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Le Teurnier Y, Rozec B, Degryse C, Levy F, Miliani Y, Godet G, Daccache G, Truc C, Steinmetz E, Ouattara A, Cholley B, Malinovsky JM, Portier D, Dupont G, Liutkus D, Viard P, Pere M, Daumas-Duport B, Magras PA, Vourc'h M. Optimization of cerebral oxygenation based on regional cerebral oxygen saturation monitoring during carotid endarterectomy: a Phase III multicenter, double-blind randomized controlled trial. Anaesth Crit Care Pain Med 2024; 43:101388. [PMID: 38710323 DOI: 10.1016/j.accpm.2024.101388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Whether the optimization of cerebral oxygenation based on regional cerebral oxygen saturation (rSO2) monitoring reduces the occurrence of cerebral ischemic lesions is unknown. METHODS This multicenter, randomized, controlled trial recruited adults admitted for scheduled carotid endarterectomy. Patients were randomized between the standard of care or optimization of cerebral oxygenation based on rSO2 monitoring using near-infrared spectroscopy. In the intervention group, in case of a decrease in rSO2 in the intervention, the following treatments were sequentially recommended: (1) increasing oxygenotherapy, (2) reducing the tidal volume, (3) legs up-raising, (4) performing a fluid challenge and (5) initiating vasopressor support. The primary endpoint was the number of new cerebral ischemic lesions detected using magnetic resonance imaging pre- and postoperatively. Secondary endpoints included new neurological deficits and mortality on day 120 after surgery. RESULTS Among the 879 patients who were randomized, 665 (75.7%) were men. There was no statistically significant difference between groups for the mean number of new cerebral ischemic lesions per patient up to 3 days after surgery: 0.35 (±1.05) in the standard group vs. 0.58 (±2.83), in the NIRS group; mean difference, 0.23 [95% CI, -0.06 to 0.52]; estimate, 0.22 [95% CI, -0.06 to 0.50]. New neurological deficits up to day 120 after hospital discharge were not different between the groups: 15 (3,39%) in the standard group vs. 42 (5,49%) in the NIRS group; absolute difference, 2,10 [95% CI, -0,62 to 4,82]. There was no significant difference between groups for the median [IQR] hospital length of stay: 4.0 [4.0-6.0] in the standard group vs. 5.0 [4.0-6.0] in the NIRS group; mean difference, -0.11 [95% CI, -0.65 to 0.44]. The mortality rate on day 120 was not different between the standard group (0.68%) vs. the NIRS group (0.92%); absolute difference = 0.24% [95% CI, -0.94 to 1.41]. CONCLUSIONS Among patients undergoing carotid endarterectomy, optimization of cerebral oxygenation based on rSO2 did not reduce the occurrence of cerebral ischemic lesions postoperatively compared with controlled hypertensive therapy. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01415648.
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Affiliation(s)
- Yann Le Teurnier
- Centre Hospitalo-Universitaire de Nantes, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Laennec, France
| | - Bertrand Rozec
- Centre Hospitalo-Universitaire de Nantes, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Laennec, France; CNRS, INSERM, Institut du thorax, Université de Nantes, France
| | - Cecile Degryse
- Centre Hospitalo-Universitaire de Bordeaux, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Pellegrin, France
| | - François Levy
- Centre Hospitalo-Universitaire de Strasbourg, Service d'Anesthésie Réanimation Chirurgicale, France
| | - Youcef Miliani
- Centre Hospitalo-Universitaire de Marseille, Service d'Anesthésie Réanimation Chirurgicale, Hôpital La Timone, France
| | - Gilles Godet
- Centre Hospitalo-Universitaire de Rennes, Service d'Anesthésie Réanimation Chirurgicale, Hôpital de Pontchailloux, France
| | - Georges Daccache
- Centre Hospitalo-Universitaire de Caen, Service d'Anesthésie Réanimation Chirurgicale, France
| | - Cyrille Truc
- Centre Hospitalo-Universitaire de Lyon, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Edouard Herriot, France
| | - Eric Steinmetz
- Centre Hospitalo-Universitaire de Dijon, Service de Chirurgie Vasculaire, Hôpital Le Bocage, France
| | - Alexandre Ouattara
- Centre Hospitalo-Universitaire de Bordeaux, Service d'Anesthésie Réanimation Cardiovasculaire, Hôpital Haut Levêque, France
| | - Bernard Cholley
- Centre Hospitalo-Universitaire Georges Pompidou, AP-HP, Service d'Anesthésie Réanimation Chirurgicale, France
| | - Jean-Marc Malinovsky
- Centre Hospitalo-Universitaire de Reims, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Robert Debré, France
| | - Denis Portier
- Hôpital Privé du Confluent, Service d'Anesthésie, Nantes, France
| | - Gregory Dupont
- Centre Hospitalo-Universitaire de Besançon, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Jean Minjoz, France
| | - Darius Liutkus
- Centre Hospitalier du Mans, Service d'Anesthésie Réanimation Chirurgicale, France
| | - Pierre Viard
- Hôpital Privé Marie-Lannelongue, Service d'Anesthésie Réanimation Chirurgicale, Paris, France
| | - Morgane Pere
- Plateforme de Méthodologie et Biostatistique, CHU de Nantes, Nantes, France
| | - Benjamin Daumas-Duport
- Centre Hospitalo-Universitaire de Nantes, Service d'imagerie Médicale, Hôpital Laennec, France
| | - Pierre-Aubin Magras
- Centre Hospitalo-Universitaire de Nantes, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Laennec, France
| | - Mickael Vourc'h
- Centre Hospitalo-Universitaire de Nantes, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Laennec, France; INSERM CIC 0004 Immunologie et infectiologie, Université de Nantes, France.
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Vlisides PE, Mentz G, Leis AM, Colquhoun D, McBride J, Naik BI, Dunn LK, Aziz MF, Vagnerova K, Christensen C, Pace NL, Horn J, Cummings K, Cywinski J, Akkermans A, Kheterpal S, Moore LE, Mashour GA. Carbon Dioxide, Blood Pressure, and Perioperative Stroke: A Retrospective Case-Control Study. Anesthesiology 2022; 137:434-445. [PMID: 35960872 PMCID: PMC10324342 DOI: 10.1097/aln.0000000000004354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. METHODS We conducted a retrospective, case-control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmHg or less, 35 mmHg or less, 45 mmHg or greater) were calculated based on total area under the curve. The association between stroke and total area under the curve values was then tested while adjusting for relevant confounders. RESULTS In total, 1,244,881 cases were analyzed. Among the cases that screened positive for stroke (n = 1,702), 126 were confirmed and successfully matched with 500 corresponding controls. Total area under the curve was significantly associated with stroke for all thresholds tested, with the strongest combination observed with mean arterial pressure less than 55 mmHg (adjusted odds ratio per 10 mmHg-min, 1.17 [95% CI, 1.10 to 1.23], P < 0.0001) and end-tidal carbon dioxide 45 mmHg or greater (adjusted odds ratio per 10 mmHg-min, 1.11 [95% CI, 1.10 to 1.11], P < 0.0001). There was no interaction effect observed between blood pressure and carbon dioxide. CONCLUSIONS Intraoperative hypotension and carbon dioxide dysregulation may each independently increase postoperative stroke risk. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Aleda M. Leis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA 48109
| | - Douglas Colquhoun
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Michael F. Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Kamila Vagnerova
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Clint Christensen
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Nathan L. Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Jeffrey Horn
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | | | - Jacek Cywinski
- Anesthesiology Institute, Cleveland Clinic, OH USA 44195
| | - Annemarie Akkermans
- Department of Anesthesiology, University Medical Center Utrecht, Netherlands
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Laurel E. Moore
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - George A. Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Correlation between brain tissue oxygen tension and regional cerebral oximetry in uninjured human brain under conditions of changing ventilation strategy. J Clin Monit Comput 2022; 36:1227-1232. [PMID: 35113286 PMCID: PMC8812359 DOI: 10.1007/s10877-022-00821-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/25/2022] [Indexed: 11/09/2022]
Abstract
Controversy surrounds regional cerebral oximetry (rSO2) because extracranial contamination and unmeasured changes in cerebral arterial:venous ratio confound readings. Correlation of rSO2 with brain tissue oxygen (PbrO2), a “gold standard” for cerebral oxygenation, could help resolve this controversy but PbrO2 measurement is highly invasive. This was a prospective cohort study. The primary aim was to evaluate correlation between PbrO2 and rSO2 and the secondary aim was to investigate the relationship between changing ventilation regimens and measurement of PbrO2 and rSO2. Patients scheduled for elective removal of cerebral metastases were anesthetized with propofol and remifentanil, targeted to a BIS range 40–60. rSO2 was measured using the INVOS 5100B monitor and PbrO2 using the Licox brain monitoring system. The Licox probe was placed into an area of normal brain within the tumor excision corridor. FiO2 and minute ventilation were sequentially adjusted to achieve two set points: (1) FiO2 0.3 and paCO2 30 mmHg, (2) FiO2 1.0 and paCO2 40 mmHg. PbrO2 and rSO2 were recorded at each. Nine participants were included in the final analysis, which showed a positive Spearman’s correlation (r = 0.50, p = 0.036) between PbrO2 and rSO2. From set point 1 to set point 2, PbrO2 increased from median 6.0, IQR 4.0–11.3 to median 22.5, IQR 9.8–43.6, p = 0.015; rSO2 increased from median 68.0, IQR 62.5–80.5 to median 83.0, IQR 74.0–90.0, p = 0.047. Correlation between PbrO2 and rSO2 is evident. Increasing FiO2 and PaCO2 results in significant increases in cerebral oxygenation measured by both monitors.
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Song J, Cheng C, Sheng K, Jiang LL, Li Y, Xia XQ, Hu XW. Association between the reactivity of local cerebral oxygen saturation after hypo-to-hypercapnic tests and delirium after abdominal surgery in older adults: A prospective study. Front Psychiatry 2022; 13:907870. [PMID: 36405895 PMCID: PMC9672925 DOI: 10.3389/fpsyt.2022.907870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between changes in regional cerebral oxygen saturation (rSO2) and postoperative delirium in older adults undergoing major abdominal surgery. MATERIALS AND METHODS This prospective study enrolled older adults scheduled for elective major abdominal surgery at the Second Affiliated Hospital of Anhui Medical University from August 2021 to January 2022. The change in rSO2 from baseline was determined using the hypo-to-hypercapnic test. The main study outcome was the occurrence of postoperative delirium. RESULTS A total of 101 participants were included for analysis, of whom 16 (15.8%) developed postoperative delirium. Compared with non-delirium participants, the mean arterial pressure and heart rate were not significantly different in the postoperative delirium group at T0, T1, T2, T3, T4, and T6 (all Pinteraction > 0.05), but the delirium group had lower pH, lower PaO2, and higher lactate levels at T4, T5, and T6 (all Pinteraction < 0.05). rSO2 at T0, T1, T2, T3, T4, and T6 was 69.0 (63.2-75.2), 70.7 ± 7.3, 68.2 ± 7.5, 72.1 ± 8.0, 69.9 ± 7.8, 67.4 ± 7.2, and 71.7 ± 8.1, respectively. The postoperative change in rSO2 during the hypercapnia test (TΔrSO2%) was 6.62 (5.31-9.36). Multivariable analysis showed that the Cumulative Illness Rating Scale (odd ratio, OR = 1.89, 95% confidence interval, CI: 1.10-3.25, P = 0.021), preoperative albumin levels (OR = 0.67, 95% CI: 0.48-0.94, P = 0.022), rSO2 at T4 (OR = 0.61, 95% CI: 0.41-0.89, P = 0.010), and postoperative TΔrSO2% (OR = 0.80, 95% CI: 0.66-0.98, P = 0.028) were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery. CONCLUSION The rSO2 measured at T4 and postoperative TΔrSO2% were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.
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Affiliation(s)
- Jie Song
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chen Cheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kui Sheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ling-Ling Jiang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yun Li
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Qiong Xia
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.,Department of Anaesthesiology, The Chaohu Affliated Hospital of Anhui Medical University, Hefei, China
| | - Xian-Wen Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Liu L, Qiang Z, Zhang J, Ren Y, Zhao X, Fu W, Xin Z, Xu Z, Wang F, Li L, Zou N, Zhang X, Feng L, Ma S. Effect of hemoglobin content on cerebral oxygen saturation during surgery for scoliosis in pediatric patients. BMC Anesthesiol 2021; 21:165. [PMID: 34074238 PMCID: PMC8167970 DOI: 10.1186/s12871-021-01382-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 05/13/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although regional cerebral oxygen saturation (rScO2) monitoring has been widely used in clinical practice, the relationship between hemoglobin (dHB) content and rScO2 is incompletely understood. The aim of this study was to analyze the effect of hemoglobin content on rScO2 in pediatric patients undergoing general anesthesia for correction of scoliosis. METHODS Ninety-two pediatric patients aged 3 to 14 years undergoing scoliosis correction surgery were enrolled. Continuous monitoring of bilateral regional cerebral oxygen saturation by near-infrared spectroscopy (NIRS, CASMED, USA) was performed after entering the operation room. rScO2 was recorded when the patients entered the operating room (T0, baseline), after anesthesia induced intubation (T1), and after radial artery puncture (T2). The lowest value of rScO2 during surgery was also recorded. The arterial blood pressure (ABP), heart rate (HR), pulse oxygen saturation (SpO2), end tidal carbon dioxide partial pressure (PetCO2) were continuously recorded. Patients were classified as low rScO2 or high rScO2 group according to whether the lowest intraoperative rScO2 was 15% lower than the baseline value. An analysis and comparison of differences in hemoglobin content in these two groups was carried out. RESULTS The preoperative hemoglobin-postoperative hemoglobin of patients in the high rScO2 group was significantly lower than that in the low rScO2 group (t = - 7.86, p < 0.01), the amount of bleeding during the operation was also less than that in the low rScO2 group (t = - 6.05, p < 0.01), and the systolic pressure of patients was higher than that in the low rScO2 group (t = 4.27, p < 0.01). CONCLUSIONS The decrease in hemoglobin level which occurs during surgery leads to a decrease in cerebral oxygen saturation. In order to ensure patient safety during surgery, it is necessary to carry out volume management and appropriate transfusion and fluid replacement in a timely manner. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1800016359 . Registered 28 May 2018.
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Affiliation(s)
- Lin Liu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhipeng Qiang
- Department of Anesthesiology, Jining NO.1 People's Hospital, Jining Medical University, Jining, Shandong, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Yi Ren
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xin Zhao
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wenya Fu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhong Xin
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zenghua Xu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Fang Wang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijing Li
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Nan Zou
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xuemei Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lei Feng
- Department of Orthopedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuxuan Ma
- Department of Transfusion Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Wasserzug O, Fishman G, Handzel O, Stockie D, Oestreicher-Kedem Y, Fliss DM, DeRowe A. Decreased cerebral oxygen saturation levels during direct laryngoscopy with spontaneous ventilation in children. Int J Pediatr Otorhinolaryngol 2020; 137:110242. [PMID: 32896354 DOI: 10.1016/j.ijporl.2020.110242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children. OBJECTIVE Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels. METHODS This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system. RESULTS Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group. CONCLUSIONS Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy.
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Affiliation(s)
- Oshri Wasserzug
- Pediatric ENT Unit, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Gadi Fishman
- Pediatric ENT Unit, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, "Dana" Children's Hospital, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Stockie
- Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Oestreicher-Kedem
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, "Dana" Children's Hospital, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, "Dana" Children's Hospital, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari DeRowe
- Pediatric ENT Unit, Tel Aviv, Israel; Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vlisides PE, Kunkler B, Thompson A, Zierau M, Lobo R, Strasser MO, Cantley MJ, McKinney A, Everett AD, Mashour GA, Picton P. Cerebrovascular Disease and Perioperative Neurologic Vulnerability: A Prospective Cohort Study. Front Neurol 2019; 10:560. [PMID: 31231299 PMCID: PMC6558425 DOI: 10.3389/fneur.2019.00560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 05/09/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Stroke is a devastating perioperative complication without effective methods for prevention or diagnosis. The objective of this study was to analyze evidence-based strategies for detecting cerebrovascular vulnerability and injury in a high-risk cohort of non-cardiac surgery patients. Methods: This was a single-center, prospective cohort study. Fifty patients undergoing non-cardiac surgery were recruited −25 with known cerebrovascular disease and 25 matched controls. Neurologic vulnerability was measured with intraoperative cerebral oximetry as the primary outcome. Perioperative neurocognitive testing and serum biomarker analysis (S-100β, neuron specific enolase, glial fibrillary acid protein, and matrix metalloproteinase-9) were measured as secondary outcomes. Results: Cerebral desaturation events (an oximetry decrease ≥20% from baseline or <50% absolute value for ≥3 min) occurred in 7/24 (29%) cerebrovascular disease patients and 2/24 (8.3%) controls (relative risk 3.5, 95% CI 0.81–15.2; P = 0.094). Cognitive function trends were similar in both groups, though overall scores (range: 1,500–7,197) were ~1 standard deviation lower in cerebrovascular patients across the entire perioperative period (−1,049 [95% CI −1,662, −436], P < 0.001). No significant serum biomarker differences were found between groups over time. One control patient experienced intraoperative hypoxic-ischemic injury, but no robust biomarker or oximetry changes were observed. Conclusions: Cerebrovascular disease patients did not demonstrate dramatic differences in cerebral oximetry, cognitive trajectory, or molecular biomarkers compared to controls. Moreover, a catastrophic hypoxic-ischemic event was neither predicted nor detected by any strategy tested. These findings support the need for novel research into cerebrovascular risk and vulnerability.
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Affiliation(s)
- Phillip E Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States.,Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Bryan Kunkler
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Aleda Thompson
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Mackenzie Zierau
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Remy Lobo
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Mary O Strasser
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Michael J Cantley
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Amy McKinney
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Allen D Everett
- Pediatric Proteome Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - George A Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States.,Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Paul Picton
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
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Different ventilation techniques and hemodynamic optimization to maintain regional cerebral oxygen saturation (rScO 2) during laparoscopic bariatric surgery: a prospective randomized interventional study. J Anesth 2018; 32:394-402. [PMID: 29626267 DOI: 10.1007/s00540-018-2493-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The purpose of this study was to assess the changes in regional cerebral oxygen saturation (rScO2) in response to different ventilation strategies: inspired oxygen concentration (FiO2), end-tidal carbon dioxide (EtCO2), and positive end expiratory pressure (PEEP) in addition to optimizing mean arterial pressure (MAP) in obese patients subjected to laparoscopic bariatric surgery in the reverse trendelenburg position. METHODS 50 obese patients were randomly assigned into one of two groups. Each group is 25 patients. Control patients subjected to a ventilation strategy aimed to maintain FiO2 0.4 and EtCO2 30 mmHg without PEEP. Study patients were assigned to specific protocol; T0, baseline rScO2; T1, 5 min following induction; T2, PP/RTP (10 min after pneumoperitoneum and reverse trendelenburg position); T3, PEEP 10 cmH2O; T4, FiO2 1.0; T5, EtCO2 40 mmHg and T6, MAP/BL; MAP back to baseline in both groups. MAIN RESULTS 10 min after PP/RTP, there was a significant decrease in rScO2 in both groups. At T4, with FiO2 1.0, there was significant improvement in rScO2 when compared to T2. At T5, with EtCO2 40 mmHg, rScO2 significantly enhanced when compared to EtCO2 30 mmHg. At T4 and T5, we observed highly significance difference between both groups. At the end of the procedure and when MAP increased back to baseline (T6) in both groups, rScO2 statistically increased in both groups when compared to T2. CONCLUSION In obese patients, subjected to laparoscopic bariatric surgery in reverse trendelenburg position, adjustment of ventilation strategies and hemodynamic optimization succeeded to improve rScO2.
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Ki SH, Rhim JH, Park JH, Han YJ, Cho YP, Kwon TW, Choi BM, Noh GJ. Quantitative analysis of the effect of end-tidal carbon dioxide on regional cerebral oxygen saturation in patients undergoing carotid endarterectomy under general anaesthesia. Br J Clin Pharmacol 2017; 84:292-300. [PMID: 28940441 DOI: 10.1111/bcp.13441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/22/2017] [Accepted: 09/16/2017] [Indexed: 12/22/2022] Open
Abstract
AIMS Regional cerebral oxygen saturation (rSO2 ) is currently the most used measure in clinical practice to monitor cerebral ischaemia in patients undergoing carotid endarterectomy (CEA). Although end-tidal carbon dioxide (PET CO2 ) is known as a factor that influences rSO2 , the relationship between PET CO2 and rSO2 has not been quantitatively evaluated in patients with severe arteriosclerosis. This study aimed to evaluate the effect of PET CO2 on rSO2 in patients undergoing CEA under general anaesthesia. METHODS The intervention to change PET CO2 was conducted between skin incision and clamping of the carotid artery. The rSO2 values were observed by changing PET CO2 in the range of 25-45 mmHg. The PET CO2 -rSO2 relationship was characterized by population analysis using a turnover model. RESULTS In total, 1651 rSO2 data points from 30 patients were used to determine the pharmacodynamic characteristics. Hypertension (HTN) and systolic blood pressure (SBP) were significant covariates on the slope factor in the stimulatory effect of PET CO2 on rSO2 and fractional turnover rate constant (kout ), respectively. The estimates of the parameters were kout (min-1 ): 3.59 for SBP <90 mmHg and 0.491 for SBP ≥90 mmHg, slope: 0.00321 for patients with HTN and 0.00664 for patients without HTN. CONCLUSION The presence of HTNattenuates the response of rSO2 after a change in PET CO2 . When cerebral blood flow is in a state of decline caused by a decrease in SBP to <90 mmHg, the response of rSO2 to PET CO2 is increased. It is advisable to maintain SBP >90 mmHg in patients with HTNduring CEA.
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Affiliation(s)
- Seung-Hee Ki
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin-Ho Rhim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae-Hong Park
- Department of Anesthesiology and Pain Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Young-Jin Han
- Department of Surgery, Division of Vascular Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Yong-Pil Cho
- Department of Surgery, Division of Vascular Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Tae-Won Kwon
- Department of Surgery, Division of Vascular Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Benni PB, MacLeod D, Ikeda K, Lin HM. A validation method for near-infrared spectroscopy based tissue oximeters for cerebral and somatic tissue oxygen saturation measurements. J Clin Monit Comput 2017; 32:269-284. [PMID: 28374103 PMCID: PMC5838152 DOI: 10.1007/s10877-017-0015-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/23/2017] [Indexed: 12/19/2022]
Abstract
We describe the validation methodology for the NIRS based FORE-SIGHT ELITE® (CAS Medical Systems, Inc., Branford, CT, USA) tissue oximeter for cerebral and somatic tissue oxygen saturation (StO2) measurements for adult subjects submitted to the United States Food and Drug Administration (FDA) to obtain clearance for clinical use. This validation methodology evolved from a history of NIRS validations in the literature and FDA recommended use of Deming regression and bootstrapping statistical validation methods. For cerebral validation, forehead cerebral StO2 measurements were compared to a weighted 70:30 reference (REF CXB) of co-oximeter internal jugular venous and arterial blood saturation of healthy adult subjects during a controlled hypoxia sequence, with a sensor placed on the forehead. For somatic validation, somatic StO2 measurements were compared to a weighted 70:30 reference (REF CXS) of co-oximetry central venous and arterial saturation values following a similar protocol, with sensors place on the flank, quadriceps muscle, and calf muscle. With informed consent, 25 subjects successfully completed the cerebral validation study. The bias and precision (1 SD) of cerebral StO2 compared to REF CXB was −0.14 ± 3.07%. With informed consent, 24 subjects successfully completed the somatic validation study. The bias and precision of somatic StO2 compared to REF CXS was 0.04 ± 4.22% from the average of flank, quadriceps, and calf StO2 measurements to best represent the global whole body REF CXS. The NIRS validation methods presented potentially provide a reliable means to test NIRS monitors and qualify them for clinical use.
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Affiliation(s)
- Paul B Benni
- CAS Medical Systems (CASMED), Inc., Branford, CT, USA.
| | - David MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Keita Ikeda
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kwak HJ, Lee JY, Wha Lee J, Kim HS, Hur HJ, Kim JY. Effect of Mild Hypercapnia on Lung Oxygenation in Sitting Position During Shoulder Arthroscopy Under General Anesthesia. Med Sci Monit 2017; 23:843-849. [PMID: 28202896 PMCID: PMC5325044 DOI: 10.12659/msm.899801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Mild hypercapnia is permitted during surgeries in sitting position under general anesthesia to maintain cerebral regional oxygen saturation (rSO2). However, since hypoventilation may cause gas exchange impairment, we evaluated effects of mild hypercapnia on lung oxygenation during shoulder arthroscopy in sitting position. Material/Methods Forty patients were randomly allocated to a normocapnia group (ETCO2 35 mmHg, n=20) or a hypercapnia group (45 mmHg, n=20). The mean arterial pressure (MAP), heart rate (HR), and rSO2 were measured 5 min after intubation in supine position (T0), and at 2, 4, 6, 8, 10, 20, 30, 40, 50, and 60 min of remaining in sitting position (T1–10). Arterial blood gas was analyzed at T0 and T5. The oxygenation index (PaO2/FiO2) and dead-space ventilation ratio (Vd/Vt) were calculated. Results There were no differences in PaO2/FiO2 at T0 and T5 between the 2 groups. At T5, the Vd/Vt was higher in the normocapnia group than in the hypercapnia group (p=0.04). The Vd/Vt at T5 increased from T0 in the normocapnia group. The incidence of cerebral desaturation in the hypercapnia group (0/20) was lower than in the normocapnia group (5/20) (p=0.047). Among rSO2, MAP, and HR, only changes in rSO2 over time between the 2 groups differed significantly (p=0.048). Conclusions Mild hypercapnia did not decrease lung oxygenation in sitting position, probably due to attenuation of the increase in dead-space ventilation ratio. Since hypercapnia maintained rSO2 without changes in oxygenation index and hemodynamic parameters, mild hypercapnia should be maintained during shoulder arthroscopy in sitting position under general anesthesia.
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Affiliation(s)
- Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine , Seoul, South Korea
| | - Hong Soon Kim
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ho Jin Hur
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine , Seoul, South Korea
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Toyama S, Matsuoka K, Tagaito Y, Shimoyama M. Retrospective evaluation of the effect of carotid artery stenosis on cerebral oxygen saturation during off-pump coronary artery bypasses grafting in adult patients. BMC Anesthesiol 2015; 15:180. [PMID: 26667409 PMCID: PMC4678630 DOI: 10.1186/s12871-015-0164-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 12/05/2015] [Indexed: 01/18/2023] Open
Abstract
Background It is unknown whether cerebral oxygenation in patients with carotid artery stenosis (CAS) undergoing off-pump coronary artery bypass grafting (CABG) differs from that in patients without CAS. Thus, the effect of the presence of CAS ≥ 50 % on cerebral oxygenation during off-pump CABG in adult patients was evaluated retrospectively. Methods Eleven patients with CAS ≥ 50 % and 14 patients without CAS ≥ 50 % were enrolled. Regional cerebral tissue oxygen saturation (rSO2) was quantified using near-infrared spectroscopy. Mean arterial pressure, cardiac index, central venous pressure (CVP), and rSO2 at specific points were collected, and significant changes in each parameter were detected using repeated analysis of variance. Mean rSO2 and minimum rSO2 during anastomosis were analyzed by one-way analysis of variance. Multiple logistic regression analysis was used to estimate the odds ratio (OR) with 95 % confidence interval (CI) for cerebral desaturation (a decrease in rSO2 ≥ 10 % from preoperative value). Results Two patients with CAS ≥ 50 % who received complete carotid artery stenting preoperatively were excluded from the analyses. In both patients with and without CAS, a decrease in rSO2 and cardiac index and an increase in CVP were observed during anastomosis. Mean (SD) maximum decrease in rSO2 from preoperative value was 9.2 (12.7) % on the left side and 8.1 (11.7) % on the right side in patients with CAS ≥ 50 %, and 13.5 (11.3) % on the left side and 16.1 (9.8) % on the right side in patients without CAS ≥ 50 % (p = 0.316). Neurological complications were not identified in both patients with and without CAS ≥ 50 %. In multiple logistic regression analysis, CAS ≥ 50 % was not associated with an increased risk of cerebral desaturation (OR 0.160, 95 % CI 0.036–0.707, p = 0.016), and rSO2 decreased with decreasing cardiac index < 2.0 l/min/m2 (OR 3.287, 95 % CI 2.218–5.076, p < 0.001). Conclusions CAS ≥ 50 % was not an independent risk factor of cerebral desaturation during off-pump CABG. Our results suggest that maintaining cardiac output can prevent a decrease in cerebral oxygenation in both patients with and without CAS ≥ 50 %.
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Affiliation(s)
- S Toyama
- Department of Anesthesiology, Medical Hospital of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
| | - K Matsuoka
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-City, Chiba, 299-0111, Japan.
| | - Y Tagaito
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-City, Chiba, 299-0111, Japan.
| | - M Shimoyama
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-City, Chiba, 299-0111, Japan. .,Department of Palliative Medicine, Jikei University Graduate School of Medicine, 3-19-18 Nishi-shimbashi, Minato-Ku, Tokyo, 105-8471, Japan.
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Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics. Anesthesiology 2015; 123:765-74. [PMID: 26244887 DOI: 10.1097/aln.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction (FIO2), end-tidal carbon dioxide (PETCO2), and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position. METHODS This is a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics. Fifty-six patients were randomized to receive desflurane or total intravenous anesthesia with propofol. Following induction of anesthesia and positioning, FIO2 and minute ventilation were sequentially adjusted for all patients. Regional cerebral oxygenation (rSO2) was the primary outcome and was recorded at each of five set points. RESULTS While maintaining FIO2 at 0.3 and PETCO2 at 30 mmHg, there was a decrease in rSO2 from 68% (SD, 12) to 61% (SD, 12) (P < 0.001) following beach chair positioning. The combined interventions of increasing FIO2 to 1.0 and increasing PETCO2 to 45 mmHg resulted in a 14% point improvement in rSO2 to 75% (SD, 12) (P <0.001) for patients anesthetized in the beach chair position. There was no significant interaction effect of the anesthetic at the study intervention points. CONCLUSIONS Increasing FIO2 and PETCO2 resulted in a significant increase in rSO2 that overcomes desaturation in patients anesthetized in the beach chair position and that appears independent of anesthetic choice.
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14
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Choi BM, Park SK, Shin S, Cho YP, Kwon TW, Choi YJ, Lee EK, Noh GJ. Neurologic Derangement and Regional Cerebral Oxygen Desaturation Associated With Patency of the Circle of Willis During Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2015; 29:1200-5. [PMID: 26384627 DOI: 10.1053/j.jvca.2015.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To explore the relationship between the maximal fractional decrease of regional cerebral oxygen saturation (rSO2) in neurologic derangement and the patency of the circle of Willis and contralateral carotid artery stenosis. DESIGN A prospective observational study. SETTINGS A tertiary-care university hospital PARTICIPANTS This study enrolled 307 patients undergoing carotid endarterectomy under regional anesthesia. INTERVENTIONS No interventions. MEASUREMENTS AND MAIN RESULTS Magnetic resonance angiography and carotid color-duplex ultrasound were performed, and the rSO2 was recorded. The relationship between the maximal fractional decrease of rSO2 from preclamp baseline against shunt insertion and patency of the circle of Willis was analyzed by a 2-way analysis of variance. Receiver operating characteristic analysis of the maximal fractional decrease of rSO2 also was performed to calculate the cut-off value for detecting neurologic derangement. In addition, probability of shunt insertion was estimated by logistic regression. Patency of the circle of Willis did not influence the maximal fractional decrease of rSO2. When both anterior and posterior circulations were nonpatent, the degree of contralateral carotid artery stenosis (Contra) was 54.7%±29.0% versus 40.7%±26.0% in patients with versus without shunting, respectively (p<0.05). The cut-off value of rSO2 for predicting shunt insertion was 25.8%, regardless of the patency of the circle of Willis. Probability of shunt insertion for nonpatent anterior circulation = exp(-2.02+0.02×Contra)/[1+exp(-2.02+0.02×Contra)]. CONCLUSIONS The rSO2 can be used to predict shunt insertion, regardless of the patency of the circle of Willis. The probability of shunt insertion increased with increasing degree of contralateral carotid artery stenosis in the absence of anterior circulation in the circle of Willis.
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Affiliation(s)
| | - Soo-kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Shin
- Surgery, Division of Vascular Surgery
| | | | | | | | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, Republic of Korea
| | - Gyu-Jeong Noh
- Clinical Pharmacology and Therapeutics/Anesthesiology and Pain Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.
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Intravenously Administered Indocyanine Green May Cause Falsely High Near-Infrared Cerebral Oximetry Readings. J Neurosurg Anesthesiol 2015; 27:57-60. [DOI: 10.1097/ana.0000000000000084] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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16
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Abstract
Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - D Stamou
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - J Mason
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
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Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Vender JS, Levin SD, Koh JL, Parikh KN, Patel SS. Effect of ventilation on cerebral oxygenation in patients undergoing surgery in the beach chair position: a randomized controlled trial. Br J Anaesth 2014; 113:618-27. [PMID: 24860157 DOI: 10.1093/bja/aeu109] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Surgery in the beach chair position (BCP) may reduce cerebral blood flow and oxygenation, resulting in neurological injuries. The authors tested the hypothesis that a ventilation strategy designed to achieve end-tidal carbon dioxide (E'(CO₂)) values of 40-42 mm Hg would increase cerebral oxygenation (Sct(O₂)) during BCP shoulder surgery compared with a ventilation strategy designed to achieve E'(CO₂) values of 30-32 mm Hg. METHODS Seventy patients undergoing shoulder surgery in the BCP with general anaesthesia were enrolled in this randomized controlled trial. Mechanical ventilation was adjusted to maintain an E'(CO₂) of 30-32 mm Hg in the control group and an E'(CO₂) of 40-42 mm Hg in the study group. Cerebral oxygenation was monitored continuously in the operating theatre using near-infrared spectroscopy. Baseline haemodynamics and Sct(O₂) were obtained before induction of anaesthesia, and these values were then measured and recorded continuously from induction of anaesthesia until tracheal extubation. The number of cerebral desaturation events (CDEs) (defined as a ≥20% reduction in Sct(O₂) from baseline values) was recorded. RESULTS No significant differences between the groups were observed in haemodynamic variables or phenylephrine interventions during the surgical procedure. Sct(O₂) values were significantly higher in the study 40-42 group throughout the intraoperative period (P<0.01). In addition, the incidence of CDEs was lower in the study 40-42 group (8.8%) compared with the control 30-32 group (55.6%, P<0.0001). CONCLUSIONS Cerebral oxygenation is significantly improved during BCP surgery when ventilation is adjusted to maintain E'(CO₂) at 40-42 mm Hg compared with 30-32 mm Hg. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT01546636.
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Affiliation(s)
| | | | - M J Avram
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron Street F5-704, Chicago, IL 60611, USA
| | | | | | | | - S D Levin
- Department of Surgery, NorthShore University HealthSystem (an affiliate of University of Chicago Pritzker School of Medicine), 2650 Ridge Ave., Evanston, IL 60201, USA
| | - J L Koh
- Department of Surgery, NorthShore University HealthSystem (an affiliate of University of Chicago Pritzker School of Medicine), 2650 Ridge Ave., Evanston, IL 60201, USA
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Pandin P, Renard M, Bianchini A, Desjardin P, Obbergh LV. Monitoring Brain and Spinal Cord Metabolism and Function. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojanes.2014.46020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Mauermann WJ, Crepeau AZ, Pulido JN, Lynch JJ, Lobbestael A, Oderich GS, Worrell GA. Comparison of Electroencephalography and Cerebral Oximetry to Determine the Need for In-Line Arterial Shunting in Patients Undergoing Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2013; 27:1253-9. [DOI: 10.1053/j.jvca.2013.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Indexed: 11/11/2022]
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22
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Atkinson CJ, Ramaswamy K, Stoneham MD. Regional anesthesia for vascular surgery. Semin Cardiothorac Vasc Anesth 2013; 17:92-104. [PMID: 23327951 DOI: 10.1177/1089253212472985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.
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Ghosh A, Elwell C, Smith M. Review article: cerebral near-infrared spectroscopy in adults: a work in progress. Anesth Analg 2012; 115:1373-83. [PMID: 23144435 DOI: 10.1213/ane.0b013e31826dd6a6] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Near-infrared spectroscopy (NIRS) has potential as a noninvasive brain monitor across a spectrum of disorders. In the last decade, there has been a rapid expansion of clinical experience using NIRS to monitor cerebral oxygenation, and there is some evidence that NIRS-guided brain protection protocols might lead to a reduction in perioperative neurologic complications after cardiac surgery. However, there are no data to support the wider application of NIRS during routine surgery under general anesthesia, and its application in brain injury, where it might be expected to have a key monitoring role, is undefined. Although increasingly sophisticated apparatuses, including broadband and time-resolved spectroscopy systems, provide insights into the potential of NIRS to measure regional cerebral oxygenation, hemodynamics, and metabolism in real-time, these innovations have yet to translate into effective monitor-guided brain protection treatment strategies. NIRS has many potential advantages over other neuromonitoring techniques, but further investigation and technological advances are necessary before it can be introduced more widely into clinical practice.
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Affiliation(s)
- Arnab Ghosh
- Department of Neurocritical Care, Box 30, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BGUK
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Picton P, Dering A, Miller B, Shanks A, Mashour GA. The influence of basic ventilation strategies and anesthetic techniques on cerebral oxygenation in the beach chair position: study protocol. BMC Anesthesiol 2012; 12:23. [PMID: 22994896 PMCID: PMC3499238 DOI: 10.1186/1471-2253-12-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 09/17/2012] [Indexed: 11/28/2022] Open
Abstract
Background Beach chair positioning during general anesthesia is associated with a high incidence of cerebral desaturation; poor neurological outcome is a growing concern. There are no published data pertaining to changes in cerebral oxygenation seen with increases in the inspired oxygen fraction or end-tidal carbon dioxide in patients anesthetized in the beach chair position. Furthermore, the effect anesthetic agents have has not been thoroughly investigated in this context. We plan to test the hypothesis that changes in inspired oxygen fraction or end-tidal carbon dioxide correlate to a significant change in regional cerebral oxygenation in anesthetized patients in beach chair position. We will also compare the effects that inhaled and intravenous anesthetics have on this process. Methods/design This is a prospective within-group study of patients undergoing shoulder arthroscopy in the beach chair position which incorporates a randomized comparison between two anesthetics, approved by the Institutional Review Board of the University of Michigan, Ann Arbor. The primary outcome measure is the change in regional cerebral oxygenation due to sequential changes in oxygenation and ventilation. A sample size of 48 will have greater than 80% power to detect an absolute 4-5% difference in regional cerebral oxygenation caused by changes in ventilation strategy. The secondary outcome is the effect of anesthetic choice on cerebral desaturation in the beach chair position or response to changes in ventilation strategy. Fifty-four patients will be recruited, allowing for drop out, targeting 24 patients in each group randomized to an anesthetic. Regional cerebral oxygenation will be measured using the INVOS 5100C monitor (Covidien, Boulder, CO). Following induction of anesthesia, intubation and positioning, inspired oxygen fraction and minute ventilation will be sequentially adjusted. At each set point, regional cerebral oxygenation will be recorded and venous blood gas analysis performed. The overall statistical analysis will use a repeated measures analysis of variance with Tukey’s HSD procedure for post hoc contrasts. Discussion If simple maneuvers of ventilation or anesthetic technique can prevent cerebral hypoxia, patient outcome may be improved. This is the first study to investigate the effects of ventilation strategies on cerebral oxygenation in patients anesthetized in beach chair position. Trial registration NCT01535274
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Affiliation(s)
- Paul Picton
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Picton P, Ramachandran SK, Shanks A, Dorje P, Mashour GA. Optimizing cerebral oxygenation in anaesthetized patients with carotid artery stenosis: the influence of inspired oxygen fraction. Br J Anaesth 2012; 108:326-7. [PMID: 22250282 DOI: 10.1093/bja/aer466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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The influence of basic ventilation strategies on cerebral oxygenation in anesthetized patients without vascular disease. J Clin Monit Comput 2010; 24:421-5. [PMID: 21061050 DOI: 10.1007/s10877-010-9265-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Optimizing cerebral oxygenation is of paramount importance in certain intraoperative situations. There is, however, a paucity of published data pertaining to changes in cerebral oxygenation seen with increases in the inspired fraction of oxygen (FIO2) or end-tidal carbon dioxide (PETCO2) in anesthetized patients without vascular disease. Here we tested the hypothesis that changes in FIO2 or PETCO2 correlate to a significant change in regional cerebral oxygenation (rSO2) in anesthetized patients without vascular disease. METHODS This was a prospective pilot study approved by the IRB. We measured rSO2 using the INVOS 5100B monitor in ten anesthetized patients. Patients were excluded if they had a history of or risk factors for vascular disease, suffered from respiratory failure, or did not speak English. Following induction of anesthesia and intubation, FIO2 and minute ventilation were sequentially adjusted. At each set point, rSO2 was recorded and arterial blood gas analysis was performed. Each patient acted as their own control. A paired-sample t test was used to evaluate the change in rSO2 resultant upon each intervention. RESULTS The baseline rSO2 was measured with patients awake, breathing room air and varied between 48 and 72%. While maintaining PETCO2 in the range 30-35 mmHg, rSO2 was 8% higher when 100% oxygen was delivered compared to FIO2 30% (P = 0.021). While maintaining PETCO2 in the range 40-45 mmHg, rSO2 was 7% higher when 100% oxygen is delivered compared to FIO2 30% (P = 0.032). While maintaining FIO2 at 100%, rSO2 was 2% higher when PETCO2 was in the range 40-45 mmHg compared to PETCO2 30-35 mmHg (P = 0.017). While maintaining FIO2 at 30%, rSO2 was not statistically different between PECO2 40-45 mmHg and PETCO2 30-35 mmHg. CONCLUSIONS Modulating oxygenation and ventilation in anesthetized patients without vascular disease leads to measurable changes in rSO2.
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Current world literature. Neuroanaesthesia. Pain medicine. Regional anaesthesia. Curr Opin Anaesthesiol 2010; 23:671-8. [PMID: 20811177 DOI: 10.1097/aco.0b013e32833f3f68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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