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Ramachandran RV, Ananthakrishnan A, Orui H, Kveraga K, Subramaniam B. The Influence of Preoperative Physical Activity on Intraoperative Brain Function in Cardiac Surgical patients. RESEARCH SQUARE 2024:rs.3.rs-4427122. [PMID: 38883767 PMCID: PMC11178032 DOI: 10.21203/rs.3.rs-4427122/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background Preoperative physical activity and intraoperative brain health are recognized to influence postoperative delirium (POD). Electroencephalogram (EEG) burst suppression and cerebral desaturation are indicators of abnormal intraoperative brain health. Our study aimed to investigate the associations between preoperative physical activity and intraoperative EEG burst suppression and cerebral desaturation. Methods We retrospectively analyzed data from 67 patients from one of the institutions participating in a multisite randomized controlled trial, PANDORA, involving patients undergoing cardiac surgery. The preoperative PCS12 score calculated using the SF12 questionnaire was used as an indicator of preoperative physical activity. Intraoperative EEG and cerebral oximetry data (not the current standard of care in this facility) were collected, and the anesthesiologists were blinded to the information. We analyzed the following associations between the PCS12 score and i) burst suppression duration, ii) the number of cerebral desaturations, and iii) the number of observations with concurrent cerebral desaturation and burst suppression using a generalized linear model. The results are presented as percentage changes in outcomes, and a 95% C.I. p value < 0.05 was considered to indicate statistical significance. Results Each unit increase in the PCS12 score was associated with a 3.3% decrease in the duration of burst suppression (-3.3 [-5.3, -1.2], p value = 0.002). The duration of burst suppression decreased by 29.2% with each successive quartile increase in the PCS-12 score, indicating a dose‒response relationship (-29.2 [-41.6, -16], p < 0.001). Specifically, the patients in the last three quartiles exhibited a 55.4% reduction in BSD compared to those in the first quartile (-55.4 [-74.4, -24.6], p = 0.002) (Fig. 2). We did not observe any significant association between the PCS12 score and cerebral desaturation. Conclusion Decreased preoperative physical activity, as measured by the SF-12 questionnaire, is significantly associated with increased EEG burst suppression duration. Preoperative physical activity did not show any association with cerebral desaturations and concurrent cerebral desaturation and burst suppression. Clinical Trial information ClinicalTrials.gov Identifier- NCT04093219 https://clinicaltrials.gov/ct2/show/NCT04093219 Principal Investigator - Balachundhar Subramaniam Date of registration - September 13, 2019.
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Kaiser HA, Bauer T, Riva T, Greif R, Riedel T, Theiler L, Nabecker S. Carbon dioxide and cardiac output as major contributors to cerebral oxygenation during apnoeic oxygenation. Sci Rep 2024; 14:3617. [PMID: 38351038 PMCID: PMC10864331 DOI: 10.1038/s41598-023-49238-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/06/2023] [Indexed: 02/16/2024] Open
Abstract
Apnoeic oxygenation has experienced a resurgence in interest in critical care and perioperative medicine. However, its effect on cerebral oxygenation and factors influencing it, have not yet been investigated in detail. By using near-infrared spectroscopy, we intended to provide further evidence for the safety of apnoeic oxygenation and to increase our understanding of the association between cerebral perfusion, haemodynamic, respiratory and demographic factors. In this secondary analysis of a prospective randomized controlled noninferiority trial, we recruited 125 patients, who underwent surgery under general anaesthesia with neuromuscular blockade. Arterial blood samples were taken every 2 min for a total of 15 min under apnoeic oxygenation with 100% oxygen. Near-infrared spectroscopy and cardiac output were continuously measured. Statistical analysis was performed using uni- and multivariable statistics. Ninety-one complete data sets were analysed. In six patients the SpO2 fell below 92% (predefined study termination criterion). The significant average increase of cerebral oxygenation was 0.5%/min and 2.1 mmHg/min for the arterial pressure of carbon dioxide (paCO2). The median cardiac output increased significantly from 5.0 l/min (IQR 4.5-6.0) to 6.5 l/min (IQR 5.7-7.5). The most significant effect on cerebral oxygenation was exhibited by the variable paCO2 and non-specific patient factors, followed by cardiac output and paO2. Apnoeic oxygenation proves to have a high safety profile while significantly increasing cerebral oxygenation, paCO2 and cardiac output. In reverse, NIRS might act as a reliable clinical surrogate of paCO2 and cardiac output during stable arterial oxygenation.
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Grants
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
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Affiliation(s)
- Heiko Andreas Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Bauer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research and Innovation, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genova, Italy
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Thomas Riedel
- Department of Paediatrics, Cantonal Hospital Graubünden, Chur, Switzerland
- Division of Respiratory Medicine, Department of Paediatrics, Inselspital, University Children's Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Theiler
- Department of Anaesthesia, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Sabine Nabecker
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Anaesthesiology and Pain Management, Sinai Health System, University of Toronto, Toronto, Canada.
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Patel NA, Bhattal HS, Griesdale DE, Hoiland RL, Sekhon MS. Impact of Skin Pigmentation on Cerebral Regional Saturation of Oxygen Using Near-Infrared Spectroscopy: A Systematic Review. Crit Care Explor 2024; 6:e1049. [PMID: 38352943 PMCID: PMC10863935 DOI: 10.1097/cce.0000000000001049] [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] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES Near-infrared spectroscopy (NIRS) is used in critical care settings to measure regional cerebral tissue oxygenation (rSo2). However, the accuracy of such measurements has been questioned in darker-skinned individuals due to the confounding effects of light absorption by melanin. In this systematic review, we aim to synthesize the available evidence on the effect of skin pigmentation on rSo2 readings. DATA SOURCES We systematically searched MEDLINE, Cochrane Database of Systematic Reviews, Embase, and Google Scholar from inception to July 1, 2023. STUDY SELECTION In compliance with our PROSPERO registration (CRD42022347548), we selected articles comparing rSo2 measurements in adults either between racial groups or at different levels of skin pigmentation. Two independent reviewers conducted full-text reviews of all potentially relevant articles. DATA EXTRACTION We extracted data on self-reported race or level of skin pigmentation and mean rSo2 values. DATA SYNTHESIS Of the 11,495 unique records screened, two studies (n = 7,549) met our inclusion criteria for systematic review. Sun et al (2015) yielded significantly lower rSo2 values for African Americans compared with Caucasians, whereas Stannard et al (2021) found little difference between self-reported racial groups. This discrepancy is likely because Stannard et al (2021) used a NIRS platform which specifically purports to control for the effects of melanin. Several other studies that did not meet our inclusion criteria corroborated the notion that skin pigmentation results in lower rSo2 readings. CONCLUSIONS Skin pigmentation likely results in attenuated rSo2 readings. However, the magnitude of this effect may depend on the specific NIRS platform used.
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Affiliation(s)
- Nikunj A Patel
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Harvir S Bhattal
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada
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MİNİKSAR ÖH, ALAGHA S, ÇİÇEKÇİOĞLU F, HONCA M, GÖÇMEN AY. The effects of on-pump and off-pump coronary artery bypass surgery on oxidative stress and cerebral oxygenation: a prospective observational study. Turk J Med Sci 2023; 54:99-114. [PMID: 38812632 PMCID: PMC11031167 DOI: 10.55730/1300-0144.5770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 02/15/2024] [Accepted: 12/14/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim In this prospective observational study, our goal was to investigate the relationship between serum levels of oxidative stress (OS) parameters and regional cerebral oxygen saturation (rSO2) in addition to evaluating postoperative clinical outcomes among patients undergoing coronary artery bypass graft surgery (CABG). Materials and methods This study comprised 64 adult patients undergoing elective CABG (on-pump [n = 48] and off-pump [n = 16]) procedures. Serum OS levels and rSO2 values were measured intraoperatively at three specific time points: T1 (after induction), T2 (15 min before aortic cross-clamp removal or the final distal anastomosis), and T3 (15 min after aortic cross-clamp removal or the last distal anastomosis). Results Serum OS and lactate values demonstrated higher levels at T2 and T3 (p < 0.001), while rSO2 values were lower at T2 (p = 0.024) in the on-pump CABG group compared to the off-pump CABG group. The rSO2 values at T2 exhibited a negative correlation with OS parameters, lactate levels at T2 and T3, aortic clamp time, postoperative mechanical ventilation time, and intensive care unit stay length. In the multivariate linear regression analysis (R2 = 0.181, p = 0.001), lactate values at T2 emerged as the sole factor affecting the OS index at T2 (t = 2.843, p = 0.006). Conclusion In our study, we observed elevated OS values and relatively low rSO2 values during on-pump CABG procedures, with rSO2 showing an association with increased OS parameters. Close monitoring of the OS response level and rSO2 during CABG could potentially enhance postoperative clinical outcomes.
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Affiliation(s)
- Ökkeş Hakan MİNİKSAR
- Department of Anesthesiology and Reanimation, Dr Abdurrahman Yurtaslan Oncology Training and Education Hospital, University of Health Sciences, Ankara,
Turkiye
| | - Sameh ALAGHA
- Department of Cardiovascular Surgery, Faculty of Medicine, Yozgat Bozok University, Yozgat,
Turkiye
| | - Ferit ÇİÇEKÇİOĞLU
- Department of Cardiovascular Surgery, Etlik City Hospital, University of Health Sciences, Ankara,
Turkiye
| | - Mehtap HONCA
- Department of Anesthesiology and Reanimation, Bilkent City Hospital, University of Health Sciences, Ankara,
Turkiye
| | - Ayse Yeşim GÖÇMEN
- Department of Biochemistry, Faculty of Medicine, Yozgat Bozok University, Yozgat,
Turkiye
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Li Z, Zhu Y, Qin S, Gao X, Kang Y, Li S, Chai J. Effects of permissive hypercapnia on intraoperative cerebral oxygenation and early postoperative cognitive function in older patients with non-acute fragile brain function undergoing laparoscopic colorectal surgery: protocol study. BMC Geriatr 2023; 23:581. [PMID: 37735369 PMCID: PMC10512528 DOI: 10.1186/s12877-023-04125-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/21/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Perioperative brain protection in older patients has been the focus of research recently; meanwhile, exploring the relationship between regional cerebral oxygen saturation (rSO2) and brain function in the perioperative period has been an emerging and challenging area-the difficulties related to the real-time monitoring of rSO2 and the choice of feasible interventions. As an advanced instrument for intraoperative rSO2 monitoring, the clinical application of near-infrared spectrum (NIRS) cerebral oxygen monitoring has gradually increased in popularity and is being recognized for its beneficial clinical outcomes in patients undergoing cardiac and noncardiac surgery. In addition, although sufficient evidence to support this hypothesis is still lacking, the effect of permissive hypercapnia (PHC) on rSO2 has expanded from basic research to clinical exploration. Therefore, monitoring intraoperative rSO2 in older patients with NIRS technology and exploring possible interventions that may change rSO2 and even improve postoperative cognitive performance is significant and clinically valuable. METHODS This study is a single-center randomized controlled trial (RCT). 76 older patients are enrolled as subjects. Patients who meet the screening criteria will be randomly assigned 1:1 to the control and intervention groups. PHC-based mechanical ventilation will be regarded as an intervention. The primary outcome is the absolute change in the percent change in rSO2 from baseline to the completion of surgery in the intervention and control groups. Secondary outcomes mainly include observations of intraoperative cerebral oxygenation and metabolism, markers of brain injury, and assessments of patients' cognitive function using scale through postoperative follow-up. DISCUSSION The findings of this RCT will reveal the effect of PHC on intraoperative rSO2 in older patients with nonacute fragile brain function (NFBF) and the approximate trends over time, and differences in postoperative cognitive function outcomes. We anticipate that the trial results will inform clinical policy decision-makers in clinical practice, enhance the management of intraoperative cerebral oxygen monitoring in older patients with comorbid NFBF, and provide guidance for clinical brain protection and improved postoperative cognitive function outcomes. TRIAL REGISTRATION ChiCTR, ChiCTR2200062093, Registered 9/15/2022.
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Affiliation(s)
- Zhichao Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shangyuan Qin
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Xin Gao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yihan Kang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Si Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun Chai
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China.
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study. J Clin Med 2022; 11:jcm11071930. [PMID: 35407537 PMCID: PMC8999949 DOI: 10.3390/jcm11071930] [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: 03/05/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The aim of this study was to evaluate whether a relevant alteration in cerebral tissue oxygen saturation (rSO2) could be detected following TAVI. Retrospective data analysis included 275 patients undergoing TAVI between October 2016 and December 2020. Overall, rSO2 significantly increased following TAVI (64.6 ± 10% vs. 68.1 ± 10%, p < 0.01). However, a significant rise was only observed in patients with a preoperative rSO2 < 60%. Of the hemodynamic confounders studied, hemoglobin, mean arterial pressure and blood pH were lowered, while central venous pressure and arterial partial pressure of carbon dioxide (PaCO2) were slightly elevated (PaCO2: 39 (36−43) mmHg vs. 42 (37−47) mmHg, p = 0.03; pH: 7.41 (7.3−7.4) vs. 7.36 (7.3−7.4), p < 0.01). Multivariate linear regression modeling identified only hemoglobin as a predictor of altered rSO2. Patients with a EuroScore II above 4% and an extended ICU stay were found to have lower rSO2, while no difference was observed in patients with postoperative delirium or between the implanted valve types. Further prospective studies that eliminate differences in potential confounding variables are necessary to confirm the rise in rSO2. Future research should provide more information on the value of cerebral oximetry for identifying high-risk patients who will require further clinical interventions in the setting of the TAVI procedure.
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Howarth C, Banerjee J, Leung T, Aladangady N. Could Near Infrared Spectroscopy (NIRS) be the new weapon in our fight against Necrotising Enterocolitis? Front Pediatr 2022; 10:1024566. [PMID: 36425397 PMCID: PMC9679512 DOI: 10.3389/fped.2022.1024566] [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: 08/21/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
There is no ideal single gut tissue or inflammatory biomarker available to help to try and identify Necrotising Enterocolitis (NEC) before its clinical onset. Neonatologists are all too familiar with the devastating consequences of NEC, and despite many advances in neonatal care the mortality and morbidity associated with NEC remains significant. In this article we review Near Infrared Spectroscopy (NIRS) as a method of measuring regional gut tissue oxygenation. We discuss its current and potential future applications, including considering its effectiveness as a possible new weapon in the early identification of NEC.
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Affiliation(s)
- Claire Howarth
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | - Jayanta Banerjee
- Neonatal Unit, Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Terence Leung
- Department of Medical Physics and Biomedical Engineering, Faculty of Engineering Sciences, University College London, London, United Kingdom
| | - Narendra Aladangady
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom.,Barts and The London School of Medicine and Dentistry, Queen Mary University of London (QMUL), London, United Kingdom
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Velegraki M, Manolaraki M, Chainaki I, Vardas E, Petrodaskalaki M, Androulakis N, Georgakaki C, Lazanaki E, Chlouverakis G, Paspatis GA. Cerebral oximetry monitoring in non-intubated patients undergoing endoscopic retrograde cholangiopancreatography under propofol-induced sedation: a prospective observational study. Ann Gastroenterol 2021; 34:736-742. [PMID: 34475746 PMCID: PMC8375660 DOI: 10.20524/aog.2021.0637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background Prolonged propofol-induced deep sedation increases the risk for sedation-related complications. Cerebral oximetry enables prompt assessment of tissue oxygenation by demonstrating the regional hemoglobin oxygen saturation (rSO2) of the cerebral cortex. This study aimed to: evaluate cerebral oxygenation under deep sedation during an endoscopic retrograde cholangiopancreatography (ERCP) procedure; determine the cerebral desaturation event (CDE) rate; and assess the predictive capacity of CDEs for sedation-related complications. Methods All consecutive patients who underwent ERCP between September and December 2019 were included prospectively. Propofol monotherapy was used and sedation level was assessed using the bispectral index (BIS). The target level of sedation was deep sedation, defined by BIS values 40-60. Participants were monitored with arterial blood gas analysis and INVOS 5100C cerebral oximeter. RSO2 values were registered prior to sedation (baseline value), every 5 min during the sedation period and at recovery of consciousness. BIS values were recorded simultaneously. CDE was defined as a drop >10% from individual baseline rSO2. Results Sixty patients were enrolled. Mean baseline rSO2 was 65.1% and BIS values ranged from 18-85. No significant correlation was observed between mean rSO2 measurements and mean BIS values throughout the recordings (P = 0.193). Data from patients aged ≥65 years were analyzed separately and the results were similar. The CDE rate was 2.7%, but no CDE was associated with clinical manifestations. Twelve sedation-related complications occurred without the presence of cerebral desaturation. Conclusion Cerebral oxygenation remained independent of changes in sedation depth and cerebral oximetry monitoring did not detect complications earlier than standard monitors.
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Affiliation(s)
- Magdalini Velegraki
- Department of Gastroenterology, Venizeleion General Hospital (Magdalini Velegraki, Emmanouil Vardas, Gregorios A. Paspatis)
| | - Maria Manolaraki
- Department of Anesthesiology, Venizeleion General Hospital (Maria Manolaraki, Irene Chainaki, Nikolaos Androulakis, Chrysanthi Georgakaki, Evangelia Lazanaki)
| | - Irene Chainaki
- Department of Anesthesiology, Venizeleion General Hospital (Maria Manolaraki, Irene Chainaki, Nikolaos Androulakis, Chrysanthi Georgakaki, Evangelia Lazanaki)
| | - Emmanouil Vardas
- Department of Gastroenterology, Venizeleion General Hospital (Magdalini Velegraki, Emmanouil Vardas, Gregorios A. Paspatis)
| | - Maria Petrodaskalaki
- Department of Quality and Research, University Hospital of Heraklion (Maria Petrodaskalaki)
| | - Nikolaos Androulakis
- Department of Anesthesiology, Venizeleion General Hospital (Maria Manolaraki, Irene Chainaki, Nikolaos Androulakis, Chrysanthi Georgakaki, Evangelia Lazanaki)
| | - Chrysanthi Georgakaki
- Department of Anesthesiology, Venizeleion General Hospital (Maria Manolaraki, Irene Chainaki, Nikolaos Androulakis, Chrysanthi Georgakaki, Evangelia Lazanaki)
| | - Evangelia Lazanaki
- Department of Anesthesiology, Venizeleion General Hospital (Maria Manolaraki, Irene Chainaki, Nikolaos Androulakis, Chrysanthi Georgakaki, Evangelia Lazanaki)
| | - Gregorios Chlouverakis
- Department of Social Medicine, Biostatistics Lab, School of Medicine, University of Crete, Voutes University Campus (Gregorios Chlouverakis); Crete, Greece
| | - Gregorios A Paspatis
- Department of Gastroenterology, Venizeleion General Hospital (Magdalini Velegraki, Emmanouil Vardas, Gregorios A. Paspatis)
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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Intraoperative cerebral oximetry in open heart surgeries reduced postoperative complications: A retrospective study. PLoS One 2021; 16:e0251157. [PMID: 34038405 PMCID: PMC8153416 DOI: 10.1371/journal.pone.0251157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022] Open
Abstract
Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.
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Lim L, Nam K, Lee S, Cho YJ, Yeom CW, Jung S, Moon JY, Jeon Y. The relationship between intraoperative cerebral oximetry and postoperative delirium in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study. BMC Anesthesiol 2020; 20:285. [PMID: 33189145 PMCID: PMC7666484 DOI: 10.1186/s12871-020-01180-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/01/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cerebral oximetry has been widely used to measure regional oxygen saturation in brain tissue, especially during cardiac surgery. Despite its popularity, there have been inconsistent results on the use of cerebral oximetry during cardiac surgery, and few studies have evaluated cerebral oximetry during off pump coronary artery bypass graft surgery (OPCAB). Methods To evaluate the relationship between intraoperative cerebral oximetry and postoperative delirium in patients who underwent OPCAB, we included 1439 patients who underwent OPCAB between October 2004 and December 2016 and among them, 815 patients with sufficient data on regional cerebral oxygen saturation (rSO2) were enrolled in this study. We retrospectively analyzed perioperative variables and the reduction in rSO2 below cut-off values of 75, 70, 65, 60, 55, 50, 45, 40, and 35%. Furthermore, we evaluated the relationship between the reduction in rSO2 and postoperative delirium. Results Delirium occurred in 105 of 815 patients. In both univariable and multivariable analyses, the duration of rSO2 reduction was significantly longer in patients with delirium at cut-offs of < 50 and 45% (for every 5 min, adjusted odds ratio (OR) 1.007 [95% Confidence interval (CI) 1.001 to 1.014] and adjusted OR 1.012 [1.003 to 1.021]; p = 0.024 and 0.011, respectively). The proportion of patients with a rSO2 reduction < 45% was significantly higher among those with delirium (adjusted OR 1.737[1.064 to 2.836], p = 0.027). Conclusions In patients undergoing OPCAB, intraoperative rSO2 reduction was associated with postoperative delirium. Duration of rSO2 less than 50% was 40% longer in the patients with postoperative delirium. The cut-off value of intraoperative rSO2 that associated with postoperative delirium was 50% for the total patient population and 55% for the patients younger than 68 years. Supplementary information Supplementary information accompanies this paper at 10.1186/s12871-020-01180-x.
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Affiliation(s)
- Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Chan-Woo Yeom
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Sanghyup Jung
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Jung Yoon Moon
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080.
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Yang HH, Chang JC, Jhan JY, Cheng YT, Huang YT, Chang BS, Chao SF. Prognostic value of peak lactate during cardiopulmonary bypass in adult cardiac surgeries: A retrospective cohort study. Tzu Chi Med J 2020; 32:386-391. [PMID: 33163386 PMCID: PMC7605302 DOI: 10.4103/tcmj.tcmj_215_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/28/2019] [Accepted: 01/08/2020] [Indexed: 12/29/2022] Open
Abstract
Objective: Tissue hypoperfusion during cardiopulmonary bypass (CPB) affects cardiac surgical outcomes. Lactate, an end product of anaerobic glycolysis from oxygen deficit, is a marker of tissue hypoxia. In this study, we aimed to identify the prognostic value of blood lactate level during CPB in predicting outcomes in adults undergoing cardiac surgeries. Materials and Methods: We retrospectively reviewed the medical records of patients who underwent cardiac surgeries with CPB from January 2015 to December 2015. Data about the characteristics of patients, preoperative status, type of surgery, and intraoperative lactate levels were collected. The outcomes were in-hospital mortality and complications. The receiver operating characteristics (ROC) curves were used to assess the ability of peak lactate level during CPB in predicting in-hospital mortality. Results: A total of 97 patients, including 61 who underwent emergent or urgent surgery, were enrolled. The types of surgery included coronary artery bypass grafting (CABG, n = 52), valve surgery (n = 27), combined surgery (CABG and valve surgery, n = 4), great vessel surgery (including aortic dissection, n = 9), and others (n = 5). The median CPB time was 139 min (interquartile range = 120–175). The median initial lactate and peak lactate levels during CPB were 0.9 and 4.2 mmol/L, respectively. In-hospital mortality was 14.4%, which was significantly associated with age and peak lactate level in the multivariate logistic regression model. When the peak lactate level during CPB reached 7.25 mmol/L, in-hospital mortality could be predicted with an area under the ROC curve of 0.75 (95% confidence interval: 0.59–0.90; P = 0.003), with a sensitivity of 57% and specificity of 93%. Conclusion: Hyperlactatemia during CPB was associated with increased in-hospital mortality. Thus, early detection of such conditions and aggressive postoperative care are important.
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Affiliation(s)
- Hsiao-Hui Yang
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jui-Chih Chang
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jin-You Jhan
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yi-Tso Cheng
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yen-Ta Huang
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Pharmacology, Tzu Chi University, Hualien, Taiwan
| | - Bee-Song Chang
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Shen-Feng Chao
- Division of Cardiovascular Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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Stannard B, Levin MA, Lin HM, Weiner MM. Regional cerebral oximetry is consistent across self-reported racial groups and predicts 30-day mortality in cardiac surgery: a retrospective analysis. J Clin Monit Comput 2020; 35:413-421. [PMID: 32086678 DOI: 10.1007/s10877-020-00487-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
Darker skin pigmentation appears to cause underestimation of regional oxygen saturation (rSO2) for certain cerebral oximetry devices. This presents a risk of triggering unindicated interventions and may limit its utility for predicting adverse outcomes. Our goal was to quantify the impact of self-reported race on oximetry measurements during cardiac surgery and elucidate whether race has a mediating role in the association of rSO2 with mortality. Data was extracted from our department's data warehouse for adult patients who underwent on-pump cardiac surgery between June 2014 and June 2018. Intraoperative rSO2 was recorded every 15 s throughout all cases. After grouping patients by self-reported race, multiple linear regression modeling was utilized to assess the association between race and mean pre-bypass rSO2 while controlling for various perioperative variables. The role of mean pre-bypass rSO2 for predicting 30-day mortality was evaluated via multiple logistic regression, and the threshold for rSO2 was selected by maximizing F1 score. There were 4267 patients included. Compared to Caucasian patients, the unadjusted difference in mean pre-bypass rSO2 was - 0.6% (95% CI - 1.3 to 0.04) for African American patients, - 1.8% (- 2.7 to - 0.9) for Asian patients, 0.1% (- 0.8 to 1.0) for Hispanic patients, - 1.6% (- 3.0 to - 0.4) for Indian/South Asian patients, and - 1.4% (- 3.7 to 0.9) for Pacific Islander patients. After adjusting for perioperative variables, differences in rSO2 readings less than 2% were observed between racial groups. Mean pre-bypass rSO2 under 63% was an independent predictor of higher 30-day mortality risk (OR: 2.86, CI 1.39 to 5.53, p = 0.003), and the interaction variable between rSO2 and race was not statistically significant (p = 0.299). Cerebral oximetry measurements are more consistent across racial groups than previously reported, supporting its utility for intraoperative monitoring and risk stratification. Pre-intervention rSO2 is associated with increased 30-day mortality at a higher threshold than previously reported and was not significantly impacted by self-reported race.
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Affiliation(s)
- Blaine Stannard
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genomics and Genetic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Wong C, Churilov L, Cowie D, Tan CO, Hu R, Tremewen D, Pearce B, Pillai P, Karalapillai D, Bellomo R, Weinberg L. Randomised controlled trial to investigate the relationship between mild hypercapnia and cerebral oxygen saturation in patients undergoing major surgery. BMJ Open 2020; 10:e029159. [PMID: 32066598 PMCID: PMC7045198 DOI: 10.1136/bmjopen-2019-029159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The effects of hypercapnia on regional cerebral oxygen saturation (rSO2) during surgery are unclear. We conducted a randomised controlled trial to investigate the relationship between mild hypercapnia and rSO2. We hypothesised that, compared with targeted normocapnia (TN), targeted mild hypercapnia (TMH) during major surgery would increase rSO2. DESIGN A prospective, randomised, controlled trial in adult participants undergoing elective major surgery. SETTING A single tertiary centre in Heidelberg, Victoria, Australia. PARTICIPANTS 40 participants were randomised to either a TMH or TN group (20 to each). INTERVENTIONS TMH (partial pressure of carbon dioxide in arterial blood, PaCO2, 45-55 mm Hg) or TN (PaCO2 35-40 mm Hg) was delivered via controlled ventilation throughout surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was the absolute difference between the two groups in percentage change in rSO2 from baseline to completion of surgery. Secondary endpoints included intraoperative pH, bicarbonate concentration, base excess, serum potassium concentration, incidence of postoperative delirium and length of stay (LOS) in hospital. RESULTS The absolute difference between the two groups in percentage change in rSO2 from the baseline to the completion of surgery was 19.0% higher in both hemispheres with TMH (p<0.001). On both sides, the percentage change in rSO2 was greater in the TMH group than the TN group throughout the duration of surgery. The difference between the groups became more noticeable over time. Furthermore, postoperative delirium was higher in the TN group (risk difference 0.3, 95% CI 0.1 to 0.5, p=0.02). LOS was similar between groups (5 days vs 5 days; p=0.99). CONCLUSION TMH was associated with a stable increase in rSO2 from the baseline, while TN was associated with a decrease in rSO2 in both hemispheres in patients undergoing major surgery. This resulted in a clear separation of percentage change in rSO2 from the baseline between TMH and TN over time. Our findings provide the rationale for larger studies on TMH during surgery. TRIAL REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry (ACTRN12616000320459).
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Affiliation(s)
- Clarence Wong
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- The Department of Medicine, Austin Health, The Univesity of Melbourne, Heidelberg, Victoria, Australia
| | - Dean Cowie
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David Tremewen
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
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Does uncontrolled diabetes mellitus affect cerebral hemodynamics in heart surgery? TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:84-91. [PMID: 32175147 DOI: 10.5606/tgkdc.dergisi.2020.18685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/20/2019] [Indexed: 01/08/2023]
Abstract
Background In this study, we aimed to investigate the effects of poor blood glucose control on the intraoperative cerebral system in patients undergoing coronary artery bypass grafting using various neuromonitors. Methods Between January 2011 and December 2011, a total of 40 adult patients (31 males, 9 females; mean age 58.8±9.2 years; range, 38 to 78 years) who were scheduled for elective coronary artery bypass grafting were included in the study. The patients were divided into four groups according to hemoglobin A1c levels as follows: Group 1 including non-diabetic controls (n=11); Group 2 including those with a hemoglobin A1c value of <7% (n=10); Group 3 including those with a hemoglobin A1c value of 7 to 10% (n=11); and Group 4 including those with a hemoglobin A1c value of ≥10% (n=8). Cerebral monitoring was performed with near-infrared spectroscopy and transcranial Doppler. Measurement periods were defined as follows: Before anesthesia induction (period 1), 10 min after anesthesia induction (period 2), during cannulation (period 3), 10 min after cardiopulmonary bypass (period 4), at 32°C temperature during cardiopulmonary bypass (period 5), at 36°C temperature during cardiopulmonary bypass (period 6), and at the end of the operation (period 7). Results There was a significant difference in the near-infrared spectroscopy values in the cannulation period for both right (p<0.001) and left (p=0.002) sides and the mean transcranial Doppler flow velocity (p=0.002) in Group 4, compared to Group 1. The heart rate was found to be significantly lower in Group 4 in the cannulation period. The near-infrared spectroscopy values and transcranial Doppler blood flow velocity decreased in Group 4 in all measurement periods. Conclusion The results of our study show that, in patients with severe diabetes undergoing open heart surgery, heart rate decreases in the cannulation period due to possible autonomic neuropathy, and cerebral blood flow and oxygenation decrease. For these patients, particularly in the cannulation period, perfusion of both cerebral and other organs should be closely monitored and necessary interventions should be performed.
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Pavlek LR, Mueller C, Jebbia MR, Kielt MJ, Fathi O. Near-Infrared Spectroscopy in Extremely Preterm Infants. Front Pediatr 2020; 8:624113. [PMID: 33553078 PMCID: PMC7859523 DOI: 10.3389/fped.2020.624113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/23/2020] [Indexed: 01/18/2023] Open
Abstract
With advances in neonatal care, survival of premature infants at the limits of viability has improved significantly. Despite these improvement in mortality, infants born at 22-24 weeks gestation are at a very high risk for short- and long-term morbidities associated with prematurity. Many of these diseases have been attributed to abnormalities of tissue oxygenation and perfusion. Near-infrared spectroscopy utilizes the unique absorption properties of oxyhemoglobin and deoxyhemoglobin to provide an assessment of regional tissue oxygen saturation, which can be used to calculate the fractional tissue oxygen extraction. This allows for a non-invasive way to monitor tissue oxygen consumption and enables targeted hemodynamic management. This mini-review provides a brief and complete overview of the background and physiology of near-infrared spectroscopy, practical use in extremely preterm infants, and potential applications in the neonatal intensive care unit. In this mini-review, we aim to summarize the three primary application sites for near-infrared spectroscopy, disease-specific indications, and available literature regarding use in extremely preterm infants.
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Affiliation(s)
- Leeann R Pavlek
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Clifford Mueller
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria R Jebbia
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Matthew J Kielt
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Omid Fathi
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
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Effect of Body Temperature on Cerebral Autoregulation in Acutely Comatose Neurocritically Ill Patients. Crit Care Med 2019; 46:e733-e741. [PMID: 29727362 DOI: 10.1097/ccm.0000000000003181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Impaired cerebral autoregulation following neurologic injury is a predictor of poor clinical outcome. We aimed to assess the relationship between body temperature and cerebral autoregulation in comatose patients. DESIGN Retrospective analysis of prospectively collected data. SETTING Neurocritical care unit of the Johns Hopkins Hospital. PATIENTS Eighty-five acutely comatose patients (Glasgow Coma Scale score of ≤ 8) admitted between 2013 and 2017. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Cerebral autoregulation was monitored using multimodal monitoring with near-infrared spectroscopy-derived cerebral oximetry index. Cerebral oximetry index was calculated as a Pearson correlation coefficient between low-frequency changes in regional cerebral oxygenation saturation and mean arterial pressure. Patients were initially analyzed together, then stratified by temperature pattern over the monitoring period: no change (< 1°C difference between highest and lowest temperatures; n = 11), increasing (≥ 1°C; n = 9), decreasing (≥ 1°C; n = 9), and fluctuating (≥ 1°C difference but no sustained direction of change; n = 56). Mixed random effects models with random intercept and multivariable logistic regression analysis were used to assess the association between hourly temperature and cerebral oximetry index, as well as between temperature and clinical outcomes. Cerebral oximetry index showed a positive linear relationship with temperature (β = 0.04 ± 0.10; p = 0.29). In patients where a continual increase or decrease in temperature was seen during the monitoring period, every 1°C change in temperature resulted in a cerebral oximetry index change in the same direction by 0.04 ± 0.01 (p < 0.001) and 0.02 ± 0.01 (p = 0.12), respectively, after adjusting for PaCO2, hemoglobin, mean arterial pressure, vasopressor and sedation use, and temperature probe location. There was no significant difference in mortality or poor outcome (modified Rankin Scale score of 4-6) between temperature pattern groups at discharge, 3, or 6 months. CONCLUSIONS In acute coma patients, increasing body temperature is associated with worsening cerebral autoregulation as measured by cerebral oximetry index. More studies are needed to clarify the impact of increasing temperature on cerebral autoregulation in patients with acute brain injury.
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Determining the Upper and Lower Limits of Cerebral Autoregulation With Cerebral Oximetry Autoregulation Curves: A Case Series. Crit Care Med 2019; 46:e473-e477. [PMID: 29419556 DOI: 10.1097/ccm.0000000000003012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Critical care guidelines recommend a single target value for mean arterial blood pressure in critically ill patients. However, growing evidence regarding cerebral autoregulation challenges this concept and supports individualizing mean arterial blood pressure targets to prevent brain and kidney hypo- or hyperperfusion. Regional cerebral oxygen saturation derived from near-infrared spectroscopy is an acceptable surrogate for cerebral blood flow and has been validated to measure cerebral autoregulation. This study suggests a novel mechanism to construct autoregulation curves based on near-infrared spectroscopy-measured cerebral oximetry. DESIGN Case-series study. SETTING Neurocritical care unit in a tertiary medical center. PATIENTS Patients with acute neurologic injury and Glasgow coma scale score less than or equal to 8. MEASUREMENTS AND MAIN RESULTS Autoregulation curves were plotted using the fractional-polynomial model in Stata after multimodal continuous monitoring of regional cerebral oxygen saturation and mean arterial blood pressure. Individualized autoregulation curves of seven patients exhibited varying upper and lower limits of autoregulation and provided useful clinical information on the autoregulation trend (curves moving to the right or left during the acute coma period). The median lower and upper limits of autoregulation were 86.5 mm Hg (interquartile range, 74-93.5) and 93.5 mm Hg (interquartile range, 83-99), respectively. CONCLUSIONS This case-series study showed feasibility of delineating real trends of the cerebral autoregulation plateau and direct visualization of the cerebral autoregulation curve after at least 24 hours of recording without manipulation of mean arterial blood pressure by external stimuli. The integration of multimodal monitoring at the bedside with cerebral oximetry provides a noninvasive method to delineate daily individual cerebral autoregulation curves.
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Srivastava S, Bhan A. Aortic arch aneurysms and dissection-open repair is the gold standard. Indian J Thorac Cardiovasc Surg 2019; 35:136-155. [PMID: 33061079 DOI: 10.1007/s12055-019-00819-w] [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: 12/09/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 10/26/2022] Open
Abstract
The aortic arch repair is one of the most complex surgeries and carries a high risk of complications as well as mortality. Since 1975, when the arch repair was first done by Randall B. Griepp using hypothermic circulatory arrest, many new technologies were introduced. But even with the use of antegrade and retrograde perfusion techniques and improvement of surgical techniques and grafts, the rate of mortality, cerebral, spinal, and visceral damage was much higher as compared to any other cardiac surgeries. With further developments aimed at less invasive approaches, thoracic endovascular aortic repair (TEVAR) along with de-branching of supra-aortic vessels or the frozen elephant trunk was introduced. Here, in this article, we review the myriad of approaches to the aortic arch and have come to a conclusion that while traditional open surgery is considered as the gold standard for treatment of extensive aortic arch pathologies, one school of thought suggests hybrid techniques such as the frozen elephant trunk and aortic arch vessel de-branching as more appropriate procedures for high-risk patients, where co-morbidities may contraindicate cardiopulmonary bypass and longer operative times required for traditional repair. No randomized trials are present to compare between open and hybrid or endovascular procedure in normal or high-risk patients. The meta-analysis of most of the studies defines open surgery as the gold standard for arch pathology because the hybrid procedures did not provide any proven survival benefits or decrease in stroke rate and spinal ischemia when compared to open surgery in early, mid, or long-term results.
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Affiliation(s)
- Swarnika Srivastava
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India.,Noida, India
| | - Anil Bhan
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India
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Hwang KY, Hwang NC. Facilitating noncardiac surgery for the patient with left ventricular assist device: A guide for the anesthesiologist. Ann Card Anaesth 2019; 21:351-362. [PMID: 30333327 PMCID: PMC6206808 DOI: 10.4103/aca.aca_239_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The introduction of left ventricular assist device (LVAD) has improved survival rates for patients with end-stage heart failure. Two categories of VADs exist: one generates pulsatile flow and the other produces nonpulsatile continuous flow. Survival is better for patients with continuous-flow LVADs. With improved survival, more of such patients now present for noncardiac surgery (NCS). This review, written for the general anesthesiologists, addresses the perioperative considerations when the patient undergoes NCS. For best outcomes, a multidisciplinary approach is essential in perioperative management of the patient.
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Affiliation(s)
- Kai-Yin Hwang
- Department of Anaesthesiology, Singapore General Hospital, 1 Hospital Drive, Singapore 169608, Singapore
| | - Nian-Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, 1 Hospital Drive, Singapore 169608; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore, 5 Hospital Drive, Singapore 169609, Singapore
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Zhang H, Gutruf P, Meacham K, Montana MC, Zhao X, Chiarelli AM, Vázquez-Guardado A, Norris A, Lu L, Guo Q, Xu C, Wu Y, Zhao H, Ning X, Bai W, Kandela I, Haney CR, Chanda D, Gereau RW, Rogers JA. Wireless, battery-free optoelectronic systems as subdermal implants for local tissue oximetry. SCIENCE ADVANCES 2019; 5:eaaw0873. [PMID: 30873435 PMCID: PMC6408152 DOI: 10.1126/sciadv.aaw0873] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/28/2019] [Indexed: 05/18/2023]
Abstract
Monitoring regional tissue oxygenation in animal models and potentially in human subjects can yield insights into the underlying mechanisms of local O2-mediated physiological processes and provide diagnostic and therapeutic guidance for relevant disease states. Existing technologies for tissue oxygenation assessments involve some combination of disadvantages in requirements for physical tethers, anesthetics, and special apparatus, often with confounding effects on the natural behaviors of test subjects. This work introduces an entirely wireless and fully implantable platform incorporating (i) microscale optoelectronics for continuous sensing of local hemoglobin dynamics and (ii) advanced designs in continuous, wireless power delivery and data output for tether-free operation. These features support in vivo, highly localized tissue oximetry at sites of interest, including deep brain regions of mice, on untethered, awake animal models. The results create many opportunities for studying various O2-mediated processes in naturally behaving subjects, with implications in biomedical research and clinical practice.
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Affiliation(s)
- Hao Zhang
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Philipp Gutruf
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ 85721, USA
| | - Kathleen Meacham
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael C. Montana
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Xingyue Zhao
- Department of Materials Science and Engineering and Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- State Key Laboratory of New Ceramics and Fine Processing and School of Materials Science and Engineering, Tsinghua University, Beijing 100084, China
| | - Antonio M. Chiarelli
- Institute of Advanced Biomedical Technologies and Department of Neuroscience, Imaging and Clinical Sciences, University G. D’Annunzio of Chieti–Pescara, Chieti 66100, Italy
| | - Abraham Vázquez-Guardado
- NanoScience Technology Center, Department of Physics and CREOL, The College of Optics and Photonics, University of Central Florida, Orlando, FL 32826, USA
| | - Aaron Norris
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Luyao Lu
- Department of Materials Science and Engineering and Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Qinglei Guo
- Department of Materials Science and Engineering and Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Department of Materials Science, Fudan University, Shanghai 200433, China
| | - Chenkai Xu
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Yixin Wu
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Hangbo Zhao
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
| | - Xin Ning
- Department of Materials Science and Engineering and Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Wubin Bai
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
- Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
| | - Irawati Kandela
- Developmental Therapeutics Core, Northwestern University, Evanston, IL 60208, USA
- Chemistry of Life Processes Institute, Northwestern University, Evanston, IL 60208, USA
| | - Chad R. Haney
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Chemistry of Life Processes Institute, Northwestern University, Evanston, IL 60208, USA
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, IL 60208, USA
| | - Debashis Chanda
- NanoScience Technology Center, Department of Physics and CREOL, The College of Optics and Photonics, University of Central Florida, Orlando, FL 32826, USA
| | - Robert W. Gereau
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - John A. Rogers
- Departments of Materials Science and Engineering, Biomedical Engineering, Neurological Surgery, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, Simpson Querrey Institute and Feinberg Medical School, Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL 60208, USA
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23
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Maillard J, Sologashvili T, Diaper J, Licker MJ, Keli Barcelos G. A Case of Persistence of Normal Tissue Oxygenation Monitored by Near-Infrared Spectroscopy (NIRS) Values Despite Prolonged Perioperative Cardiac Arrest. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:21-25. [PMID: 30610182 PMCID: PMC6330994 DOI: 10.12659/ajcr.911399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patient: Male, 65 Final Diagnosis: Aortic dissection Symptoms: Hemiplegia • hypotension Medication:— Clinical Procedure: Emergent surgery Specialty: Surgery
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Affiliation(s)
- Julien Maillard
- Department of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Department of Surgery, Division Cardiovascular Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Marc-Joseph Licker
- Department of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Gleicy Keli Barcelos
- Department of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
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24
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Rivera-Lara L, Geocadin R, Zorrilla-Vaca A, Healy R, Radzik BR, Palmisano C, Mirski M, Ziai WC, Hogue C. Validation of Near-Infrared Spectroscopy for Monitoring Cerebral Autoregulation in Comatose Patients. Neurocrit Care 2018; 27:362-369. [PMID: 28664392 DOI: 10.1007/s12028-017-0421-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transcranial Doppler (TCD) noninvasively measures cerebral blood flow (CBF) velocity and is a well-studied method to monitor cerebral autoregulation (CA). Near-infrared spectroscopy (NIRS) has emerged as a promising noninvasive method to determine CA continuously by using regional cerebral oxygen saturation (rSO2) as a surrogate for CBF. Little is known about its accuracy to determine CA in patients with intracranial lesions. The purpose of this study was to assess the accuracy of rSO2-based CA monitoring with TCD methods in comatose patients with acute neurological injury. METHODS Thirty-three comatose patients were monitored at the bedside to measure CA using both TCD and NIRS. Patients were monitored daily for up to three days from coma onset. The cerebral oximetry index (COx) was calculated as the moving correlation between the slow waves of rSO2 and mean arterial pressure (MAP). The mean velocity index (Mx) was calculated as a similar coefficient between slow waves of TCD-measured CBF velocity and MAP. Optimal blood pressure was defined as the MAP with the lowest Mx and COx. Averaged Mx and COx as well as optimal MAP, based on both Mx and COx, were compared using Pearson's correlation. Bias analysis was performed between these same CA metrics. RESULTS The median duration of monitoring was 60 min (interquartile range [IQR] 48-78). There was a moderate correlation between the averaged values of COx and Mx (R = 0.40, p = 0.005). Similarly, there was a strong correlation between optimal MAP calculated for COx and Mx (R = 0.87, p < 0.001). Bland-Altman analysis showed moderate agreement with bias (±standard deviation) of -0.107 (±0.191) for COx versus Mx and good agreement with bias of 1.90 (±7.94) for optimal MAP determined by COx versus Mx. CONCLUSIONS Monitoring CA with NIRS-derived COx is correlated and had good agreement with previously validated TCD-based method. These results suggest that COx may be an acceptable substitute for Mx monitoring in patients with acute intracranial injury.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
| | - Romergryko Geocadin
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Faculty of Health, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Ryan Healy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Batya R Radzik
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Caitlin Palmisano
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Marek Mirski
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Wendy C Ziai
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Charles Hogue
- Department of Anesthesiology, Northwestern University Feinberg, School of Medicine, Chicago, IL, 606011, USA
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25
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Wong JJM, Chen CK, Moorakonda RB, Wijeweera O, Tan TYS, Nakao M, Allen JC, Loh TF, Lee JH. Changes in Near-Infrared Spectroscopy After Congenital Cyanotic Heart Surgery. Front Pediatr 2018; 6:97. [PMID: 29707528 PMCID: PMC5908891 DOI: 10.3389/fped.2018.00097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/26/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Since oxygen saturation from pulse oximetry (SpO2) and partial pressure of arterial oxygen (PaO2) are observed to improve immediately after surgical correction of cyanotic congenital heart disease (CHD), we postulate that cerebral (CrO2) and somatic (SrO2) oximetry also improves immediately post-correction. We aim to prospectively examine CrO2 and SrO2, before, during, and after surgical correction as well as on hospital discharge in children with cyanotic CHD to determine if and when these variables increase. METHODS This is a prospective observational trial. Eligibility criteria included children below 18 years of age with cyanotic CHD who required any cardiac surgical procedure. CrO2 and SrO2 measurements were summarized at six time-points for comparison: (1) pre-cardiopulmonary bypass (CPB); (2) during CPB; (3) post-CPB; (4) Day 1 in the pediatric intensive care unit (PICU); (5) Day 2 PICU; and (6) discharge. Categorical and continuous variables are presented as counts (percentages) and median (interquartile range), respectively. RESULTS Twenty-one patients were analyzed. 15 (71.4%) and 6 (28.6%) patients underwent corrective and palliative surgeries, respectively. In the corrective surgery group, SpO2 increased immediately post-CPB compared to pre-CPB [99 (98, 100) vs. 86% (79, 90); p < 0.001] and remained in the normal range through to hospital discharge. Post-CPB CrO2 did not change from pre-CPB [72.8 (58.8, 79.0) vs. 72.1% (63.0, 78.3); p = 0.761] and even decreased on hospital discharge [60.5 (53.6, 62.9) vs. 72.1% (63.0, 78.3); p = 0.005]. Post-CPB SrO2 increased compared to pre-CPB [87.3 (77.2, 89.5) vs. 72.7% (65.6, 77.3); p = 0.001] but progressively decreased during PICU stay to a value lower than baseline at hospital discharge [66.9 (57.3, 76.9) vs. 72.7% (65.6, 77.3); p = 0.048]. CONCLUSION CrO2 and SrO2 did not increase after corrective surgery of cyanotic CHD even up to hospital discharge. Future larger studies are required to validate these findings. (This study is registered with ClinicalTrials.gov ID: NCT02417259.).
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Affiliation(s)
- Judith Ju-Ming Wong
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Ching Kit Chen
- Cardiology Services, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rajesh Babu Moorakonda
- Singapore Clinical Research Institute, Singapore, Singapore.,Duke-NUS Medical School, Centre for Quantitative Medicine, Singapore, Singapore
| | - Olivia Wijeweera
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Tracy Yi Shuen Tan
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - John Carson Allen
- Duke-NUS Medical School, Centre for Quantitative Medicine, Singapore, Singapore
| | - Tsee Foong Loh
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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26
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Rummel C, Basciani R, Nirkko A, Schroth G, Stucki M, Reineke D, Eberle B, Kaiser HA. Spatially extended versus frontal cerebral near-infrared spectroscopy during cardiac surgery: a case series identifying potential advantages. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-11. [PMID: 29359545 DOI: 10.1117/1.jbo.23.1.016012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 12/19/2017] [Indexed: 06/07/2023]
Abstract
Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.
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Affiliation(s)
- Christian Rummel
- University of Bern, Support Center for Advanced Neuroimaging, University Institute for Diagnostic an, Switzerland
| | - Reto Basciani
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - Arto Nirkko
- University of Bern, Department of Neurology, Schlaf-Wach-Epilepsie-Zentrum, Inselspital, Bern, Switzerland
| | - Gerhard Schroth
- University of Bern, Support Center for Advanced Neuroimaging, University Institute for Diagnostic an, Switzerland
| | - Monika Stucki
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - David Reineke
- University of Bern, Department of Cardiovascular Surgery, Inselspital, Bern, Switzerland
| | - Balthasar Eberle
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
| | - Heiko A Kaiser
- University of Bern, Department of Anesthesiology and Pain Therapy, Inselspital, Bern, Switzerland
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27
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Serraino GF, Murphy GJ. Effects of cerebral near-infrared spectroscopy on the outcome of patients undergoing cardiac surgery: a systematic review of randomised trials. BMJ Open 2017; 7:e016613. [PMID: 28882917 PMCID: PMC5595187 DOI: 10.1136/bmjopen-2017-016613] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Goal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that the use of NIRS cerebral oximetry results in reductions in cerebral injury (neurocognitive function, serum biomarkers), injury to other organs including the heart and brain, transfusion rates, mortality and resource use. DESIGN Systematic review and meta-analysis. SETTING Tertiary cardiac surgery centres in North America, Europe and Asia. PARTICIPANTS A search of Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature Plus from inception to November 2016 identified 10 randomised trials, enrolling a total of 1466 patients, all in adult cardiac surgery. INTERVENTIONS NIRS-based algorithms designed to optimise cerebral oxygenation versus standard care (non-NIRS-based) protocols in cardiac surgery patients during cardiopulmonary bypass. OUTCOME MEASURES Mortality, organ injury affecting the brain, heart and kidneys, red cell transfusion and resource use. RESULTS Two of the 10 trials identified in the literature search were considered at low risk of bias. Random-effects meta-analysis demonstrated similar mortality (risk ratio (RR) 0.76, 95% CI 0.30 to 1.96), major morbidity including stroke (RR 1. 08, 95% CI 0.40 to 2.91), red cell transfusion and resource use in NIRS-treated patients and controls, with little or no heterogeneity. Grades of Recommendation, Assessment, Development and Evaluation of the quality of the evidence was low or very low for all of the outcomes assessed. CONCLUSIONS The results of this systematic review did not support the hypotheses that cerebral NIRS-based algorithms have clinical benefits in cardiac surgery. TRIAL REGISTRATION NUMBER PROSPERO CRD42015027696.
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Affiliation(s)
- Giuseppe Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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28
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Vranken NP, Weerwind PW, Sutedja NA, Ševerdija EE, Barenbrug PJ, Maessen JG. Cerebral Oximetry and Autoregulation during Cardiopulmonary Bypass: A Review. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2017; 49:182-191. [PMID: 28979042 PMCID: PMC5621582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
Postoperative neurological complications (PNCs) following cardiac surgery with cardiopulmonary bypass (CPB) is a detrimental complication, contributing to increased mortality rates and health care costs. To prevent intraoperative cerebral desaturations associated with PNC, continuous brain monitoring using near-infrared spectroscopy has been advocated. However, clear evidence for a defined desaturation threshold requiring intervention during CPB is still lacking. Since cerebral oximetry readings are nonspecific, cerebral tissue oxygenation values need to be interpreted with caution and in the context of all available clinical information. Therefore, maintaining an intact autoregulatory activity during CPB rather than solely focusing on regional cerebral oxygen saturation measurements will collectively contribute to optimization of patient care during CPB.
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Affiliation(s)
| | | | - Nadia A. Sutedja
- Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
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29
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Cerebral oxygen desaturation occurs frequently in patients with hypertension undergoing major abdominal surgery. J Clin Monit Comput 2017; 32:285-293. [DOI: 10.1007/s10877-017-0024-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 04/26/2017] [Indexed: 11/27/2022]
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30
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Rawat RS. Should cerebral oximetry be used as routine monitoring for cardiovascular surgical cases? Ann Card Anaesth 2017; 19:392-3. [PMID: 27397440 PMCID: PMC4971964 DOI: 10.4103/0971-9784.185516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rajinder Singh Rawat
- Department of Cardiac Anaesthesiology, Salalah Heart Center, Salalah, Sultanate of Oman
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31
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Bailey SM, Mally PV. Review of splanchnic oximetry in clinical medicine. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:091306. [PMID: 27165703 DOI: 10.1117/1.jbo.21.9.091306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/13/2016] [Indexed: 06/05/2023]
Abstract
Global tissue perfusion and oxygenation are important indicators of physiologic function in humans. The monitoring of splanchnic oximetry through the use of near-infrared spectroscopy (NIRS) is an emerging method used to assess tissue oxygenation status. Splanchnic tissue oxygenation (SrSO2) is thought to be potentially of high value in critically ill patients because gastrointestinal organs can often be the first to suffer ischemic injury. During conditions of hypovolemia, cardiac dysfunction, or decreased oxygen-carrying capacity, blood flow is diverted toward vital organs, such as the brain and the heart at the expense of the splanchnic circulation. While monitoring SrSO2 has great potential benefit, there are limitations to the technology and techniques. SrSO2 has been found to have a relatively high degree of variability that can potentially make it difficult to interpret. In addition, because splanchnic organs only lie near the skin surface in children and infants, and energy from currently available sensors only penetrates a few centimeters deep, it can be difficult to use clinically in a noninvasive manner in adults. Research thus far is showing that splanchnic oximetry holds great promise in the ability to monitor patient oxygenation status and detect disease states in humans, especially in pediatric populations.
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32
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O'Neal JB, Shaw AD. Predicting, preventing, and identifying delirium after cardiac surgery. Perioper Med (Lond) 2016; 5:7. [PMID: 27119013 PMCID: PMC4845390 DOI: 10.1186/s13741-016-0032-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/29/2016] [Indexed: 02/07/2023] Open
Abstract
Delirium after cardiac surgery is a major problem. The exact mechanisms behind delirium are not understood. Potential pathways of delirium include neurotransmitter interference, global cognitive disorder, and neuroinflammation. Several predisposing and precipitating risk factors have been identified for postoperative delirium. The development of delirium following cardiac surgery is associated with worse outcomes in the perioperative period. Multiple interventions are being explored for the prevention and treatment of delirium. Studies investigating the potential roles of biomarkers in delirium as well as pharmacological interventions to reduce the incidence and duration of delirium are necessary to mitigate this negative outcome.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
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33
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He JW, Liu H, Peng YB. Hemodynamic and Light-Scattering Changes of Rat Spinal Cord and Primary Somatosensory Cortex in Response to Innocuous and Noxious Stimuli. Brain Sci 2015; 5:400-18. [PMID: 26426059 PMCID: PMC4701020 DOI: 10.3390/brainsci5040400] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/20/2015] [Accepted: 09/24/2015] [Indexed: 12/28/2022] Open
Abstract
Neuroimaging technologies with an exceptional spatial resolution and noninvasiveness have become a powerful tool for assessing neural activity in both animals and humans. However, the effectiveness of neuroimaging for pain remains unclear partly because the neurovascular coupling during pain processing is not completely characterized. Our current work aims to unravel patterns of neurovascular parameters in pain processing. A novel fiber-optic method was used to acquire absolute values of regional oxy- (HbO) and deoxy-hemoglobin concentrations, oxygen saturation rates (SO₂), and the light-scattering coefficients from the spinal cord and primary somatosensory cortex (SI) in 10 rats. Brief mechanical and electrical stimuli (ranging from innocuous to noxious intensities) as well as a long-lasting noxious stimulus (formalin injection) were applied to the hindlimb under pentobarbital anesthesia. Interhemispheric comparisons in the spinal cord and SI were used to confirm functional activation during sensory processing. We found that all neurovascular parameters showed stimulation-induced changes; however, patterns of changes varied with regions and stimuli. Particularly, transient increases in HbO and SO₂ were more reliably attributed to brief stimuli, whereas a sustained decrease in SO₂ was more reliably attributed to formalin. Only the ipsilateral SI showed delayed responses to brief stimuli. In conclusion, innocuous and noxious stimuli induced significant neurovascular responses at critical centers (e.g., the spinal cord and SI) along the somatosensory pathway; however, there was no single response pattern (as measured by amplitude, duration, lateralization, decrease or increase) that was able to consistently differentiate noxious stimuli. Our results strongly suggested that the neurovascular response patterns differ between brief and long-lasting noxious stimuli, and can also differ between the spinal cord and SI. Therefore, a use of multiple-parameter strategy tailored by stimulus modality (brief or long-lasting) as well as region-dependent characteristics may be more effective in detecting pain using neuroimaging technologies.
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Affiliation(s)
- Ji-Wei He
- Departments of Psychology, University of Texas at Arlington, Arlington, TX 76019, USA.
- Department of Neurological Surgery, University of California San Francisco, 1700 Owens Street, San Francisco, CA 94158, USA.
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76019, USA.
| | - Yuan Bo Peng
- Departments of Psychology, University of Texas at Arlington, Arlington, TX 76019, USA.
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