohmae
- Hamamatsu Photonics K.K., Central Research Laboratory, 5000 Hirakuchi, Hamamatsu, Shizuoka, 434-8601, Japan.
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Liebold A, Khosravi A, Westphal B, Skrabal C, Choi YH, Stamm C, Kaminski A, Alms A, Birken T, Zurakowski D, Steinhoff G. Effect of closed minimized cardiopulmonary bypass on cerebral tissue oxygenation and microembolization. J Thorac Cardiovasc Surg 2006; 131:268-76. [PMID: 16434253 DOI: 10.1016/j.jtcvs.2005.09.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Revised: 09/02/2005] [Accepted: 09/13/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Coronary artery bypass grafting with cardiopulmonary bypass carries a risk for neurologic complications because of cerebral hypoperfusion and microembolization. The basic goals of a novel closed minimized extracorporeal circulation are to prevent excessive hemodilution and to avoid blood-air interface. The aim of this prospective randomized study was to determine the effect of using the minimized extracorporeal circulation system compared with open conventional extracorporeal circulation on cerebral tissue oxygenation and microembolization. METHODS Forty patients undergoing coronary artery bypass grafting (20 in each group) were continuously monitored for changes in cerebral oxygenated hemoglobin and tissue oxygenation index by using near-infrared spectroscopy. Total microembolic count and gaseous embolic count in both median cerebral arteries were monitored with multifrequency transcranial Doppler instrumentation. RESULTS In the conventional extracorporeal circulation group there was a highly significant reduction in both cerebral oxygenated hemoglobin and tissue oxygenation index from the start to the end of cardiopulmonary bypass (P < .01). The rate of decrease in cerebral oxygenated hemoglobin after aortic cannulation was faster in the conventional extracorporeal circulation group (F test = 9.03, P < .001). No significant changes with respect to cerebral oxygenated hemoglobin or tissue oxygenation index occurred in the minimized extracorporeal circulation group, except at the beginning of rewarming (P < .01). Total embolic count, as well as gaseous embolic count, in the left and right median cerebral arteries was significantly lower in the minimized extracorporeal circulation group (all P < .05). Postoperative bleeding was greater (P < .05) and the transfusion rate was higher (P < .05) in the conventional extracorporeal circulation group. CONCLUSIONS Use of closed minimized cardiopulmonary bypass compared with conventional open cardiopulmonary bypass preserves cerebral tissue oxygenation and reduces cerebral microembolization.
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Affiliation(s)
- A Liebold
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany.
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Imamaki M, Nakajima N, Masuda M, Ishida A, Shimura H, Miyazaki M. Is it safe to initiate selective cerebral perfusion with normothermia? J Card Surg 2005; 20:408-11. [PMID: 16153269 DOI: 10.1111/j.1540-8191.2005.200436.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Preceding selective cerebral perfusion (P-SCP) is a method whereby SCP and systemic perfusion start simultaneously, and the arch vessels are clamped. Cerebral circulation is isolated from systemic circulation to avoid cerebral embolization due to detachment of atherosclerotic material from the aorta, caused by the "sandblasting" effect of high-velocity jets of blood exiting the aortic cannula. However, neither the safety of SCP at normothermia nor the influence of extended SCP time has been sufficiently clarified. To clarify the safety of P-SCP, the comparison study of P-SCP and conventional SCP (C-SCP) was performed retrospectively. METHODS Fifty-seven patients (C-SCP group: 29 patients; P-SCP: 28 patients) underwent surgery between 1992 and 2002. RESULTS Nine (15.8%) in-hospital death occurred; 4 in the C-SCP group (13.8%) and 5 in the P-SCP group (17.9%) (NS). The SCP time was 136.6 +/- 68.5 minutes in the C-SCP group and 195.8 +/- 30.7 minutes in the P-SCP group (p < 0.05). One patient in each group exhibited postoperative neurological dysfunction. CONCLUSION It may be little dangerous to initiate the SCP with normothermia. P-SCP may be useful in cases in which there is pedunculated atherosclerotic material, or mural thrombus in the ascending and arch aorta.
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Affiliation(s)
- Mizuho Imamaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Abstract
A debate has emerged in recently published studies about the optimum cardiopulmonary bypass temperature for good neurological outcome - warm vs. cold, i.e. normothermic vs. hypothermic. Although many comparative studies have been performed, the results of these studies are inconclusive and are difficult to interpret. Brain function has been studied in terms of neurological and neuropsychological outcome, protein S100beta levels as a marker of brain damage, and cerebral oxygenation using jugular bulb oximetry and near-infrared spectroscopy. The studies produce no conclusive proof of the superiority of warm or cold cardiopulmonary bypass. However, it appears that any degree of bypass hypothermia (< 35 degrees C) may protect the brain. On the other hand, even a slight increase in bypass temperature to > 37 degrees C may cause marked brain injury.
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Affiliation(s)
- M Shaaban Ali
- Department of Anaesthesia, College of Medicine, Assiut University Hospital, Assiut, BO Box 71111, Egypt.
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Ueno T, Ikeda K, Matsuyama S. Characteristic changes in cerebral perfusion during on-pump and off-pump coronary artery surgery. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2005; 53:138-42. [PMID: 15828293 DOI: 10.1007/s11748-005-0019-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE We investigated the cerebral perfusion status during on-pump or off-pump coronary artery bypass grafting (CABG). METHODS We monitored somatosensory evoked potential (SEP) and regional cerebral oxygen saturation (rSO2) as parameters of cerebral perfusion in an on-pump group (n=10) and an off-pump group (n=16). The percent changes from control values were calculated before, during, and after aortic clamping, and after weaning from cardiopulmonary bypass, in the on-pump group. In the off-pump group, these were calculated before, during, and after heart displacement for distal anastomosis. RESULTS In the on-pump group, the amplitudes of the SEP were significantly enhanced during and after aortic cross-clamping and were associated with a significant decrease in rSO2. Latency was prolonged immediately after aortic cross-clamping, but was shortened afterwards. There was little change in these parameters throughout the operation, in the off-pump group. CONCLUSIONS Cerebral perfusion remains stable during off-pump CABG. The etiology of a simultaneous increase in SEP amplitude and decrease in rSO2 during the rewarming period in the on-pump group requires further investigation.
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Affiliation(s)
- Tetsuya Ueno
- Division of Cardiovascular Surgery, Ureshino Medical Center, Ureshino-machi, Saga, Japan
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Taillefer MC, Denault AY. Cerebral near-infrared spectroscopy in adult heart surgery: systematic review of its clinical efficacy. Can J Anaesth 2005; 52:79-87. [PMID: 15625262 DOI: 10.1007/bf03018586] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE This systematic review is aimed at answering the following questions: 1) Is near-infrared spectroscopy (NIRS) clinically effective in detecting cerebral desaturation during heart surgery? 2) Are these results based on studies with solid methodology? SOURCES MEDLINE, internet, and hand searches up to February 2004 for English and French papers on NIRS. PRINCIPAL FINDINGS Forty-eight papers were retrieved, with a total of 5,931 cardiac surgery patients monitored by NIRS. More than 83% of patients underwent coronary artery bypass graft surgery. The majority of studies were prospective for the monitored group. Clinically, NIRS monitoring appears to detect brain desaturation episodes encountered during surgery. However, the majority of studies retrieved suffered from major methodological limitations and a low level of evidence. NIRS validity vs jugular bulb oximetry is questioned together with its predictive value in identifying those who will suffer postoperatively from neurological deficits. The sole randomized controlled trial appears to have recorded negative results in this respect. CONCLUSION The clinical application of NIRS in heart surgery as a brain-monitoring device seems interesting. However, NIRS has to be investigated more rigorously to prove its clinical utility in cardiac surgery.
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Affiliation(s)
- Marie-Christine Taillefer
- Department of Anesthesiology, Montreal Heart Institute, Room R-2230, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada.
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Li ZJ, Yin XM, Ye J. Effects of pH management during deep hypothermic bypass on cerebral oxygenation: alpha-stat versus pH-stat. JOURNAL OF ZHEJIANG UNIVERSITY. SCIENCE 2004; 5:1290-1297. [PMID: 15362203 PMCID: PMC1388736 DOI: 10.1631/jzus.2004.1290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2003] [Accepted: 03/09/2004] [Indexed: 05/24/2023]
Abstract
OBJECTIVE There is a remarkable lack of scientific evidence to support the option to use alpha-stat or pH-stat management, as to which is more beneficial to brain protection during deep hypothermic CPB. This study examined cortical blood flow (CBF), cerebral oxygenation, and brain oxygen consumption in relation to deep hypothermic CPB with alpha-stat or pH-stat management. METHODS Twenty-two pigs were cooled with alpha-stat or pH-stat during CPB to 15 degrees C esophageal temperature. CBF and cerebral oxygenation were measured continuously with a laser flowmeter and near-infrared spectroscopy, respectively. Brain oxygen consumption was measured with standard laboratory techniques. RESULTS During CPB cooling, CBF was significantly decreased, about 52.2%+/-6.3% (P<0.01 vs 92.6%+/-6.5% of pH-stat) at 15 degrees C in alpha-stat, whereas there were no significant changes in CBF in pH-stat. While cooling down, brain oxygen extraction (OER) progressively decreased, about 9.5%+/-0.9% and 10.9%+/-1.5% at 15 degrees C in alpha-stat and pH-stat, respectively. At 31 degrees C the decreased value in pH-stat was lower than in alpha-stat (29.9%+/-2.7% vs 22.5%+/-1.9%; P<0.05). The ratio of CBF/OER were 2.0+/-0.3 in alpha-stat and pH-stat, respectively; it was kept in constant level in alpha-stat, and significantly increased by 19 degrees C to 15 degrees C in pH-stat (4.9+/-0.9 vs 2.3+/-0.4; P<0.01). In mild hypothermia, cerebral oxyhemoglobin and oxygen saturation in alpha-stat were greater than that in pH-stat (102.5%+/-1.4% vs 99.1%+/-0.7%; P<0.05). In deep hypothermia, brain oxygen saturation in pH-stat was greater than that in alpha-stat (99.2%+/-1.0% vs 93.8%+/-1.0%; P<0.01), and deoxyhemoglobin in pH-stat decreased more greatly than that in alpha-stat (28.7%+/-6.8% vs 54.1%+/-4.7%; P<0.05). CONCLUSIONS In mild hypothermic CPB, brain tissue oxygen saturation was greater in alpha-stat than in pH-stat. However, cerebral oxygenation and brain tissue oxygen saturation were better in pH-stat than in alpha-stat during profound hypothermia. PH-stat strategy provided much more oxygen to brain tissue before deep hypothermic circulatory arrest.
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Affiliation(s)
- Zhi-jun Li
- Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou 310016, China.
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Ali MS, Harmer M, Vaughan RS, Dunne JA, Latto IP, Haaverstad R, Kulatilake ENP, Butchart EG. Changes in cerebral oxygenation during cold (28 degrees C) and warm (34 degrees C) cardiopulmonary bypass using different blood gas strategies (alpha-stat and pH-stat) in patients undergoing coronary artery bypass graft surgery. Acta Anaesthesiol Scand 2004; 48:837-44. [PMID: 15242427 DOI: 10.1111/j.1399-6576.2004.00436.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Impaired cerebral oxygenation, which is reflected by measuring jugular bulb oxygenation, is thought to play an important role in the development of neurological injury after cardiac operations with cardiopulmonary bypass (CPB). The effects of cardiopulmonary temperature and blood gas strategy on cerebral oxygenation are not fully appreciated. METHODS Sixty patients were randomly allocated into four equal groups (cold alpha-stat, cold pH-stat, warm alpha-stat and warm pH-stat) to compare the effect of these perfusion strategies on cerebral oxygenation monitored by jugular bulb oximetry [jugular bulb oxygen saturation (SjO(2)) and arterial-jugular bulb oxygen content difference (AjDO(2))]. Jugular bulb oxygen saturation and AjDO(2) were measured before CPB, after 5, 20, 40 min on CPB, at start and end of rewarming, 5 min before the end of CPB and 10 min after CPB. Two-way analysis of variance was used to model the lowest SjO(2) and highest AjDO(2) during CPB, with CPB temperature and blood gas management as contributing factors. RESULTS Significant changes in SjO(2) were only related to the type of blood gas management, with no significant difference between warm and cold CPB patients. In addition, during rewarming, desaturation (SjO(2) </= 50%) occurred in seven patients of 30 in the alpha-stat groups and in one patient of 30 in the pH-stat groups (P = 0.021), and in five patients of 30 in the cold groups vs. three of 30 in the warm groups (P = 0.434). However, no significant changes were found in the highest AjDO(2) between the four groups. CONCLUSION Cold CPB failed to offer any further brain protection in terms of better preservation of cerebral oxygenation than warm CPB. Therefore, warm CPB (34 degrees C) with different blood gas strategies appears to be a satisfactory alternative to cold CPB (28 degrees C).
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Affiliation(s)
- M Shaaban Ali
- Department of Anaesthetics, Assiut University Hospital, Assiut, Egypt.
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Hoffman GM, Stuth EA, Jaquiss RD, Vanderwal PL, Staudt SR, Troshynski TJ, Ghanayem NS, Tweddell JS. Changes in cerebral and somatic oxygenation during stage 1 palliation of hypoplastic left heart syndrome using continuous regional cerebral perfusion. J Thorac Cardiovasc Surg 2004; 127:223-33. [PMID: 14752434 DOI: 10.1016/j.jtcvs.2003.08.021] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Stage 1 palliation of hypoplastic left heart syndrome requires the interruption of whole-body perfusion. Delayed reflow in the cerebral circulation secondary to prolonged elevation in vascular resistance occurs in neonates after deep hypothermic circulatory arrest. We examined relative changes in cerebral and somatic oxygenation with near-infrared spectroscopy while using a modified perfusion strategy that allowed continuous cerebral perfusion. METHODS Nine neonates undergoing stage 1 palliation for hypoplastic left heart syndrome had regional tissue oxygenation continuously measured by frontal cerebral and thoraco-lumbar (T10-L2) somatic (renal) reflectance oximetry probes (rSO(2), INVOS; Somanetics, Troy, Mich). Surgery was accomplished using cardiopulmonary bypass with whole-body cooling (18 degrees C-20 degrees C) and regional cerebral perfusion through the innominate artery at flow rates guided by estimated minimum flow requirements and measured rSO(2) during reconstruction of the aortic arch. Data were logged at 1-minute intervals and analyzed using repeated measures analysis of variance. RESULTS A total of 3176 minutes of data were analyzed. Prebypass cerebral rSO(2) was 65.4 +/- 8.9, and somatic rSO(2) was 58.9 +/- 12.4 (P <.001, cerebral vs somatic). During regional cerebral perfusion, cerebral rSO(2) was 80.7 +/- 8.6, and somatic rSO(2) was 41.4 +/- 7.1 (P <.001). Postbypass cerebral rSO(2) was 53.2 +/- 14.9, and somatic rSO(2) was 76.4 +/- 7.7 (P <.001). The risk of cerebral desaturation was significantly increased after cardiopulmonary bypass. CONCLUSIONS Cerebral oxygenation was maintained during regional cerebral perfusion at prebypass levels with deep hypothermia. However, after rewarming and separation from cardiopulmonary bypass, cerebral oxygenation was lower compared with prebypass or somatic values. These results indicate that cerebrovascular resistance is increased after deep hypothermic cardiopulmonary bypass, even with continuous perfusion techniques, placing the cerebral circulation at risk postoperatively.
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Affiliation(s)
- George M Hoffman
- Department of Pediatric Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee 53226, USA.
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Shaaban Ali M, Harmer M, Elliott M, Thomas AL, Kirkham F. A pilot study of evaluation of cerebral function by S100? protein and near-infrared spectroscopy during cold and warm cardiopulmonary bypass in infants and children undergoing open-heart surgery. Anaesthesia 2004; 59:20-6. [PMID: 14687094 DOI: 10.1111/j.1365-2044.2004.03578.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cerebral injury in children undergoing cardiopulmonary bypass (CPB) remains a major source of morbidity. The effect of cardiopulmonary bypass temperature on cerebral function in terms of serum S100beta protein level and cerebral oxygenation monitored by near infrared spectroscopy (NIRO-300) in children is not known. In this study, 18 children undergoing open-heart surgery at the Hospital for Sick Children in London were equally assigned by minimisation to warm (35 +/- 1 degrees C) or cold (25 +/- 1 degrees C) CPB. Changes in S100beta protein and cerebral oxygenation were studied in both groups. S100beta protein serum level increased significantly after CPB in both groups. There was no significant difference in serum S100beta protein concentrations between the two groups. However, cerebral oxygenation in terms of tissue oxygen index (TOI) was significantly impaired during rewarming from cold CPB. Five patients were desaturated (TOI < 50%) during rewarming in the cold bypass group compared to two in the warm patients. This study supports the use of warm CPB in children undergoing open-heart surgery, although further studies recruiting more patients are warranted.
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Affiliation(s)
- M Shaaban Ali
- Lecturer of Anaesthesia, Department of Anaesthesia, Assiut University Hospital, Assiut, BO Box 71111, Egypt.
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Kadoi Y, Fujita N. Increasing mean arterial pressure improves jugular venous oxygen saturation in patients with and without preexisting stroke during normothermic cardiopulmonary bypass. J Clin Anesth 2003; 15:339-44. [PMID: 14507558 DOI: 10.1016/s0952-8180(03)00063-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To examine whether increasing mean arterial pressure (MAP) with the administration of phenylephrine would improve internal jugular venous oxygen saturation (SjvO2) during normothermic cardiopulmonary bypass (CPB) in patients with preexisting stroke. DESIGN Prospective, controlled study. SETTING Cardiovascular center and university hospital. PATIENTS 17 patients with preexisting stroke who were scheduled for elective coronary artery bypass graft (CABG) surgery, and a control group of 17 age-matched patients without preexisting stroke. INTERVENTIONS After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor SjvO2. After measuring the baseline partial pressure of the arterial and jugular venous blood gases and cardiovascular hemodynamic values immediately before the start of the study protocol, MAP was increased by the repeated administration of a 10 microg bolus of phenylephrine, until it reached 200% of baseline values. MEASUREMENTS Partial pressure of the arterial and jugular venous blood gases and cardiovascular hemodynamic values before and after the treatment were recorded. MAIN RESULTS There was no significant difference between the groups in SjvO2 values at baseline (Mann-Whitney U test: p = 0.22). SjvO2 values in both groups were increased after the administration of phenylephrine (SjvO2 values in the control group: 60 +/- 5%, SjvO2 values in the stroke group: 57 +/- 5%). There was no significant difference between the stroke and control groups in SjvO2 values after the administration of phenylephrine (Mann-Whitney U test: p = 0.08). CONCLUSIONS Increasing MAP improves SjvO2 in patients with or without preexisting stroke during normothermic CPB.
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Affiliation(s)
- Yuji Kadoi
- Department of Intensive Care Medicine, Gunma University, School of Medicine, Maebashi, Gunma, Japan.
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Kawahara F, Kadoi Y, Saito S, Goto F, Fujita N. Slow rewarming improves jugular venous oxygen saturation during rewarming. Acta Anaesthesiol Scand 2003; 47:419-24. [PMID: 12694140 DOI: 10.1034/j.1399-6576.2003.00063.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There have been many studies regarding the etiology of postoperative cognitive dysfunction after coronary artery bypass graft (CABG) surgery. Although its etiology remains unresolved, one possible factor related to postoperative cognitive dysfunction is a reduced internal jugular venous oxygen hemoglobin saturation (SjvO2) during the rewarming period. The purpose of this study was to examine the effect of rewarming rates on SjvO2 during rewarming. METHODS One-hundred patients scheduled for elective CABG surgery were randomly divided into two groups; control group (0.48 +/- 0.09 degrees C, n = 50), slow rewarming group (0.24 +/- 0.09 degrees C, n = 50). After the induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to monitor SjvO2 continuously. Hemodynamic parameters, arterial and jugular venous blood gases were measured at nine time-points. RESULTS Cerebral desaturation (defined as a SjvO2 value below 50%) during rewarming was more frequent in the control group than in the slow group. Cerebral desaturation time (duration when SjvO2 was less than 50%) and the ratio of the cerebral desaturation time to the total CPB time in the control group differed significantly from those in the slow group (control group: 17 +/- 11 min, 12 +/- 4%, slow group: 10 +/- 8 min, 7 +/- 4%, respectively, P < 0.05). There was no significant difference in mini-mental state examination on the day before the operation nor at 1 month after the surgery among four values (the day before the operation: control group; 48 +/- 8, slow group; 48 +/- 7, at one month after the surgery: control group; 46 +/- 7, slow group; 45 +/- 9). CONCLUSIONS A slow rewarming rate could reduce the chance of a decrease in SjvO2 during rewarming.
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Affiliation(s)
- F Kawahara
- Department of Anesthesiology and Reanimatology, Gunma University, School of Medicine and Department of Anesthesiology, Keiyu Orthopedic Hospital, Gunma, Japan
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Kadoi Y, Saito S, Kunimoto F, Goto F, Fujita N. Comparative effects of propofol versus fentanyl on cerebral oxygenation state during normothermic cardiopulmonary bypass and postoperative cognitive dysfunction. Ann Thorac Surg 2003; 75:840-6. [PMID: 12645704 DOI: 10.1016/s0003-4975(02)04498-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The purpose of this study was to examine the comparative effects of propofol and fentanyl on cerebral oxygenation during normothermic cardiopulmonary bypass and postoperative cognitive dysfunction. METHODS One hundred eighty patients scheduled for elective coronary artery bypass grafting were randomly divided into two groups: propofol group (n = 90) and fentanyl group (n = 90). After induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to monitor jugular venous oxygen hemoglobin saturation continuously. Hemodynamic measurements and arterial and jugular venous blood gases were measured at seven time points. All patients underwent a battery of neurologic and neuropsychological tests on the day before the operation and at 6 months after the operation. RESULTS Cerebral desaturation (defined as a jugular venous oxygen hemoglobin saturation value less than 50%) during cardiopulmonary bypass was more frequent in the fentanyl group than in the propofol group. Cerebral desaturation time (duration when jugular venous oxygen hemoglobin saturation was less than 50%) and the ratio of cerebral desaturation time to total cardiopulmonary bypass time in the fentanyl group differed significantly from those in the propofol group (fentanyl group: 27 +/- 14 minutes, 20% +/- 9%; propofol group: 18 +/- 11 minutes, 14% +/- 7%, respectively, p < 0.05). There was no significant difference in postoperative cognitive dysfunction at 6 months after operation between the two groups (propofol group: 5 of 77, 6%; fentanyl group: 5 of 75, 7%). CONCLUSIONS Propofol preserved cerebral oxygenation state estimated by jugular venous oxygenation during cardiopulmonary bypass compared with the fentanyl group. However, propofol did not affect postoperative cognitive dysfunction.
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Affiliation(s)
- Yuji Kadoi
- Division of Intensive Care Medicine, Gunma University, School of Medicine, Maebashi, Gunma, Japan.
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Kadoi Y, Saito S, Yoshikawa D, Goto F, Fujita N, Kunimoto F. Increasing mean arterial blood pressure has no effect on jugular venous oxygen saturation in insulin-dependent patients during tepid cardiopulmonary bypass. Anesth Analg 2002; 95:266-72, table of contents. [PMID: 12145032 DOI: 10.1097/00000539-200208000-00002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Preexisting diabetes mellitus is one of the major factors related to adverse postoperative neurological disorders after cardiac surgery. In previous reports, we found that diabetic patients more often experienced cerebral desaturation than nondiabetic patients during normothermic cardiopulmonary bypass (CPB). The purpose of this study was to examine the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen hemoglobin saturation (SjvO2) during tepid CPB in diabetic patients. We studied 20 diabetic patients scheduled for elective coronary artery bypass graft surgery and, as a control, 20 age-matched nondiabetic patients. After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor SjvO2. After measuring the baseline partial pressure of the arterial and jugular venous blood gases and cardiovascular hemodynamic values, MAP was increased by the repeated administration of a 10-microg bolus of phenylephrine until it reached 100% of baseline values. There was a significant difference in SjvO2 value between the Diabetic and CONTROL GROUPs after the administration of phenylephrine (Diabetic group, 56% +/- 6%; CONTROL GROUP 60% +/- 4%) (P < 0.05). There was a significant difference in the arterial-jugular oxygen content difference value between the Diabetic and CONTROL GROUPs after the administration of phenylephrine (diabetic group, 4.9% +/- 0.6%; CONTROL GROUP, 4.5% +/- 0.4%) (P < 0.05). We subdivided the Diabetic group into three groups (Diet Therapy group [n = 4], Glibenclamide group [n = 10], and Insulin-Dependent group [n = 6]). There was a significant difference in the mean slopes of SjvO2 versus cerebral perfusion pressure for increasing cerebral perfusion pressure between the Insulin-Dependent group and the other groups (Dunnett test: P = 0.04). Increasing MAP had no effects on the SjvO2 value in insulin-dependent patients during tepid CPB. IMPLICATIONS We examined the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen saturation (SjvO2) during tepid cardiopulmonary bypass in diabetic patients and found that increasing MAP had no effect on the SjvO2 value in insulin-dependent patients.
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Affiliation(s)
- Yuji Kadoi
- Department of Anesthesiology and Reanimatology and Division of Intensive Care Unit, School of Medicine, Gunma University, Gunma, Japan.
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Kadoi Y, Saito S, Yoshikawa D, Goto F, Fujita N, Kunimoto F. Increasing Mean Arterial Blood Pressure Has No Effect on Jugular Venous Oxygen Saturation in Insulin-Dependent Patients During Tepid Cardiopulmonary Bypass. Anesth Analg 2002. [DOI: 10.1213/00000539-200208000-00002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kadoi Y, Saito S, Goto F, Fujita N. Slow rewarming has no effects on the decrease in jugular venous oxygen hemoglobin saturation and long-term cognitive outcome in diabetic patients. Anesth Analg 2002; 94:1395-401, table of contents. [PMID: 12031995 DOI: 10.1097/00000539-200206000-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED The purpose of this study was to examine the effects of rewarming rate on internal jugular venous oxygen hemoglobin saturation (SjvO(2)) during the rewarming period, and long-term cognitive outcome in diabetic patients. We studied 30 diabetic patients scheduled for elective coronary artery bypass graft surgery. As a control, 30 age-matched nondiabetic patients were identified. The diabetic patients were randomly divided into two groups: the Slow Rewarming group (n = 15) (mean rewarming speed: 0.22 degrees +/- 0.07 degrees C/min, mean +/- SD) or the Standard Rewarming group (Standard group) (n = 15) (mean rewarming speed: 0.46 degrees +/- 0.09 degrees C/min, mean +/- SD). After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor SjvO(2) continuously. Hemodynamic variables and arterial and jugular venous blood gases were measured at nine time points. All patients underwent a battery of neurologic and neuropsychologic tests on the day before the operation and at 4 mo after surgery. The SjvO(2) values in the Standard group were decreased during the rewarming period compared with at the induction of anesthesia (P < 0.05). There was a significant difference in the SjvO(2) value in the Control group between standard rewarming and slow rewarming during rewarming periods (Standard Control group: 51% +/- 8%, Slow Control groups: 58% +/- 5%) (P < 0.05). However, there was no difference in the SjvO(2) value in diabetic patients between standard rewarming and slow rewarming during the rewarming period. The rewarming rates (odds ratio: 0.8; 95% confidence interval: 0.5-1.3; P = 0.6) had no correlation with cognitive impairment at 4 mo after the surgery. Diabetes (odds ratio: 1.6; 95% confidence interval: 0.9-2.6; P = 0.04) was a factor in relation to cognitive impairment at 4 mo after the surgery. We concluded that a slow rewarming rate had no effects on the reduction in SjvO(2) value and long-term cognitive outcome in diabetic patients. IMPLICATIONS We examined the effects of rewarming rate on internal jugular venous oxygen hemoglobin saturation in diabetic and nondiabetic patients during the rewarming period and long-term cognitive outcome. Slow rewarming could not prevent the frequency of the reduction in internal jugular venous oxygen hemoglobin saturation and adverse cognitive outcome in diabetic patients.
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Affiliation(s)
- Yuji Kadoi
- Department of Anesthesiology and Reanimatology, Gunma University School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.
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Kadoi Y, Saito S, Goto F, Fujita N. Slow Rewarming Has No Effects on the Decrease in Jugular Venous Oxygen Hemoglobin Saturation and Long-Term Cognitive Outcome in Diabetic Patients. Anesth Analg 2002. [DOI: 10.1213/00000539-200206000-00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shaaban-Ali M, Harmer M, Vaughan RS, Dunne JA, Latto IP. Changes in jugular bulb oxygenation in patients undergoing warm coronary artery bypass surgery (34-37 degrees C). Eur J Anaesthesiol 2001; 18:93-9. [PMID: 11270031 DOI: 10.1046/j.0265-0215.2000.00787.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Imbalance between cerebral oxygen supply and demand is thought to play an important role in the development of cerebral injury during cardiac surgery with cardiopulmonary bypass. METHODS We studied jugular bulb oxygen saturation, jugular bulb oxygen tension, arterial-jugular bulb oxygen content difference and oxygen extraction ratio in 20 patients undergoing warm coronary artery bypass surgery (34-37 degrees C) with pH-stat blood gas management. RESULTS Only two patients showed desaturation (jugular bulb oxygen saturation < 50%) at 5 min on bypass, and none from 20 min onwards. Multiple regression models were performed after using bypass temperature, mean arterial pressure, cerebral perfusion pressure, haemoglobin concentration and arterial carbon dioxide tension as independent variables, and arterial-jugular bulb oxygen content difference, jugular bulb oxygen saturation, oxygen extraction ratio and jugular bulb oxygen tension as individual dependent variables. CONCLUSIONS We found that jugular bulb oxygen saturation, jugular bulb oxygen tension and oxygen extraction ratio are mainly dependent on arterial carbon dioxide tension, and arterial-jugular bulb oxygen content difference is dependent on arterial carbon dioxide tension and the bypass temperature. Our results suggest jugular bulb oxygenation is mainly dependent on arterial carbon dioxide tension during warm cardiopulmonary bypass.
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Affiliation(s)
- M Shaaban-Ali
- Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Hospital, Heath Park, Cardiff, CF14 4XN, UK
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Abstract
Imbalance between cerebral oxygen supply and demand is thought to play an important role in the development of cerebral injury during cardiac surgery. This article presents an overview of cerebral oxygenation monitored by jugular bulb oximetry during cardiac surgery with cardiopulmonary bypass. The general principles of jugular bulb oximetry including physiology, intermittent and continuous monitoring, technical considerations, limitations and potential complications are discussed. Different applications of jugular bulb oximetry during bypass surgery and the possible therapeutic approaches to impaired cerebral oxygenation are described.
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Affiliation(s)
- M Shaaban Ali
- Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, UK
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Rees K, Beranek-Stanley M, Burke M, Ebrahim S. Hypothermia to reduce neurological damage following coronary artery bypass surgery. Cochrane Database Syst Rev 2001; 2001:CD002138. [PMID: 11279752 PMCID: PMC8407455 DOI: 10.1002/14651858.cd002138] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Coronary artery bypass surgery (CABG) may be life saving, but known side effects include neurological damage and cognitive impairment. The temperature used during cardiopulmonary bypass (CPB) may be important with regard to these adverse outcomes, where hypothermia is used as a means of neuroprotection. OBJECTIVES To assess the effectiveness of hypothermia during CABG in reducing neurological damage and subsequent cognitive deficits. SEARCH STRATEGY The Cochrane Controlled Trials Register was searched for randomised controlled trials (RCT) and this was updated by searching MEDLINE and EMBASE to December 1999 using database specific RCT filters. Reference lists of retrieved articles were searched and experts in the field were contacted. SELECTION CRITERIA Only RCTs were considered. All patients undergoing CABG, either first time or revisions, elective or emergency procedures, were included. Any hypothermia protocol was considered. Only trials reporting neurological outcomes were included. DATA COLLECTION AND ANALYSIS Studies were selected independently and data were extracted from the source papers independently by two reviewers. Authors were contacted for further information. Studies were combined with meta-analysis where appropriate, and meta-regression was used to explore heterogeneity. MAIN RESULTS There was a trend towards a reduction in the incidence of non fatal strokes in the hypothermic group (OR 0.68 (0.43, 1.05)). Conversely, there was a trend for the number of non stroke related perioperative deaths to be higher in the hypothermic group (OR 1.46 (0.9, 2.37)). Hypothermia had no effect on the incidence of non fatal myocardial infarction (OR 1.05 (0.81, 1.37)), but the incidence of another marker of myocardial damage, low output syndrome, was higher in the hypothermic group (OR 1.21 (0.99, 1.48). When pooling all "bad" outcomes (stroke, perioperative death, myocardial infarction, low output syndrome, intra aortic balloon pump use) there was no significant advantage of either hypothermia or normothermia (OR 1.07 (0.92, 1.24)). Only 4 of 17 trials reported neuropsychological function as an outcome. REVIEWER'S CONCLUSIONS This review could find no definite advantage of hypothermia over normothermia in the incidence of clinical events. Hypothermia was associated with a reduced stroke rate, but this is off set by a trend towards an increase in non stroke related perioperative mortality and myocardial damage. There is insufficient data to date to draw any conclusions about the use of mild hypothermia. Similarly, there is insufficient data to date to comment on the effect of temperature during CPB on subtle neurological deficits, and further trials are needed in these areas.
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Affiliation(s)
- K Rees
- Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR.
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Miyamoto TA, Miyamoto KJ. Monitoring adequacy of brain oxygenation. Ann Thorac Surg 2000; 70:336-7. [PMID: 10921748 DOI: 10.1016/s0003-4975(00)01427-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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36
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37
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Kadoi Y, Saito S. Reply:. J Thorac Cardiovasc Surg 2000. [DOI: 10.1016/s0022-5223(00)70031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Okano N, Owada R, Fujita N, Kadoi Y, Saito S, Goto F. Cerebral oxygenation is better during mild hypothermic than normothermic cardiopulmonary bypass. Can J Anaesth 2000; 47:131-6. [PMID: 10674506 DOI: 10.1007/bf03018848] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Normothermic cardiopulmonary bypass (CPB) has been recently used in cardiac surgery. However, there is a controversy whether there is a difference in incidence of neurological disorder after coronary artery bypass graft (CABG) surgery between normothermic CPB and mild hypothermic CPB. In this study, we assessed the effects of normothermia and mild hypothermia (32 degrees C) during CPB on jugular oxygen saturation (SjvO2). METHODS Twenty patients scheduled for elective CABG surgery were divided into two groups. Group 1 (n = 10) underwent normothermic (>35 degrees C) CPB, and Group 2 (n = 10) underwent mild hypothermic (32 degrees C) CPB. Alpha-stat blood gas regulation was applied. After inducing anesthesia, a 4.0 French fibre optic oximetry oxygen saturation catheter was inserted into the right jugular bulb to monitor SjvO2 continuously throughout anesthesia and surgery. RESULTS The SjvO2 in the normothermic group was decreased at 20 (41.5+/-2.4%) and 40 min (43.8+/-2.8%) after the onset of CPB compared with control (53.9+/-5.4%, P<0.05). However, there was no change in SjvO2 in the mild hypothermic group during the study. No changes in jugular venous-arterial differences of lactate or creatine phosphokinase isoenzyme BB were observed in two groups during the study. CONCLUSIONS Cerebral oxygenation, as assessed by SjvO2 was increased during mild hypothermic CPB than during normothermic CPB.
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Affiliation(s)
- N Okano
- Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center, Japan
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