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Mizunoya K, Yagi Y, Morimoto Y, Hirano S. Altered microvascular reactivity assessed by near-infrared spectroscopy after hepato-pancreato-biliary surgery. J Clin Monit Comput 2021; 36:703-712. [PMID: 33829357 DOI: 10.1007/s10877-021-00697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
Little is known about microcirculatory dysfunction following abdominal surgeries. This study aimed to evaluate changes in microvascular reactivity (MVR) before and after major abdominal surgery, assessed by near-infrared spectroscopy in conjunction with a vascular occlusion test. This prospective observational study included 50 adult patients who underwent hepato-pancreato-biliary surgery lasting ≥ 8 h. MVR was assessed by tissue oxygen saturation (StO2) changes in the plantar region of the foot during 3 min of vascular occlusion and subsequent release under general anesthesia before and after surgery. The primary outcome was alteration in the recovery slope of StO2 (RecStO2) and recovery time (tM) between the preoperative and postoperative values. Postoperative short-term outcome was represented by the Post-operative Morbidity Survey (POMS) score on the morning of postoperative day 2. After surgery, RecStO2 was reduced (0.74% [0.58-1.06]/s vs. 0.89% [0.62-1.41]/s, P = 0.001), and tM was longer (57.0 [42.9-71.0] s vs. 41.3 [35.5-56.5] s, P < 0.001), compared to the preoperative values. Macrohemodynamic variables such as cardiac index, arterial pressure, and stroke volume during postoperative measurement did not differ with or without relative MVR decline. In addition, the POMS score was not associated with postoperative alterations in microcirculatory responsiveness. MVR in the plantar region of the foot was reduced after major hepato-pancreato-biliary surgery regardless of macrocirculatory adequacy. Impaired MVR was not associated with short-term outcomes as long as macrocirculatory indices were well maintained. The impact of relative microcirculatory changes, especially combined with inadequate macrocirculation, on postoperative complications remains to be elucidated.Clinical Trial Registrations UMIN-CTR trial ID: 000033461.
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Affiliation(s)
- Kazuyuki Mizunoya
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan.
| | - Yasunori Yagi
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Sapporo, Japan
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2
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Shaaban-Ali M, Momeni M, Denault A. Clinical and Technical Limitations of Cerebral and Somatic Near-Infrared Spectroscopy as an Oxygenation Monitor. J Cardiothorac Vasc Anesth 2020; 35:763-779. [PMID: 32709385 DOI: 10.1053/j.jvca.2020.04.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/12/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022]
Abstract
Cerebral and somatic near-infrared spectroscopy monitors are commonly used to detect tissue oxygenation in various circumstances. This form of monitoring is based on tissue infrared absorption and can be influenced by several physiological and non-physiological factors that can induce error in the interpretation. This narrative review explores those clinical and technical limitations and proposes solutions and alternatives in order to avoid some of those pitfalls.
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Affiliation(s)
- Mohamed Shaaban-Ali
- Department of Anesthesia, College of Medicine, Assiut University, Assiut, Egypt
| | - Mona Momeni
- Department of Acute Medicine, Section Cardiothoracic and Vascular Anesthesia, Cliniques Universitaires Saint Luc, UCLouvain, Brussels, Belgium
| | - André Denault
- Department of Anesthesia and Critical Care Medicine, Montreal Heart Institute, Université de Montréal, and Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
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3
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Bergeron EJ, Mosca MS, Aftab M, Justison G, Reece TB. Neuroprotection Strategies in Aortic Surgery. Cardiol Clin 2017; 35:453-465. [DOI: 10.1016/j.ccl.2017.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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4
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Aly SA, Zurakowski D, Glass P, Skurow-Todd K, Jonas RA, Donofrio MT. Cerebral tissue oxygenation index and lactate at 24 hours postoperative predict survival and neurodevelopmental outcome after neonatal cardiac surgery. CONGENIT HEART DIS 2016; 12:188-195. [DOI: 10.1111/chd.12426] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/31/2016] [Accepted: 10/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Safwat A. Aly
- Department of Pediatrics; Children's National Medical Center; Washington District of Columbia, USA
| | - David Zurakowski
- Departments of Anesthesia and Surgery; Boston Children's Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Penny Glass
- Department of Psychiatry and Behavioral Science; Children's National Medical Center; Washington District of Columbia USA
| | - Kami Skurow-Todd
- Division of Cardiology; Children's National Medical Center; Washington District of Columbia USA
| | - Richard A. Jonas
- Division of Cardiothoracic Surgery; Children's National Medical Center; Washington District of Columbia USA
| | - Mary T. Donofrio
- Division of Cardiology; Children's National Medical Center; Washington District of Columbia USA
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5
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Keenan JE, Benrashid E, Kale E, Nicoara A, Husain AM, Hughes GC. Neurophysiological Intraoperative Monitoring During Aortic Arch Surgery. Semin Cardiothorac Vasc Anesth 2016; 20:273-282. [PMID: 27708177 DOI: 10.1177/1089253216672441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Circulatory management during replacement of the aortic arch is complex and involves a period of circulatory arrest to provide a bloodless field during arch vessel anastomosis. To guard against ischemic brain injury, tissue metabolic demand is reduced by systemically cooling the patient prior to circulatory arrest. Neurophysiological intraoperative monitoring (NIOM) is often used during the course of these procedures to provide contemporaneous assessment of brain status to help direct circulatory management decisions and detect brain ischemia. In this review, we discuss the characteristics of electrocerebral activity through the process of cooling, circulatory arrest, and rewarming as depicted through commonly used NIOM modalities, including electroencephalography and peripheral nerve somatosensory-evoked potentials. Attention is directed toward the role NIOM has traditionally played during deep hypothermic circulatory arrest, where it is used to define the point of electrocerebral inactivity or maximal cerebral metabolic suppression prior to initiating circulatory arrest while also discussing the evolving utility of NIOM when systemic circulatory arrest is initiated at more moderate degrees of hypothermia in conjunction with regional brain perfusion. The use of cerebral tissue oximetry by near-infrared spectroscopy as an alternative NIOM modality during surgery of the aortic arch is addressed as well. Finally, special considerations for NIOM and the detection of spinal cord ischemia during hybrid aortic arch repair and emerging operative techniques are also discussed.
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Affiliation(s)
- Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Emily Kale
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Aatif M Husain
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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6
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Durandy Y, Rubatti M, Couturier R. Near Infrared Spectroscopy during pediatric cardiac surgery: errors and pitfalls. Perfusion 2011; 26:441-6. [DOI: 10.1177/0267659111408755] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As a result of improvements in early outcomes, long-term neurologicalal outcomes are becoming a major issue in pediatric cardiac surgery. The mechanisms of brain injury are numerous, but a vast majority of injuries are impervious to therapy and only a few are modifiable. The quality of perfusion during cardiac surgery is a modifiable factor and cerebral monitoring during bypass is the way to assess the quality of intra-operative cerebral perfusion. Near infrared spectroscopy (NIRS), as a diagnostic tool, has gained in popularity within the perfusion community. However, NIRS is becoming the standard of care before its scientific validation. This manuscript relates four clinical cases, demonstrating the limitations of NIRS monitoring during pediatric cardiac surgery as well as uncertainties about the interpretation of the recorded values. The clinical relevance of cerebral oxymetry is needed before the use of NIRS as a decision making tool. Multimodal brain monitoring with NIRS, trans-cranial Doppler and electroencephalogram are currently under way in several pediatric centers. The benefit of this time-consuming and expensive monitoring system has yet to be demonstrated.
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Affiliation(s)
- Y Durandy
- Department of Perfusion and Intensive Care, Institut Hospitalier Jacques Cartier, Massy, France
| | - M Rubatti
- Department of Anesthesiology, Institut Hospitalier Jacques Cartier, Massy, France
| | - R Couturier
- Department of Anesthesiology, Institut Hospitalier Jacques Cartier, Massy, France
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Papademetriou MD, Tachtsidis I, Banaji M, Elliott MJ, Hoskote A, Elwell CE. Regional cerebral oxygenation measured by multichannel near-infrared spectroscopy (optical topography) in an infant supported on venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2011; 141:e31-3. [PMID: 21334016 PMCID: PMC3853439 DOI: 10.1016/j.jtcvs.2011.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 12/29/2010] [Accepted: 01/17/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Maria D Papademetriou
- Biomedical Optics Research Laboratory, Department of Medical Physics and Bioengineering, University College London, United Kingdom.
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8
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Sasaki T, Boni L, Riemer RK, Yeung JT, Ramamoorthy C, Beckman R, Gisner C, Shuttleworth P, Hanley FL, Reddy VM. Cerebral Oxygen Metabolism During Total Body Flow and Antegrade Cerebral Perfusion at Deep and Moderate Hypothermia. Artif Organs 2010; 34:980-6. [DOI: 10.1111/j.1525-1594.2010.01131.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jonas RA. Advances in cardiopulmonary bypass and extracorporeal membrane oxygenation for the neonate and infant. World J Pediatr Congenit Heart Surg 2010; 1:217-25. [PMID: 23804824 DOI: 10.1177/2150135110372638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There have been numerous advances in all of the associated subspecialty areas necessary for successful congenital cardiac surgery over the last 2 decades. Within the operating room itself, advances have occurred in instrumentation, prosthetics and biomaterials, surgical optics including loupes, and fiberoptic lighting. However, some of the most important advances have been in the techniques and hardware of cardiopulmonary bypass, the use of extracorporeal membrane oxygenation support in the intensive care unit, and the refinement of strategies to optimize neurodevelopmental outcomes.
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Affiliation(s)
- Richard A Jonas
- Children's National Heart Institute, Children's National Medical Center, Washington, DC, USA
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10
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Kim SH, Kim TY, Lee HH, Yoon TG. Cerebral oxygen saturation monitoring for off-pump coronary bypass graft surgery with Moyamoya disease: A case report. Korean J Anesthesiol 2009; 56:433-437. [PMID: 30625766 DOI: 10.4097/kjae.2009.56.4.433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We report a case using cerebral oxygen saturation (rCbO2) for off-pump coronary artery bypass graft (OPCAB) surgery in a patient with co-existing Moyamoya disease. The rCbO2 with the routine monitoring for OPCAB surgery were monitored intraoperatively. In spite of infusing nimodipine (0.2 microgram/kg/min) and maintaining the end-tidal CO2 tension at 35-40 mmHg, a sudden reduction in the right-side rCbO2 from the base line value of 70-80%/78-83% (Left/Right) to 70-72%/65-70% was developed during the harvesting of the vascular graft. We increased the rate of phenylephrine infusion to increase systemic and cerebral perfusion pressure, and both rCbO2 values were elevated to 80%/70% within 3 minutes. However, the preferential reduction in the right-side rCbO2 compared with the left-side value was not corrected. While suspecting cerebral ischemia due to cerebral vascular spasm, we administered nimodipine 2 mg bolus and increased infusion rate to 0.5 microgram/kg/min. Finally, the preferential rCbO2 reduction in the right-side was corrected and both rCbO2 reached 84%/91%. We concluded rCbO2 monitoring is useful for detecting an intraoperative episode of cerebral ischemia and maintaining the optimal cerebral perfusion during OPCAB surgery with Moyamoya disease.
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Affiliation(s)
- Seong Hyop Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Konkuk University, Seoul, Korea.
| | - Tae Yop Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Konkuk University, Seoul, Korea.
| | - Hyun Ha Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Konkuk University, Seoul, Korea.
| | - Tae Gyoon Yoon
- Department of Anesthesiology and Pain Medicine, School of Medicine, Konkuk University, Seoul, Korea.
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11
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Near-infrared spectroscopy: What we know and what we need to know—A systematic review of the congenital heart disease literature. J Thorac Cardiovasc Surg 2009; 137:154-9, 159e1-12. [DOI: 10.1016/j.jtcvs.2008.08.005] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 05/05/2008] [Accepted: 08/02/2008] [Indexed: 11/18/2022]
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12
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Kawauchi S, Sato S, Ooigawa H, Nawashiro H, Ishihara M, Kikuchi M. Simultaneous measurement of changes in light absorption due to the reduction of cytochrome c oxidase and light scattering in rat brains during loss of tissue viability. APPLIED OPTICS 2008; 47:4164-76. [PMID: 18670575 DOI: 10.1364/ao.47.004164] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
We performed the simultaneous measurement of intrinsic optical signals (IOSs) related to metabolic activity and cellular and subcellular morphological characteristics, i.e., light scattering for a rat global ischemic brain model made by rapidly removing blood by saline infusion. The signals were measured on the basis of multiwavelength diffuse reflectances in which 605 and 830 nm were used to detect the IOSs that are thought to be dominantly affected by redox changes of heme aa(3) and CuA in cytochrome c oxidase (CcO), respectively. For measuring the scattering signal, the wavelength that was found to be most insensitive to the absorption changes, e.g., approximately 620 nm, was used. The measurements suggested that an increase in the absorption due to reduction of heme aa(3) occurred soon after blood clearance, and this was followed by a large triphasic change in light scattering, during which time a decrease in the absorption due to reduction of CuA occurred. Through the triphasic scattering change, scattering signals increased by 5.2 +/- 1.5% (n = 5), and the increase in light scattering showed significant correlation with both the reflectance intensity changes at 605 and 830 nm. This suggests that morphological changes in cells correlate with reductions of heme aa(3) and CuA. Histological analysis of tissue after the triphasic scattering change showed no alteration in either the nuclei or the cytoskeleton, but electron microscopic observation revealed deformed, enlarged mitochondria and expanded dendrites. These findings suggest that the simultaneous measurement of absorption signals related to the redox changes in the CcO and the scattering signal is useful for monitoring tissue viability in the brain.
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Affiliation(s)
- Satoko Kawauchi
- Department of Medical Engineering, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
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13
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Tachtsidis I, Tisdall M, Leung TS, Cooper CE, Delpy DT, Smith M, Elwell CE. Investigation ofin vivomeasurement of cerebral cytochrome-c-oxidase redox changes using near-infrared spectroscopy in patients with orthostatic hypotension. Physiol Meas 2006; 28:199-211. [PMID: 17237591 DOI: 10.1088/0967-3334/28/2/008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We have previously used a continuous four-wavelength near-infrared spectrometer to measure changes in the cerebral concentrations of oxy-haemoglobin (Delta[HbO(2)] and deoxy-haemoglobin (Delta[HHb]) during head-up tilt in patients with primary autonomic failure. The measured changes in light attenuation also allow calculation of changes in the concentration of oxidized cytochrome-c-oxidase (Delta[(ox)CCO]), and this paper analyses the Delta[(ox)CCO] during the severe episodes of orthostatic hypotension produced by this experimental protocol. We studied 12 patients during a passive change in position from supine to a 60 degrees head-up tilt. The challenge caused a reduction in mean blood pressure of 59.93 (+/-26.12) mmHg (Mean (+/-SD), p < 0.0001), which was associated with a reduction in the total concentration of haemoglobin (Delta[HbT] = Delta[HbO(2)] + Delta[HHb]) of 5.02 (+/-3.81) microM (p < 0.0001) and a reduction in the haemoglobin difference concentration (Delta[Hb(diff)] = Delta[HbO(2)] - Delta[HHb]) of 14.4 (+/-6.73) microM (p < 0.0001). We observed a wide range of responses in Delta[(ox)CCO]. Six patients demonstrated a drop in Delta[(ox)CCO] (0.17 +/- 0.15 microM); four patients demonstrated no change (0.01 +/- 0.12 microM) and two patients showed an increase in Delta[(ox)CCO] (0.21 +/- 0.01 microM). Investigation of the association between the changes in concentrations of haemoglobin species and the Delta[(ox)CCO] for each patient show a range of relationships. This suggests that a simple mechanism for crosstalk, which might produce artefactual changes in [(ox)CCO], is not present between the haemoglobin and the (ox)CCO NIRS signals. Further investigation is required to determine the clinical significance of the changes in [(ox)CCO].
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Affiliation(s)
- I Tachtsidis
- Department of Medical Physics and Bioengineering, Malet Place Engineering Building, University College London, Gower Street, London, UK.
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Scholl FG, Webb D, Christian K, Drinkwater DC. Rapid diagnosis of cannula migration by cerebral oximetry in neonatal arch repair. Ann Thorac Surg 2006; 82:325-7. [PMID: 16798245 DOI: 10.1016/j.athoracsur.2005.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 08/30/2005] [Accepted: 09/12/2005] [Indexed: 11/28/2022]
Abstract
Although it has gained much interest in other surgical specialties, the application of near-infrared spectroscopy to assess cerebral perfusion during cardiac surgery is relatively new. Regional cerebral oxygen saturation (rSO2) is a function of cerebral oxygen supply and demand. Continuous monitoring of the rSO2 permits early detection of cerebral ischemia allowing for prompt intervention. The following is a description of a repair of truncus arteriosus with type A interrupted aortic arch during which continuous cerebral oximetry assisted with the positioning of the arterial cannula avoiding a prolonged episode of cerebral ischemia.
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MESH Headings
- Aorta, Thoracic/abnormalities
- Aorta, Thoracic/surgery
- Blood Gas Monitoring, Transcutaneous
- Brachiocephalic Trunk
- Catheterization
- Catheters, Indwelling/adverse effects
- Cerebrovascular Circulation
- Foreign-Body Migration/blood
- Foreign-Body Migration/diagnosis
- Humans
- Hypoxia-Ischemia, Brain/blood
- Hypoxia-Ischemia, Brain/diagnosis
- Hypoxia-Ischemia, Brain/etiology
- Infant, Newborn
- Intraoperative Complications/blood
- Intraoperative Complications/diagnosis
- Intraoperative Complications/etiology
- Male
- Monitoring, Intraoperative
- Oxyhemoglobins/analysis
- Spectroscopy, Near-Infrared
- Subclavian Artery
- Truncus Arteriosus, Persistent/surgery
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Affiliation(s)
- Frank G Scholl
- Division of Pediatric Cardiac Surgery, Monroe Carrell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee 37232-9292, USA.
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Zaramella P, Freato F, Quaresima V, Ferrari M, Bartocci M, Rubino M, Falcon E, Chiandetti L. Surgical closure of patent ductus arteriosus reduces the cerebral tissue oxygenation index in preterm infants: a near-infrared spectroscopy and Doppler study. Pediatr Int 2006; 48:305-12. [PMID: 16732800 DOI: 10.1111/j.1442-200x.2006.02209.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effects of patent ductus arteriosus (PDA) ligature on cerebral oxygen saturation, cerebral blood volume (CBV) and cerebral blood flow velocity by means of near-infrared spectroscopy (NIRS) and transcranial Doppler simultaneous examinations. METHODS This is an observational study considering 16 babies of gestational age 24-34 weeks diagnosed with PDA who underwent surgical ligation. The cerebral oxygen saturation, CBV and blood gases values were obtained 35 min before ligation, so also around the 14th and 27th min after the clip's insertion. RESULTS Cerebral oxygen saturation, measured as tissue oxygenation index (TOI), decreased significantly after PDA ligation from a basal value of 61.1 (3.8) before surgery to 56.6 (3.3) and 55.8 (2.6)%, for the 14th and 27th min, respectively (P<0.04). CBV before and after clipping was unvaried. A negative correlation was found between DeltapH and DeltaCBV after ligation (R=0.52, P=0.03), whilst a positive correlation was found between DeltaCBV and DeltaP(aCO2) (R=0.62, P=0.009). pH increased at the 27th min post-ligation. CONCLUSIONS NIRS is a tool for obtaining information on cerebral oxygen saturation and CBV changes during surgical PDA ligation at the bedside. A fall in TOI suggests an increased oxygen extraction during PDA surgery. The lack of increase in DeltaCBV or in diastolic flow velocity show that the PDA before the clipping did not limit cerebral blood flow, the drop in TOI suggests increased oxygen consumption over the clip and the need for accurate monitoring of oxygen utilization after the surgical treatment.
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MESH Headings
- Blood Flow Velocity/physiology
- Blood Volume/physiology
- Brain/metabolism
- Brain/physiopathology
- Cerebrovascular Circulation/physiology
- Ductus Arteriosus, Patent/diagnostic imaging
- Ductus Arteriosus, Patent/metabolism
- Ductus Arteriosus, Patent/surgery
- Follow-Up Studies
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/metabolism
- Infant, Premature, Diseases/surgery
- Oxygen Consumption/physiology
- Spectroscopy, Near-Infrared
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Patrizia Zaramella
- Department of Paediatrics, Neonatal Intensive Care Unit, University of Padova, Padova, Italy.
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Nollert G. Clinical evaluation of near-infrared spectroscopy. Can J Anaesth 2006; 53:323; author reply 324. [PMID: 16527801 DOI: 10.1007/bf03022224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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17
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Toet MC, Flinterman A, Laar IVD, Vries JWD, Bennink GBWE, Uiterwaal CSPM, Bel FV. Cerebral oxygen saturation and electrical brain activity before, during, and up to 36 hours after arterial switch procedure in neonates without pre-existing brain damage: its relationship to neurodevelopmental outcome. Exp Brain Res 2005; 165:343-50. [PMID: 15940492 DOI: 10.1007/s00221-005-2300-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Accepted: 02/02/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To monitor the pattern of cerebral oxygen saturation (rSat), by use of NIRS, in term infants before, during and after the arterial switch operation and to evaluate its relation to neurodevelopmental outcome. METHODS In 20 neonates without pre-existing brain damage hemodynamics and arterial oxygen saturation (AO2-Sat) were monitored simultaneously with rSat and amplitude-integrated EEG (aEEG) from 4 h to 12 h before up to 36 h after cardiopulmonary bypass (CPB) and short duration of cardiac arrest during deep hypothermia (DHCA). The Bayleys developmental scale was performed at 30 months. RESULTS Before surgery rSat was <50% in 16 patients. During CPB rSat increased to normal values, with a sharp decrease during brief CA (median 6.5 min). Post-CPB rSat showed a transient decrease (30-45%) despite normal PaO2 with sustained normalization after 6-26 h. Recovery time of the rSat seemed longer when pre-operative rSat was below 35%, and for lower minimum nasopharyngeal temperature and longer duration of CPB and of DHCA. Recovery time of the aEEG varied and did not correlate with normalization of rSat. Neurodevelopmental outcome was normal in all but two patients. Patients with lower pre-operative rSat (<35%) tended to have lower DQ (developmental quotient) scores at 30-36 months. (median: mental 102 and motor 101 (range 58-125) compared with mental 100 and motor 110 (range 83-125)) CONCLUSION Despite prompt normalization of circulation and oxygenation after surgery, recovery of rSat of the brain took 6-26 h, probably because of higher energy demand after CPB. Pre-operative cerebral oxygenation may be underestimated as a possible cause of adverse post-operative outcome.
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Affiliation(s)
- Mona C Toet
- Department of Neonatology, KE 04.123.1, University Medical Center Utrecht/ Wilhelmina Children's Hospital, P.B. 85090, 3508 Utrecht, The Netherlands.
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Schultz S, Creed J, Schears G, Zaitseva T, Greeley W, Wilson DF, Pastuszko A. Comparison of low-flow cardiopulmonary bypass and circulatory arrest on brain oxygen and metabolism. Ann Thorac Surg 2004; 77:2138-43. [PMID: 15172283 DOI: 10.1016/j.athoracsur.2003.12.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND In the neonatal brain we measured oxygen (Bo(2)), extracellular striatal dopamine (DA), and striatal tissue levels of ortho-tyrosine (o-tyr) during low-flow cardiopulmonary bypass (LFCPB) or deep hypothermic circulatory arrest (DHCA) and the post-bypass recovery period. METHODS Newborn piglets were assigned to sham (n = 6), LFCPB (n = 8), or DHCA (n = 6) groups. Animals were cooled to 18 degrees C and underwent DHCA or LFCPB (20 mL x kg(-1) x min(-1)) for 90 minutes. The Bo(2) was measured by quenching the phosphorescence, DA by microdialysis, and hydroxyl radicals by o-tyr levels. The results are presented as the mean +/- SD (p < 0.05 was significant). RESULTS Baseline Bo(2) was between 45 to 60 mm Hg. At the end of LFCPB, Bo(2) was 10.5 +/- 1.2 mm Hg. By 5 and 30 minutes of arrest during DHCA, Bo(2) fell to 4.2 +/- 2.5 mm Hg and 1.4 +/- 0.7 mm Hg, respectively. Compared with control, extracellular DA did not change during LFCPB. During DHCA extracellular levels of DA increased, by 750-fold from baseline at 45 minutes and to a maximum of 53000-fold at 75 minutes. After 2 hours of recovery from DHCA, the o-tyr within the striatum increased about sixfold as compared with control. There was no change in o-tyr measured after LFCPB. CONCLUSIONS In DHCA, but not LFCPB, levels of DA and o-tyr increased considerably in the striatum of piglets, a finding that may indicate the exhaustion of cellular energy levels and contribute substantially to cellular injury.
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Affiliation(s)
- Steven Schultz
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Sakamoto T, Duebener LF, Laussen PC, Jonas RA. Cerebral ischemia caused by obstructed superior vena cava cannula is detected by near-infrared spectroscopy. J Cardiothorac Vasc Anesth 2004; 18:293-303. [PMID: 15232808 DOI: 10.1053/j.jvca.2004.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Bicaval venous cannulation is being used with increasing frequency in neonates and infants to avoid circulatory arrest. However, superior vena cava (SVC) cannula obstruction may result in cerebral ischemia with no change in blood pressure or mixed venous O2 saturation. The authors hypothesized that near-infrared spectroscopy (NIRS) would allow noninvasive detection of SVC cannula obstruction. METHODS Fifteen Yorkshire piglets (9.07 +/- 0.20 kg) underwent total cardiopulmonary bypass (CPB) (100 mL/kg/min, pH-stat strategy, hematocrit of 20%) with ascending aortic and bicaval cannulations. Femoral arterial and SVC pressure were monitored as well as mixed venous O2 saturation. NIRS monitoring of tissue oxygenation index (TOI) as well as oxyhemoglobin and deoxyhemoglobin (HHb) was undertaken. Animals were cooled to an esophageal temperature of 25 degrees C over 20 minutes. CPB flow was reduced to 50 mL/kg/min for 20 minutes. Animals then underwent a 60-minute study period of continuous CPB at 50 mL/kg/min with manipulation of the SVC cannula: group 1, open; group 2, partial occlusion; and group 3, complete occlusion. Animals were rewarmed to 37 degrees C at full flow with the SVC cannula open. Cerebral blood flow was assessed at onset of CPB, at end of cooling, at end of low flow, at end of SVC manipulation period, and at end of rewarming using radioactive microspheres. RESULTS CBF decreased to 27.9 +/- 1.5 mL/min/100 g with complete occlusion (p < 0.01 v group 1: 39.7 +/- 1.9, group 2, 38.3 +/- 2.0 mL/min/100 g) with no change in arterial pressure or mixed venous saturation. There were also significant differences in cerebral oxygen delivery between group 3 and other groups (p < 0.01). SVC pressure increased to 19.5 +/- 4.5 and 32.5 +/- 3.1mmHg with partial and complete occlusion. NIRS indicated significant cerebral ischemia with a decrease in TOI (p < 0.05; group 3 v group 1 and 2) and an increase in HHb (p < 0.05; group 3 v group 1). At the end of the study, significant acidosis was found in group 3 compared with group 1 (p < 0.05). CONCLUSION SVC cannula obstruction causes cerebral ischemia with no change in blood pressure or venous oxygen saturation. In view of the difficulties and risks of CVP monitoring in babies, it is recommended to use other monitoring modalities such as NIRS to assess adequacy of cerebral perfusion if bicaval cannulation is used in neonates and infants.
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Affiliation(s)
- Takahiko Sakamoto
- Department of Cardiac Surgery, Children's Hospital, Harvard Medical School, Boston, MA, USA
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Pigula FA. Arch reconstruction without circulatory arrest: scientific basis for continued use and application to patients with arch anomalies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 5:104-15. [PMID: 11994870 DOI: 10.1053/pcsu.2002.31480] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aortic arch hypoplasia is a common constituent of congenital heart disease. While repair of these lesions has been performed routinely during deep hypothermia and circulatory arrest, new approaches are emerging. One such approach, regional low-flow perfusion, will be described here. This technique exploits the anticipated modified Blalock-Taussig shunt as a perfusion conduit. With control of the brachiocephalic vessels and the descending thoracic aorta, circulatory support can be provided to the neonate with exposure identical to that obtained by circulatory arrest. While first applied to children undergoing the Norwood operation for hypoplastic left heart syndrome, this technique has recently been applied to children requiring complex arch surgery in the setting of biventricular repair. To date, 36 neonates requiring arch reconstruction (27 Norwood operations, 9 biventricular repairs) have been supported with regional low-flow perfusion. Thirty-day and hospital discharge survival has been 74% (20/27) for neonates undergoing Norwood operation, and 88% (8/9) for those undergoing biventricular repair. We will review the operative technique, methodologies, and clinical studies that led us to conclude that regional low-flow perfusion provides cerebral, as well as somatic, circulatory support to the neonate undergoing arch reconstruction.
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Affiliation(s)
- Frank A Pigula
- Department of Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh, PA 15213, USA
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Sakamoto T, Kurosawa H, Shin'oka T, Aoki M, Isomatsu Y. The influence of pH strategy on cerebral and collateral circulation during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease: results of a randomized trial and real-time monitoring. J Thorac Cardiovasc Surg 2004; 127:12-9. [PMID: 14752407 DOI: 10.1016/j.jtcvs.2003.08.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The optimal pH strategy during hypothermic cardiopulmonary bypass remains controversial. Systemic pulmonary collateral circulation may develop in patients with cyanotic anomalies. The purpose of this study was to evaluate the effect of pH strategies on cerebral oxygenation and systemic pulmonary collateral circulation during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease. METHODS Forty cyanotic patients (age > 1 year) with heart disease were prospectively randomized into 2 groups. Group 1 (n = 19, 14.3 +/- 1.5 kg) underwent hypothermic cardiopulmonary bypass with alpha-stat strategy and group 2 (n = 21, 12.5 +/- 0.9 kg) with pH-stat. Cardiopulmonary bypass was established with pump-assisted drainage. Cerebral oxygenation was assessed by near-infrared spectroscopy and the systemic pulmonary collateral circulation was calculated by pump flows [% systemic pulmonary collateral circulation = perfusion flow - drainage flow)/perfusion flow x 100]. Lactate was measured as an index of systemic anaerobic metabolism. RESULTS There were no significant differences in preoperative hematocrit, oxygen saturation, Qp/Qs, cardiopulmonary bypass duration, minimum temperatures, perfusion flow and pressure, urine output, and depth of anesthesia between the groups. Oxyhemoglobin signal and tissue oxygenation index of near-infrared spectroscopy monitoring were significantly lower in group 1 compared with group 2 (P =.008 and P <.0001, respectively), suggesting inadequate cerebral oxygenation with alpha-stat. Deoxygenated hemoglobin signal was significantly higher in group 1 relative to group 2 (P <.0001). The % systemic pulmonary collateral circulation was significantly lower in group 2 compared with group 1, suggesting a reduced pulmonary collateral circulation with pH-stat (P <.0001, average; group 1, 20.1% +/- 1.2%; group 2; 7.7% +/- 0.7%). Serum lactate was significantly lower in group 2 (P <.0001). CONCLUSIONS The pH-stat strategy results in an improved environment, including sufficient cerebral oxygenation, decreased systemic pulmonary collateral circulation, and lower lactate level during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease. Future studies should investigate the long-term neurological outcome.
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Affiliation(s)
- Takahiko Sakamoto
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Japan.
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Nagdyman N, Fleck T, Barth S, Abdul-Khaliq H, Stiller B, Ewert P, Huebler M, Kuppe H, Lange PE. Relation of cerebral tissue oxygenation index to central venous oxygen saturation in children. Intensive Care Med 2004; 30:468-71. [PMID: 14722637 DOI: 10.1007/s00134-003-2101-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2003] [Accepted: 11/14/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the relationship between the cerebral tissue oxygenation index measured by near-infrared spectroscopy and central venous oxygen saturation (SvO2) after corrective surgery of congenital heart defects in children. DESIGN Prospective observational clinical study. SETTING A tertiary neonatal and paediatric intensive care unit for paediatric cardiology. PATIENTS Neonates and children consecutively admitted to the paediatric cardiology intensive care unit after corrective surgery of non-cyanotic congenital heart defects. MEASUREMENTS AND RESULTS Forty-three children were studied. Cerebral tissue oxygenation index, measured non-invasively by near-infrared spectroscopy, was compared to SvO2, measured by a catheter placed in the right atrium, and to haemodynamic and respiratory parameters. Pearson's correlation coefficients and p values were calculated. Simultaneously measured values for SvO2 (62.2+/-9.8%, 39.8-80.4%) and cerebral tissue oxygenation index (56.7+/-8.8%, 35.8-71.2%) showed a significant correlation ( r=0.52, p<0.001). CONCLUSION Cerebral tissue oxygenation index and SvO2 are not interchangeable parameters, but cerebral tissue oxygenation index reflects the haemodynamic influence on cerebral oxygenation after cardiovascular surgery. Further work is necessary to confirm the clinical role of continuous non-invasive measurement of cerebral tissue oxygenation index with regard to the variations of global systemic oxygen consumption after cardiac surgery in children.
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Affiliation(s)
- Nicole Nagdyman
- Department of Intensive Care and Paediatric Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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A Case of Arteriosclerosis Obliterans With Monitored Regional Oxygen Saturation During Treatment With a Lumbar Sympathetic Ganglion Block. Reg Anesth Pain Med 2003. [DOI: 10.1097/00115550-200309000-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schears G, Schultz SE, Creed J, Greeley WJ, Wilson DF, Pastuszko A. Effect of perfusion flow rate on tissue oxygenation in newborn piglets during cardiopulmonary bypass. Ann Thorac Surg 2003; 75:560-5. [PMID: 12607673 DOI: 10.1016/s0003-4975(02)04342-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Our knowledge of the best perfusion flow rate to use during cardiopulmonary bypass (CPB) in order to maintain tissue oxygenation remains incomplete. The present study examined the effects of perfusion flow rate and patent ductus arteriosus (PDA) during normothermic CPB on oxygenation in several organ tissues of newborn piglets. METHODS The experiments were performed on 12 newborn piglets: 6 with PDA ligation (PDA-L), and 6 without PDA ligation (PDA-NL). CPB was performed through the chest at 37 degrees C. During CPB, the flow rate was changed at 15-minute intervals, ranging from 100 to 250 ml/kg/min. Tissue oxygenation was measured by quenching of phosphorescence. RESULTS For the PDA-L group, oxygen in the brain did not change significantly with changes in flow rate. In contrast, for the PDA-NL group, oxygen was dependent upon the flow rate. Statistically significant decreases in cortical oxygen were observed with flow rates below 175 ml/kg/min. Within the myocardium, liver, and intestine, there were no significant differences in the oxygen levels between the PDA-L and PDA-NL groups. In these tissues, the oxygen decreased significantly as the flow rate decreased below 150 ml/kg/min, 125 ml/kg/min, and 175 ml/kg/min, respectively. Oxygen pressure in skeletal muscle was not dependent on either PDA ligation or flow rate. CONCLUSIONS In newborn piglets undergoing CPB, the presence of a PDA results in reduced tissue oxygenation to the brain but not to other organs. In general, perfusion flow rates of 175 ml/kg/min or greater are required in order to maintain normal oxygenation of all organs except muscle.
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Affiliation(s)
- Gregory Schears
- Department of Biochemistry and Biophysics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Obrig H, Steinbrink J, Villringer A. The Blushing Brain: Changes in Brain Colour Indicate the Functional State of the Cerebral Cortex. ACTA ACUST UNITED AC 2003. [DOI: 10.1078/1615-1615-00104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kunihara T, Sasaki S, Shiiya N, Murashita T, Matsui Y, Yasuda K. Near infrared spectrophotometry reflects cerebral metabolism during hypothermic circulatory arrest in adults. ASAIO J 2001; 47:417-21. [PMID: 11482497 DOI: 10.1097/00002480-200107000-00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Near-infrared spectrophotometry (NIRS) is assumed to reflect cerebral oxygenation during hypothermic circulatory arrest (HCA). However, the rationale for the use of NIRS as a marker of cerebral metabolism remains to be elucidated. We examined whether cerebral oxygenation measured by NIRS correlated with cerebral metabolic function assessed by cerebral oxygen extraction ratio (OER) during HCA in adults. NIRS was continuously monitored in 14 patients undergoing thoracic aortic surgery using HCA (17.9 +/- 2.9 degrees C esophageal temperature at HCA onset). Jugular venous oxygen saturation and OER were also monitored. OER was significantly reduced from 37.3 +/- 7.2% at the onset of cardiopulmonary bypass to 13.6 +/- 6.2% at the onset of HCA (p < 0.0001). A linear decrease in oxygenated-hemoglobin (oxy-Hb) and increase in deoxygenated-hemoglobin (deoxy-Hb) were found during HCA, which returned to baseline levels after rewarming. The rate of decrease in oxy-Hb and increase in deoxy-Hb were -0.63 +/- 0.45 and 0.51 +/- 0.30 (10(-5) OD/cm per sec), respectively, both of which significantly correlated with OER at the onset of HCA (R2=0.739 and 0.633; p < 0.0001 and p = 0.0007, respectively). NIRS may serve as a reliable diagnostic modality for monitoring cerebral metabolism during aortic surgery using HCA.
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Affiliation(s)
- T Kunihara
- Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan
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27
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Abdul-Khaliq H, Schubert S, Troitzsch D, Huebler M, Boettcher W, Baur MO, Lange PE. Dynamic changes in cerebral oxygenation related to deep hypothermia and circulatory arrest evaluated by near-infrared spectroscopy. Acta Anaesthesiol Scand 2001; 45:696-701. [PMID: 11421827 DOI: 10.1034/j.1399-6576.2001.045006696.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Total circulatory arrest in deep hypothermia, which is used in corrective surgery of complex cardiovascular malformations, has been said to cause brain injury. Near-infrared spectroscopy (NIRS) is a new non-invasive method that potentially monitors changes in cerebral oxygenation and tissue oxygen utilisation. The aim of this experimental study in rabbits was to evaluate the change in intravascular and intracellular oxygenation patterns during cooling, deep hypothermic circulatory arrest and rewarming using a commercially available NIRS-cerebral oximeter. METHODS Ten New Zealand White male rabbits (weight, 3.1+/-0.25 kg BW) were included in this study. All animals underwent cardiopulmonary bypass (CPB), cooling to a rectal temperature below 15 degrees C, 60 min of deep hypothermic circulatory arrest (DHCA) followed by reperfusion and rewarming. Cerebral oxyhaemoglobin (HbO2), deoxyhaemoglobin (HHb) and cytochrome oxidase aa3 (CytOxaa3) concentrations were continuously measured during the entire procedure using the Cerebral RedOx Monitor 2020 (Criticon cerebral redox monitor 2020, Johnson & Johnson Medical). Total haemoglobin concentration (tHb) and regional cerebral oxygen saturation (rSO2) values were calculated by integrated algorithm. RESULTS In all animals an initial increase of oxygenated haemoglobin (HbO2, rSO2) and a fall in deoxygenated haemoglobin (HHb) were found during cooling on bypass. A slight decrease in CytOxaa3 signal was observed in response to initial cooling. Variation in intravascular haemoglobin oxygenation parameters (HbO2, HHb) were related to haemodynamic changes associated with fluid loading, initiation and termination of CPB, bypass flow rate and cooling and rewarming. When the pump flow was stopped all NIRS parameters, except the HHb value, decreased precipitously during the DHCA-period (P<0.01). After reperfusion and rewarming, all haemoglobin oxygen saturation readings returned nearly to pre-CPB levels (P=0.09), but the CytOxaa3 was still significantly lower than the pre-CPB levels (P<0.05). CONCLUSION The change in the NIRS-derived haemoglobin oxygenation parameters may reflect physiological changes in systemic and cerebral haemodynamics. CytOxaa3 values may represent related effects on cellular oxygenation. Thus, continuous, real-time NIRS-monitoring may identify critical periods with inadequate brain tissue oxygenation, particularly during DHCA. The neurological implications of the observed changes in NIRS oxygenation parameters, however, require further quantitative morphological evaluation of the brain in animals surviving a longer reperfusion and observation period.
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Affiliation(s)
- H Abdul-Khaliq
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Institute Berlin, Germany.
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Yoshitani K, Kawaguchi M, Sugiyama N, Sugiyama M, Inoue S, Sakamoto T, Kitaguchi K, Furuya H. The Association of High Jugular Bulb Venous Oxygen Saturation with Cognitive Decline After Hypothermic Cardiopulmonary Bypass. Anesth Analg 2001; 92:1370-6. [PMID: 11375807 DOI: 10.1097/00000539-200106000-00003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED This study was conducted to investigate whether jugular bulb venous oxygen saturation (SjVO(2)) predicted cognitive decline after cardiac surgery with hypothermic cardiopulmonary bypass (CPB). We studied 35 patients undergoing cardiac surgery. After the induction of anesthesia, a 5.5F fiberoptic oximetry catheter was retrogradely inserted into the jugular bulb, and SjVO(2) and other cerebral oxygenation variables were analyzed before, during, and after CPB. At each point, an oxyhemoglobin dissociation curve was drawn, and the P(50) value of jugular bulb venous blood was calculated by computer analysis. Cognitive function was assessed with the revised version of Hasegawa's Dementia Scale and the Benton Revised Visual Retention Test before and early after the operation. In 15 patients (the Decline group), cognitive function was declined after surgery, whereas it remained unchanged in 20 patients (the Normal group). SjVO(2) was significantly higher and cerebral oxygen extraction was significantly lower before and during CPB in the Decline group than in the Normal group (P < 0.05). The oxygen pressure at an oxygen saturation of 50% was significantly lower before and after CPB in the Decline group than in the Normal group (P < 0.05). Logistic regression analysis showed that high SjVO(2) was a predictor of cognitive decline after cardiac surgery. We conclude that high SjVO(2) was associated with cognitive decline after cardiac surgery with hypothermic CPB. IMPLICATIONS Jugular bulb venous oxygen desaturation has been suggested as a predictor of cognitive decline after cardiac surgery. However, the clinical value of jugular bulb venous oxygen saturation (SjVO(2)) may be limited during hypothermic cardiopulmonary bypass (CPB) when oxygen affinity to hemoglobin is increased. This study shows that high SjVO(2) before and during hypothermic CPB is a predictor of subsequent cognitive decline.
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Affiliation(s)
- K Yoshitani
- Department of Anesthesiology, Nara Medical University, Nara, Japan.
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Ali MS, Harmer M, Vaughan RS, Dunne JA, Latto IP. Spatially resolved spectroscopy (NIRO-300) does not agree with jugular bulb oxygen saturation in patients undergoing warm bypass surgery. Can J Anaesth 2001; 48:497-501. [PMID: 11394522 DOI: 10.1007/bf03028317] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Near infrared spectroscopy (NIRS) is a promising non-invasive method for continuous monitoring of cerebral oxygenation during cardiac surgery with cardiopulmonary bypass (CPB). This study was designed to study the agreement between tissue oxygen index (TOI) measured by spatially resolved spectroscopy (NIRO-300) and jugular bulb oxygen saturation (SjO2) in patients undergoing warm coronary bypass surgery. METHODS Seventeen patients undergoing warm coronary artery bypass surgery were studied. NIRS was continuously monitored and was averaged before CPB, five, 20, 40, 60 min on CPB, five minutes before end of CPB and ten minutes after CPB to coincide with SjO2 measurements. Bypass temperature was maintained at 34-37 degrees C. RESULTS Bland and Altman analysis showed a bias (TOI-SjO2) of -6.7%, and wide limits of agreement (from 16% to -28%) between the two methods. In addition, mean TOI was lower than mean SjO2 during and after CPB. We observed a statistically significant correlation between arterial carbon dioxide and SjO2 measurements (r2=0.33; P=0.0003), but the former did not correlate with TOI values (r2=0.001; P=0.7). CONCLUSION Our results demonstrate a lack of agreement between SjO2 and TOI for monitoring cerebral oxygenation during cardiac surgery. We conclude that the two methods are not interchangeable.
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Affiliation(s)
- M S Ali
- Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Health Hospital, Cardiff, UK.
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Abstract
Imbalance between cerebral oxygen supply and demand is thought to play an important role in the development of cerebral injury during cardiac surgery. This article presents an overview of cerebral oxygenation monitored by jugular bulb oximetry during cardiac surgery with cardiopulmonary bypass. The general principles of jugular bulb oximetry including physiology, intermittent and continuous monitoring, technical considerations, limitations and potential complications are discussed. Different applications of jugular bulb oximetry during bypass surgery and the possible therapeutic approaches to impaired cerebral oxygenation are described.
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Affiliation(s)
- M Shaaban Ali
- Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, UK
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Boas DA, Gaudette T, Strangman G, Cheng X, Marota JJ, Mandeville JB. The accuracy of near infrared spectroscopy and imaging during focal changes in cerebral hemodynamics. Neuroimage 2001; 13:76-90. [PMID: 11133311 DOI: 10.1006/nimg.2000.0674] [Citation(s) in RCA: 324] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Near infrared spectroscopy (NIRS) can detect changes in the concentrations of oxy-hemoglobin ([HbO]) and deoxy-hemoglobin ([Hb]) in tissue based upon differential absorption at multiple wavelengths. The common analysis of NIRS data uses the modified Beer-Lambert law, which is an empirical formulation that assumes global concentration changes. We used simulations to examine the errors that result when this analysis is applied to focal hemodynamic changes, and we performed simultaneous NIRS measurements during a motor task in adult humans and a neonate to evaluate the dependence of the measured changes on detector-probe geometry. For both simulations and in vivo measurements, the wide range of NIRS results was compared to an imaging analysis, diffuse optical tomography (DOT). The results demonstrate that relative changes in [HbO] and [Hb] cannot, in general, be quantified with NIRS. In contrast to that method, DOT analysis was shown to accurately quantify simulated changes in chromophore concentrations. These results and the general principles suggest that DOT can accurately measure changes in [Hb] and [HbO], but NIRS cannot accurately determine even relative focal changes in these chromophore concentrations. For the standard NIRS analysis to become more accurate for focal changes, it must account for the position of the focal change relative to the source and detector as well as the wavelength dependent optical properties of the medium.
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Affiliation(s)
- D A Boas
- NMR Center, Harvard Medical School, Charlestown, Massachusetts 02129, USA
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Pigula FA, Nemoto EM, Griffith BP, Siewers RD. Regional low-flow perfusion provides cerebral circulatory support during neonatal aortic arch reconstruction. J Thorac Cardiovasc Surg 2000; 119:331-9. [PMID: 10649209 DOI: 10.1016/s0022-5223(00)70189-9] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Because of concerns regarding the effects of deep hypothermia and circulatory arrest on the neonatal brain, we have developed a technique of regional low-flow perfusion that provides cerebral circulatory support during neonatal aortic arch reconstruction. METHODS We studied the effects of regional low-flow perfusion on cerebral oxygen saturation and blood volume as measured by near-infrared spectroscopy in 6 neonates who underwent aortic arch reconstruction and compared these effects with 6 children who underwent cardiac repair with deep hypothermia and circulatory arrest. RESULTS All the children survived with no observed neurologic sequelae. Near-infrared spectroscopy documented significant decreases in both cerebral blood volume and oxygen saturations in children who underwent repair with deep hypothermia and circulatory arrest as compared with children with regional low-flow perfusion. Reacquisition of baseline cerebral blood volume and cerebral oxygen saturations were accomplished with a regional low-flow perfusion rate of 20 mL x kg(-1) x min(-1). CONCLUSIONS Regional low-flow perfusion is a safe and simple bypass management technique that provides cerebral circulatory support during neonatal aortic arch reconstruction. The reduction of deep hypothermia and circulatory arrest time required may reduce the risk of cognitive and psychomotor deficits.
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Affiliation(s)
- F A Pigula
- Department of Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA.
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Shin'oka T, Nollert G, Shum-Tim D, du Plessis A, Jonas RA. Utility of near-infrared spectroscopic measurements during deep hypothermic circulatory arrest. Ann Thorac Surg 2000; 69:578-83. [PMID: 10735702 DOI: 10.1016/s0003-4975(99)01322-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is used to monitor cerebral oxygenation during cardiac surgery. However, interpretation of the signals is controversial. The aim of the study was to determine which NIRS variable best correlated with brain damage as assessed by animal behavior and neurohistologic score and to compare the accuracy of NIRS and magnetic resonance spectroscopy (MRS) in predicting brain injury. METHODS Forty 5-week-old piglets underwent 60 minutes of deep hypothermic circulatory arrest (DHCA) at 15 degrees C. Changes in brain adenosine triphosphate (ATP), phosphocreatine (PCr), and intracellular pH (pHi) were determined by MRS and correlated to changes in oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (Hb), and oxidized cytochrome a,a3 (CytOx) NIRS signals. Brains were fixed on day 4 and examined using a neurohistologic score. RESULTS Reductions in CytOx and HbO2 values were correlated closely with decreases in ATP, PCr, and pHi. The changes in CytOx and PCr showed the strongest correlation (r = 0.623). Maximal CytOx reduction during DHCA of more than -25 microM * differential pathlength factor (DPF) predicted brain damage with a sensitivity of 100% and a specificity of 75%. The histologic score was also correlated with a decrease in ATP (r = -0.52 for CytOx; r = -0.32 for ATP); HbO2, PCr, and pHi showed no correlations. CONCLUSIONS Reduction in CytOx correlates with decreased brain energy state and predicts histologic brain injury after DHCA with a high sensitivity. These data suggest that the level of CytOx could be a very important predictor of brain damage during DHCA.
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Affiliation(s)
- T Shin'oka
- Department of Cardiovascular Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
Computers can offer significant enhancement to the monitoring of the critically ill. Their value is derived from improved vigilance, better charting, and an opportunity to assess practitioner compliance with unit protocols. However, their true value can only be attained when they are integrated into a total information system.
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Affiliation(s)
- F V Booth
- Department of Surgery, State University of New York, Buffalo General Hospital, USA
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