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Zhu M, Lee TXY, Hsieh YW, Lai LF, Condello G, Donnelly CJ, Smith M, Hamzah SH, Lim BH, Huang CY, Chi NF, Kuo CH. Vascular function in the aging human brain during muscle exertion. Aging (Albany NY) 2022; 14:3910-3920. [PMID: 35500246 PMCID: PMC9134944 DOI: 10.18632/aging.204052] [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: 09/01/2021] [Accepted: 03/08/2022] [Indexed: 11/25/2022]
Abstract
To determine how brain oxygenation is stably maintained during advancing age, cerebral oxygenation and hemoglobin were measured real-time at 10 Hz using near-infrared spectroscopy (NIRS) at rest (30 seconds) and during a 10-repeated handgrip strength test (30 seconds) for 834 adults (M/F = 45/55%) aged 20-88 y. The amplitude of cerebral hemodynamic fluctuation was reflected by converting 300 values of % oxygen saturation and hemoglobin of each 30-second phase to standard deviation as indicatives of brain oxygenation variability (BOV) and brain hemodynamic variability (BHV) for each participant. Both BOV (+21-72%) and BHV (+94-158%) increased during the maximal voluntary muscle exertions for all age levels (α < 0.05), suggesting an increased vascular recruitment to maintain oxygen homeostasis in the brain. Intriguingly, BHV was >100 folds for both resting and challenged conditions (α < 0.001) in >80% of adults aged above 50 y despite similar BOV compared with young age counterparts, indicating a huge cost of amplifying hemodynamic oscillation to maintain a stable oxygenation in the aging brain. Since vascular endothelial cells are short-lived, our results implicate a hemodynamic compensation to emergence of daily deficits in replacing senescent endothelial cells after age 50 y.
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Affiliation(s)
- Maijian Zhu
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC
| | - Tania Xu Yar Lee
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC
| | - Yu-Wen Hsieh
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC
| | - Li-Fan Lai
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC
| | - Giancarlo Condello
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC.,Department of Medicine and Surgery, University of Parma, Via Gramsci, Parma 43126, Italy
| | - Cyril J Donnelly
- Rehabilitation Research Institute of Singapore, Nanyang Technological University, Singapore
| | - Marc Smith
- Body Composition Technologies, Pty Ltd., South Perth, Western Australia, Australia
| | - Sareena Hanim Hamzah
- Centre for Sport and Exercise Sciences, University Malaya, Kuala Lumpur 50603, Malaysia
| | - Boon-Hooi Lim
- Centre for Sport and Exercise Sciences, University Malaya, Kuala Lumpur 50603, Malaysia
| | - Chih-Yang Huang
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan, ROC.,Center of General Education, Buddhist Tzu Chi Medical Foundation, Tzu Chi University of Science and Technology, Hualien 970, Taiwan, ROC.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 404, Taiwan, ROC.,Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, National Yang Ming Chiao Tung University School of Medicine, Taiwan, ROC.,Department of Neurology, Taipei Veterans General Hospital, Taiwan, ROC
| | - Chia-Hua Kuo
- Laboratory of Exercise Biochemistry, University of Taipei, Taipei City 11153, Taiwan, ROC
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2
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de Vries RJ, Cronin SEJ, Romfh P, Pendexter CA, Jain R, Wilks BT, Raigani S, van Gulik TM, Chen P, Yeh H, Uygun K, Tessier SN. Non-invasive quantification of the mitochondrial redox state in livers during machine perfusion. PLoS One 2021; 16:e0258833. [PMID: 34705828 PMCID: PMC8550443 DOI: 10.1371/journal.pone.0258833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
Ischemia reperfusion injury (IRI) is a critical problem in liver transplantation that can lead to life-threatening complications and substantially limit the utilization of livers for transplantation. However, because there are no early diagnostics available, fulminant injury may only become evident post-transplant. Mitochondria play a central role in IRI and are an ideal diagnostic target. During ischemia, changes in the mitochondrial redox state form the first link in the chain of events that lead to IRI. In this study we used resonance Raman spectroscopy to provide a rapid, non-invasive, and label-free diagnostic for quantification of the hepatic mitochondrial redox status. We show this diagnostic can be used to significantly distinguish transplantable versus non-transplantable ischemically injured rat livers during oxygenated machine perfusion and demonstrate spatial differences in the response of mitochondrial redox to ischemia reperfusion. This novel diagnostic may be used in the future to predict the viability of human livers for transplantation and as a tool to better understand the mechanisms of hepatic IRI.
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Affiliation(s)
- Reinier J. de Vries
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
- Department of Surgery, Amsterdam University Medical Centers–Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Stephanie E. J. Cronin
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Padraic Romfh
- Pendar Technologies, Cambridge, MA, United States of America
| | - Casie A. Pendexter
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Rohil Jain
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Benjamin T. Wilks
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Siavash Raigani
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas M. van Gulik
- Department of Surgery, Amsterdam University Medical Centers–Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peili Chen
- Pendar Technologies, Cambridge, MA, United States of America
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
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3
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Nieves Aleicel CR, Luis Felipe RDM, Marta GN, Juan ZA, Álvaro FH. Diagnostic Validation Study. Relationship Between Optical Spectroscopy and Ankle Brachial Index Tests for Peripheral Artery Disease. Ann Vasc Surg 2021; 77:132-137. [PMID: 34455048 DOI: 10.1016/j.avsg.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/23/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Ankle brachial index (ABI) is an essential diagnostic test for peripheral artery disease. It has some important limitations so it can´t always be performed. In those cases, tissue oximetry based on near-infrared spectrum could overcome these limitations. OBJECTIVES Assessment of the relationship between ABI and tissue oximetry tests and the ability of the oximetry to detect postoperative improvement. METHOD AND MATERIALS Prospective observational study. Several measures were made by both, ankle pressure and tissue oximetry tests, in lower limbs. Absolute values were collected at foot level (anterior and posterior tibial arteries) and the indexes were calculated in relation to a control (upper limbs for ABI and left infraclavicular region for tissue oximetry). In order to evaluate the correlation between ankle pressure and tissue oximetry values, Pearson correlation coefficient and linear regression analyses were applied. T-Student and ROC curve analysis were made to evaluate the postoperative improvement detected by both ankle pressure and tissue oximetry tests. RESULTS 60 patients with peripheral artery disease were included. Ankle pressure and tissue oximetry were measured in 70 lower limbs, in 45 of them before and after revascularization. Compared to ankle pressure, tissue oximetry was able to detect improvement in absolute values and indexes after revascularization. This indexes improvement was parallel (P=0.234 for anterior tibial artery and P=0.356 for posterior tibial artery). We weren´t able to determine a cutoff point between both tests (ROC curve analysis). We observed a significative positive correlation in absolute values of both tests (Pearson correlation coefficient, r = 0,281; P < 0.001). CONCLUSION Tissue oximetry is able to detect improvement after revascularization of lower limbs.
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Affiliation(s)
| | | | | | - Zafra Angulo Juan
- Department of Vascular Surgery, University Hospital La Paz, Madrid Spain
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4
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Commentary: Near-infrared technology continues to evolve, but the holy grail remains elusive. J Thorac Cardiovasc Surg 2020; 159:2026-2027. [DOI: 10.1016/j.jtcvs.2019.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 11/23/2022]
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5
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Perry DA, Salvin JW, Romfh P, Chen P, Krishnamurthy K, Thomson LM, Polizzotti BD, McGowan FX, Vakhshoori D, Kheir JN. Responsive monitoring of mitochondrial redox states in heart muscle predicts impending cardiac arrest. Sci Transl Med 2018; 9:9/408/eaan0117. [PMID: 28931652 DOI: 10.1126/scitranslmed.aan0117] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/20/2017] [Accepted: 08/15/2017] [Indexed: 11/02/2022]
Abstract
Assessing the adequacy of oxygen delivery to tissues is vital, particularly in the fields of intensive care medicine and surgery. As oxygen delivery to a cell becomes deficient, changes in mitochondrial redox state precede changes in cellular function. We describe a technique for the continuous monitoring of the mitochondrial redox state on the epicardial surface using resonance Raman spectroscopy. We quantify the reduced fraction of specific electron transport chain cytochromes, a metric we name the resonance Raman reduced mitochondrial ratio (3RMR). As oxygen deficiency worsens, heme moieties within the electron transport chain become progressively more reduced, leading to an increase in 3RMR. Myocardial 3RMR increased from baseline values of 18.1 ± 5.9 to 44.0 ± 16.9% (P = 0.0039) after inferior vena cava occlusion in rodents (n = 8). To demonstrate the diagnostic power of this measurement, 3RMR was continuously measured in rodents (n = 31) ventilated with 5 to 8% inspired oxygen for 30 min. A 3RMR value exceeding 40% at 10 min predicted subsequent cardiac arrest with 95% sensitivity and 100% specificity [area under the curve (AUC), 0.98], outperforming all current measures, including contractility (AUC, 0.51) and ejection fraction (AUC, 0.39). 3RMR correlated with indices of intracellular redox state and energy production. This technique may permit the real-time identification of critical defects in organ-specific oxygen delivery.
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Affiliation(s)
- Dorothy A Perry
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Joshua W Salvin
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | | | - Peili Chen
- Pendar Technologies, Cambridge, MA 02138, USA
| | | | - Lindsay M Thomson
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Brian D Polizzotti
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, PA 19104, USA.,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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6
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Mielgo VE, Valls-I-Soler A, Lopez-de-Heredia JM, Rabe H, Rey-Santano C, Rey-Santano C. Hemodynamic and metabolic effects of a new pediatric dobutamine formulation in hypoxic newborn pigs. Pediatr Res 2017; 81:511-518. [PMID: 27886191 DOI: 10.1038/pr.2016.257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 10/12/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of our study was to measure drug-related changes in hemodynamics and oxygen metabolism in response to different doses of an age-appropriate dobutamine formulation in hypoxic pigs. A secondary aim was to validate superior vena cava flow (SVCF) as a marker of cardiac index (CI) for subsequent clinical trials of this formulation in humans. METHODS Newborn pigs (n = 18) were exposed to 2-h hypoxia (10-15% oxygen) followed by reoxygenation (21-30% oxygen 4 h). After 1-h reoxygenation, pigs were randomized to: control group (no treatment), dobutamine infusion at a rate of 10-15 or 15-20 µg/kg/min. Dobutamine groups received two dobutamine doses during 30 min with a 60 min washout period between doses. Cardiovascular profile and oxygen metabolism were monitored. In four animals, an ultrasonic perivascular flow probe was placed around superior vena cava to measure SVCF. RESULTS Hypoxia significantly decreased CI, systemic vascular resistance and mean arterial blood pressure (MABP). Dobutamine doses significantly increased heart-rate, CI, and oxygen-delivery without changes in stroke-volume and MABP. Only 10-15 µg/kg/min increased oxygen consumption and peripheral tissue oxygenation measured by Near-infrared spectroscopy. A positive correlation was observed between SVCF and CI. CONCLUSION The new pediatric dobutamine formulation improved hemodynamic status, with dose-specific differences in metabolic response. SVCF may be a useful surrogate for CI in subsequent clinical trials.
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Affiliation(s)
- Victoria E Mielgo
- Experimental Unit, BioCruces Health Research Institute and Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Adolf Valls-I-Soler
- Experimental Unit, BioCruces Health Research Institute and Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Juan M Lopez-de-Heredia
- Experimental Unit, BioCruces Health Research Institute and Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
| | - Carmen Rey-Santano
- Experimental Unit, BioCruces Health Research Institute and Cruces University Hospital, Barakaldo, Bizkaia, Spain
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7
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Sakamoto T, Asou T, Takeda Y, Date K, Nanaumi M. Long-Term Outcome of Intracardiac Repair under Simple Deep Hypothermia. Asian Cardiovasc Thorac Ann 2016; 14:458-61. [PMID: 17130318 DOI: 10.1177/021849230601400603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Development of cardiopulmonary bypass has contributed to pediatric cardiac surgery, but at the dawn of cardiac surgery, simple deep hypothermia was used to avoid the deleterious effect of cardiopulmonary bypass. Between 1981 and 1990, 45 patients with simple cardiac anomalies underwent definitive surgery under deep hypothermia. Age at operation was 35 days to 20 months, and body weight was 2.3 to 8.0 kg. Under morphine and ether anesthesia, a median sternotomy was performed when the esophageal temperature reached 26.3°C ± 1.3°C by the application of surface cooling. At a minimum esophageal temperature of 19.6°C ± 2.3°C, inflow occlusion and cold cardioplegia were applied to induce circulatory arrest for 32.4 ± 10.2 min. Direct cardiac massage was used to restore cardiac activity during rewarming. All but one patient was in New York Heart Association functional class I postoperatively. The latest cardiothoracic ratio was 49.8% ± 4.7%. All but 2 patients are free from medication. Five of 30 patients showed developmental delay in the long-term; 2 of these had a long circulatory arrest period, and 3 had prolonged heart failure postoperatively. The other 25 patients had excellent physiologic and mental development. The long-term outcome of perfusionless hypothermic cardiac surgery is satisfactory when applied appropriately.
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Affiliation(s)
- Takahiko Sakamoto
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan.
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8
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Abstract
Applying scalp sensors in the operating theater, intensive care, or resuscitation scenarios to detect and monitor brain function is achievable, practical, and affordable. The modalities are complex and the output of the monitor needs careful interpretation. The monitor may have technical problems, and a single reading must be considered with caution. These monitors may have a use for monitoring trends in specific situations, but evidence does not support their widespread use. Nevertheless, research should continue to investigate their role. Future techniques and treatments may show that these monitors can monitor brain function and prevent harm.
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Affiliation(s)
- Michael Sury
- Department of Anaesthesia, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
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9
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Vernick WJ, Gutsche JT. Pro: Cerebral Oximetry Should be a Routine Monitor During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:385-9. [DOI: 10.1053/j.jvca.2012.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Indexed: 12/13/2022]
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10
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Nachar RA, Booth EA, Friedlich P, Borzage M, Soleymani S, Wider MD, Seri I. Dose-dependent hemodynamic and metabolic effects of vasoactive medications in normotensive, anesthetized neonatal piglets. Pediatr Res 2011; 70:473-9. [PMID: 21775923 DOI: 10.1203/pdr.0b013e31822e178e] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The developmentally regulated hemodynamic effects of vasoactive medications have not been well characterized. We used traditional and near-infrared spectroscopy monitoring technologies and investigated the changes in heart rate, blood pressure, common carotid artery (CCA) blood flow (BF), cerebral, renal, intestinal, and muscle regional tissue O2 saturation, and acid-base and electrolyte status in response to escalating doses of vasoactive medications in normotensive anesthetized neonatal piglets. We used regional tissue O2 saturation and CCA BF as surrogates of organ and systemic BF, respectively, and controlled minute ventilation and oxygenation. Low to medium doses of dopamine, epinephrine, dobutamine, and norepinephrine increased blood pressure and systemic and regional BF in a drug-specific manner, whereas milrinone exerted minimal effects. At higher doses, dopamine, epinephrine, and norepinephrine but not dobutamine decreased systemic, renal, intestinal, and muscle BF, while cerebral BF remained unchanged. Epinephrine induced significant increases in muscle BF and serum glucose and lactate concentrations. The findings reveal novel drug- and dose-specific differences in the hemodynamic response to escalating doses of vasoactive medications in the neonatal cardiovascular system and provide information for future clinical studies investigating the use of vasoactive medications for the treatment of neonatal cardiovascular compromise.
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Affiliation(s)
- Raul A Nachar
- Department of Pediatrics, Clinica Alemana, Santiago de Chile 1900, Chile
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11
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Rubio A, Hakami L, Münch F, Tandler R, Harig F, Weyand M. Noninvasive control of adequate cerebral oxygenation during low-flow antegrade selective cerebral perfusion on adults and infants in the aortic arch surgery. J Card Surg 2009; 23:474-9. [PMID: 18928485 DOI: 10.1111/j.1540-8191.2008.00644.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Real-time readings of the regional oxygen saturation (rSO(2)) using near-infrared spectroscopy (NIRS) during the aortic arch surgery can provide an early detection of perfusion or oxygenation abnormalities. BACKGROUND Aortic arch repair techniques using low-flow antegrade selective cerebral perfusion have been standardized to a certain degree. However, some of the often-stated beneficial effects have never been proven. Especially, the existence of an adequate continuous flow in both cerebral hemispheres during the surgical procedure still remains unclear as the monitoring of an effective perfusion remains a nonstandardized technique. METHODS Seventeen patients underwent surgical reconstruction of the aortic arch due to aortic aneurysm surgery (adult group n = 8 patients) or of the hypoplastic aortic arch due to hypoplastic left heart syndrome (HLHS) or aortic coarctation (infant group n = 9 patients) under general anesthesia and mild hypothermia (adult group 28 degrees C; infant group 25 degrees C). Mean weights were 92.75 +/- 14.00 kg and 4.29 +/- 1.32 kg, and mean ages were 58.25 +/- 10.19 years and 55.67 +/- 51.11 days in the adult group and the infant group, respectively. The cerebral O(2) saturation measurement was performed by continuous plotting of the somatic reflectance oximetry of the frontal regional tissue on both cerebral hemispheres (rSO(2), INVOS; Somanetics Corporation, Troy, MI, USA). RESULTS During low-flow antegrade perfusion via innominate artery, continuous plots with similar values of O(2) saturation (rSO(2)) in both cerebral hemispheres were observed, whereas a decrease in the rSO(2) values below the desaturation threshold correlated with a displacement or an incorrect positioning of the arterial cannula in the right subclavian artery. CONCLUSIONS Continuous monitorization of the cerebral O(2) saturation during aortic arch surgery in adults and infants is a feasible technique to control an adequate cannula positioning and to optimize clinical outcomes avoiding neurological complications related to cerebral malperfusion.
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Affiliation(s)
- Alvaro Rubio
- Department of Cardiac Surgery, Erlangen University Hospital, Erlangen, Germany.
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12
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Tisdall MM, Tachtsidis I, Leung TS, Elwell CE, Smith M. Increase in cerebral aerobic metabolism by normobaric hyperoxia after traumatic brain injury. J Neurosurg 2008; 109:424-32. [PMID: 18759572 DOI: 10.3171/jns/2008/109/9/0424] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traumatic brain injury (TBI) is associated with depressed aerobic metabolism and mitochondrial dysfunction. Normobaric hyperoxia (NBH) has been suggested as a treatment for TBI, but studies in humans have produced equivocal results. In this study the authors used brain tissue O(2) tension measurement, cerebral microdialysis, and near-infrared spectroscopy to study the effects of NBH after TBI. They investigated the effects on cellular and mitochondrial redox states measured by the brain tissue lactate/pyruvate ratio (LPR) and the change in oxidized cytochrome c oxidase (CCO) concentration, respectively. METHODS The authors studied 8 adults with TBI within the first 48 hours postinjury. Inspired oxygen percentage at normobaric pressure was increased from baseline to 60% for 60 minutes and then to 100% for 60 minutes before being returned to baseline for 30 minutes. RESULTS The results are presented as the median with the interquartile range in parentheses. During the 100% inspired oxygen percentage phase, brain tissue O2 tension increased by 7.2 kPa (range 4.5-9.6 kPa) (p < 0.0001), microdialysate lactate concentration decreased by 0.26 mmol/L (range 0.0-0.45 mmol/L) (p = 0.01), microdialysate LPR decreased by 1.6 (range 1.0-2.3) (p = 0.02), and change in oxidized CCO concentration increased by 0.21 mumol/L (0.13-0.38 micromol/L) (p = 0.0003). There were no significant changes in intracranial pressure or arterial or microdialysate glucose concentration. The change in oxidized CCO concentration correlated with changes in brain tissue O(2) tension (r(s)= 0.57, p = 0.005) and in LPR (r(s)= -0.53, p = 0.006). CONCLUSIONS The authors have demonstrated oxidation in cerebral cellular and mitochondrial redox states during NBH in adults with TBI. These findings are consistent with increased aerobic metabolism and suggest that NBH has the potential to improve outcome after TBI. Further studies are warranted.
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Affiliation(s)
- Martin M Tisdall
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, UK
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13
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Kakihana Y, Matsunaga A, Yasuda T, Imabayashi T, Kanmura Y, Tamura M. Brain oxymetry in the operating room: current status and future directions with particular regard to cytochrome oxidase. JOURNAL OF BIOMEDICAL OPTICS 2008; 13:033001. [PMID: 18601545 DOI: 10.1117/1.2940583] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Near-infrared spectroscopy (NIRS) is a cerebral monitoring method that noninvasively and continuously measures cerebral hemoglobin oxygenation and the redox state of cytochrome oxidase using highly tissue-permeable near-infrared light. This technique now has wide clinical application, and its usefulness in the measurement of cerebral hemoglobin oxygenation has been confirmed under global cerebral injury and/or hypoxemic hypoxia; however, regional cerebral infarction located far from the monitoring site may not be detected by NIRS. Furthermore, the specificity and accuracy of the measurement of the redox state of cytochrome oxidase remain controversial. We apply NIRS to both animal and clinical investigations. Based on these results, we discuss the significance of the measurement of cerebral hemoglobin oxygenation and cytochrome oxidase in vivo and in clinical medicine. Using our algorithm, cytochrome oxidase signals are unaffected by hemoglobin signals, even when hematocrit values change from 35 to 5% under cardiopulmonary bypass in a dog model. In the clinical study, cytochrome oxidase during surgery is likely to be a good (though not perfect) predictor of postoperative cerebral outcome. NIRS appears to be a promising technology, but additional investigations are required to establish its clinical efficacy and justify its routine use during operative and perioperative periods.
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Affiliation(s)
- Yasuyuki Kakihana
- Kagoshima University Hospital, Division of Intensive Care Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
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14
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Halstead JC, Wurm M, Meier DM, Zhang N, Spielvogel D, Weisz D, Bodian C, Griepp RB. Avoidance of hemodilution during selective cerebral perfusion enhances neurobehavioral outcome in a survival porcine model. Eur J Cardiothorac Surg 2007; 32:514-20. [PMID: 17644341 DOI: 10.1016/j.ejcts.2007.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 06/07/2007] [Accepted: 06/11/2007] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The ideal hematocrit (HCT) level during hypothermic selective cerebral perfusion (SCP)--to ensure adequate oxygen delivery without excessive perfusion--has not yet been determined. METHODS Twenty pigs (26.0+/-2.6 kg) were randomized to low or high HCT management. The cardiopulmonary bypass (CPB) circuit was primed with crystalloid in the low HCT group (21+/-1%), and with donor blood in the high HCT group (30+/-1%). Pigs were cooled to 20 degrees C and SCP was carried out for 90 min. During rewarming, whole blood was added in the low HCT group and crystalloid in the high HCT group to produce equivalent HCT levels by the end of the procedure. Using fluorescent microspheres and sagittal sinus sampling, cerebral blood flow (CBF) and oxygen metabolism (CMRO2) were assessed at baseline, after cooling, at two points during SCP (30 and 90 min), and at 15 min and 2 h post-CPB. In addition, a range of physiological and metabolic parameters, including intracranial pressure (ICP), were recorded throughout the procedure. The animals' behavior was videotaped and assessed blindly for 7 days postoperatively (maximum score=5). RESULTS HCT levels were equivalent at baseline, 2 h post-CPB, and at sacrifice, but significantly different (p<0.0001) during cooling and SCP. Mean arterial pressure, pH and pCO2, and CMRO2 were equivalent between groups throughout. ICP was similar in the two groups throughout cooling, SCP, and rewarming, but was significantly higher in the low HCT animals after the termination of CPB. CBF was similar at baseline, but thereafter markedly higher in the low HCT group. Neurobehavioral performance was significantly better in the high HCT animals (median score 3.5 vs 4.5 on day 3, and 4.5 vs 4.75 on day 7, p=0.003). CONCLUSIONS Higher HCT levels for SCP produced a significantly superior functional outcome, suggesting that the higher CBF with a lower HCT may be injurious, possibly because of an increased embolic load.
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Affiliation(s)
- James C Halstead
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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15
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Lee J, Armstrong J, Kreuter K, Tromberg BJ, Brenner M. Non-invasive in vivo diffuse optical spectroscopy monitoring of cyanide poisoning in a rabbit model. Physiol Meas 2007; 28:1057-66. [PMID: 17827653 DOI: 10.1088/0967-3334/28/9/007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of this study is to establish a cyanide toxicity animal model and to investigate the ability of broadband diffuse optical spectroscopy (DOS) to non-invasively monitor physiological changes that occur during the development of cyanide toxicity in a rabbit model. Broadband DOS combines multi-frequency frequency-domain photon migration (FDPM) with time-independent near-infrared spectroscopy (NIRS) to quantitatively measure bulk tissue absorption and scattering spectra between 600 nm and 1000 nm. Serum cyanide concentration and arterial and venous blood gas analysis at pre- and post-cyanide infusion were presented. To investigate the ability of DOS to non-invasively monitor physiologic changes occurring during development of CN toxicity, tissue concentrations of deoxyhemoglobin [Hb-R], oxyhemoglobin [Hb-O2], cytochrome c oxidase oxidized state [CcO_Ox] and reduced state [CcO_Re] were determined from absorption spectra acquired in 'real time' during cyanide infusions (NaCN 6 mg/60 ml normal saline) in six pathogen-free New Zealand white rabbits. During cyanide infusion, in vivo tissue oxygen saturation increased ( approximately 10%). In addition, broadband DOS was able to detect a concurrent increase in [CcO_Re] and decrease in [CcO_Ox]. Changes in tissue scattering properties in all six animals were detected during these events, confirming the need for DOS-based methods over traditional NIR spectroscopy to obtain accurate results.
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Affiliation(s)
- Jangwoen Lee
- Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, CA 92612-1475, USA.
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16
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Tisdall MM, Tachtsidis I, Leung TS, Elwell CE, Smith M. Near-infrared spectroscopic quantification of changes in the concentration of oxidized cytochrome c oxidase in the healthy human brain during hypoxemia. JOURNAL OF BIOMEDICAL OPTICS 2007; 12:024002. [PMID: 17477717 DOI: 10.1117/1.2718541] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The near-IR cytochrome c oxidase (CCO) signal has potential as a clinical marker of changes in mitochondrial oxygen utilization. We examine the CCO signal response to reduced oxygen delivery in the healthy human brain. We induced a reduction in arterial oxygen saturation from baseline levels to 80% in eight healthy adult humans, while minimizing changes in end tidal carbon dioxide tension. We measured changes in the cerebral concentrations of oxidized CCO (Delta[oxCCO]), oxyhemoglobin (Delta[HbO(2)]), and deoxyhemoglobin (Delta[HHb]) using broadband near-IR spectroscopy (NIRS), and estimated changes in cerebral oxygen delivery (ecDO(2)) using pulse oximetry and transcranial Doppler ultrasonography. Results are presented as median (interquartile range). At the nadir of hypoxemia ecDO(2) decreased by 9.2 (5.4 to 12.1)% (p<0.0001), Delta[oxCCO] decreased by 0.24 (0.06 to 0.28) micromoles/l (p<0.01), total hemoglobin concentration increased by 2.83 (2.27 to 4.46) micromoles/l (p<0.0001), and change in hemoglobin difference concentration (Delta[Hbdiff]=Delta[HbO(2)]-Delta[HHb]) decreased by 12.72 (11.32 to 16.34) micromoles/l (p<0.0001). Change in ecDO(2) correlated with Delta[oxCCO] (r=0.78, p<0.001), but not with either change in total hemoglobin concentration or Delta[Hbdiff]. This is the first description of cerebral Delta[oxCCO] during hypoxemia in healthy adults. Studies are ongoing to investigate the clinical relevance of this signal in patients with traumatic brain injury.
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Affiliation(s)
- Martin M Tisdall
- The National Hospital for Neurology and Neurosurgery, Department of Neuroanaesthesia and Neurocritical Care, Queen Square, London WC1N 3BG, United Kingdom.
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Hoffman GM. Pro: near-infrared spectroscopy should be used for all cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2007; 20:606-12. [PMID: 16884998 DOI: 10.1053/j.jvca.2006.05.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Indexed: 11/11/2022]
Affiliation(s)
- George M Hoffman
- Department of Anesthesiology and Pediatrics, Medical College of Wisconsin, Pediatric Anesthesiology and Critical Care Medicine, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA.
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Miura T, Sakamoto T, Kobayashi M, Shin'oka T, Kurosawa H. Hemodilutional anemia impairs neurologic outcome after cardiopulmonary bypass in a piglet model. J Thorac Cardiovasc Surg 2007; 133:29-36. [PMID: 17198777 DOI: 10.1016/j.jtcvs.2006.08.048] [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: 01/01/2006] [Revised: 08/12/2006] [Accepted: 08/28/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The effect of hemodilution on neurologic outcome after cardiopulmonary bypass remains unclear. We studied the influences of hematocrit on cerebral oxygenation and neuropathologic outcome in a piglet model. METHODS Eleven piglets (9.3 +/- 1.1 kg) were randomized into 2 groups. Five piglets (group H) received a total blood prime resulting in a high hematocrit (33.0% +/- 2.3%), and 6 piglets (group L) received a crystalloid prime resulting in a low hematocrit (14.0% +/- 3.2%). Both groups underwent 90 minutes of moderate hypothermic cardiopulmonary bypass (28 degrees C) with alpha-stat strategy. Cerebral oxygenation was monitored by near-infrared spectroscopy. Group L received a blood transfusion immediately after cardiopulmonary bypass to reach the postoperative target hematocrit of 30%. The brain was fixed in situ 6 hours after weaning from cardiopulmonary bypass, and a histologic score for neurologic injury was assessed. RESULTS There were no significant differences in arterial blood gas analyses throughout the experiment between the groups. Mean arterial pressure, mixed venous oxygen saturation, and heart rate were significantly higher in group H compared with group L during hypothermia. Oxyhemoglobin and total hemoglobin signals detected by near-infrared spectroscopy were significantly lower in group L (analysis of variance, P < .0001), although the tissue oxygenation index was not different during cardiopulmonary bypass. Group L showed a poorer histologic score compared with group H (P = .0071). CONCLUSIONS Excessive hemodilution, such as a hematocrit of less than 15%, may be associated with a high incidence of neurologic injury. Further studies are required to determine the safety limits of hematocrit during pediatric cardiopulmonary bypass.
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Nelson LA, McCann JC, Loepke AW, Wu J, Ben Dor B, Kurth CD. Development and validation of a multiwavelength spatial domain near-infrared oximeter to detect cerebral hypoxia-ischemia. JOURNAL OF BIOMEDICAL OPTICS 2006; 11:064022. [PMID: 17212545 DOI: 10.1117/1.2393251] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Detection of cerebral hypoxia-ischemia in infants remains problematic, as current monitors in clinical practice are impractical, insensitive, or nonspecific. Our study develops a multiwavelength spatial domain construct for near-infrared spectroscopy (NIRS) to detect cerebral hypoxia-ischemia and evaluates the construct in several models. The NIRS probe contains photodiode detectors 2, 3, and 4 cm from a three-wavelength, light-emitting diode. A construct determines cerebral O(2) saturation based on spatial domain principles. Device performance and construct validity are examined in in-vitro models simulating the brain, and in piglets subjected to hypoxia, hypoxia-ischemia, and hyperoxic conditions using a weighted average of arterial and cerebral venous O(2) saturation measured by CO-oximetry. The results in the brain models verify key equations in the construct and demonstrate reliable performance of the device. In piglets, the device measures cerebral O(2) saturation with bias +/-4% and precision +/-8%. In conclusion, this NIRS device accurately detects cerebral hypoxia-ischemia and is of a design that is practical for clinical application.
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Affiliation(s)
- Lindsey A Nelson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Department of Anesthesia and Pediatrics, Institute of Pediatric Anesthesia, Cincinnati, Ohio 45229-3039, USA
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Anttila V, Hagino I, Zurakowski D, Iwata Y, Duebener L, Lidov HGW, Jonas RA. Specific bypass conditions determine safe minimum flow rate. Ann Thorac Surg 2006; 80:1460-7. [PMID: 16181887 DOI: 10.1016/j.athoracsur.2005.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Revised: 04/04/2005] [Accepted: 04/05/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study is to define a safe minimum flow rate for specific bypass conditions using continuous monitoring with near-infrared spectroscopy and direct observation of the cerebral microcirculation. METHODS Two series of experiments (n = 72 in each) were conducted in which piglets were cooled to a temperature of 15 degrees, 25 degrees, or 34 degrees C on cardiopulmonary bypass with hematocrit 20% or 30%, pH-stat management in all, followed by 1 or 2 hours of reduced flow (10, 25, or 50 mL.kg(-1).min(-1)). Animals in series one had a cranial window placed over the parietal cortex to evaluate the microcirculation with intravital microscopy. Plasma was labeled with fluorescein-isothiocyanate-dextran for assessment of functional capillary density (FCD) and microvascular diameter. In series two, near-infrared spectroscopy was utilized to detect tissue oxygenation index (TOI). Outcome measures included histologic and neurologic injury scores. RESULTS The TOI during low flow and FCD during rewarming and after weaning from cardiopulmonary bypass were associated with neurologic injury. Failure of FCD to return to baseline during rewarming predicted worse functional and histologic outcome (p < 0.001). Regression analysis indicated that temperature and low-flow rate were multivariable predictors of TOI and FCD during rewarming (p < 0.001). CONCLUSIONS Tissue oxygen index derived from near-infrared spectroscopy is a useful real-time monitor for detecting inadequate cerebral perfusion during cardiopulmonary bypass. Minimal safe pump flow rate varies according to the conditions of bypass: using pH stat management and with an hematocrit of either 20% or 30%, a flow rate as low as 10 mL.kg(-1).min(-1) is safe for as long as 2 hours at a temperature of 15 degrees C. However, under the same conditions at 34 degrees C, a flow rate of 10 mL.kg(-1).min(-1) is very likely to be associated with neurologic injury.
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Affiliation(s)
- Vesa Anttila
- Department of Pathology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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21
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Ghanayem NS, Mitchell ME, Tweddell JS, Hoffman GM. Monitoring the brain before, during, and after cardiac surgery to improve long-term neurodevelopmental outcomes. Cardiol Young 2006; 16 Suppl 3:103-9. [PMID: 17378048 DOI: 10.1017/s1047951106000837] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Innovation in surgical and medical management of cardiac disease has generated a dramatic improvement in operative survival. Along with these favourable results in terms of survival is the heightened awareness of neurologic complications, which often become evident beyond the early postoperative period. A large, multicentre prospective study found serious neurologic injury occurs in about one-twentieth of patients after myocardial revascularization in adults.1More subtle evidence of persistent cognitive decline and functional impairment has been shown to occur in over two-fifths of such patients.2Acute neurologic abnormalities are reported in up to one-fifth of infants and children who undergo cardiac surgery.3–6Lasting impairments in cognitive, motor, and expressive functioning have been reported in up to three-fifths of children who have undergone complex cardiac surgery during infancy.7Specifically, gross and fine motor delays, visual-spatial problems, language deficits and long-term emotional and behavioural problems have been found.8–13
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Affiliation(s)
- Nancy S Ghanayem
- Department of Pediatrics, Division of Cardiothoracic Surgery, Medical College of Wisconsin 53122, USA.
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22
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Muehlschlegel S, Lobato EB. Con: All Cardiac Surgical Patients Should Not Have Intraoperative Cerebral Oxygenation Monitoring. J Cardiothorac Vasc Anesth 2006; 20:613-5. [PMID: 16884999 DOI: 10.1053/j.jvca.2006.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Susanne Muehlschlegel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 36210, USA
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Bein B, Cavus E, Stadlbauer KH, Tonner PH, Steinfath M, Scholz J, Dörges V. Monitoring of cerebral oxygenation with near infrared spectroscopy and tissue oxygen partial pressure during cardiopulmonary resuscitation in pigs. Eur J Anaesthesiol 2006; 23:501-9. [PMID: 16507191 DOI: 10.1017/s0265021506000366] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The present study was designed to compare cerebral oxygenation measured with near infrared spectroscopy and local brain tissue oxygen partial pressure, respectively, in pigs during cardiopulmonary resuscitation. Since tissue overlying the brain may have an impact on near infrared spectroscopy readings, we tested whether optode placement on intact skin or on the skull yielded comparable results. METHODS Twelve healthy pigs were anaesthetized and subjected to continuous haemodynamic, near infrared spectroscopy and brain tissue oxygen partial pressure monitoring. After 4 min of untreated ventricular fibrillation, cardiopulmonary resuscitation was started and arginine vasopressin was administered repeatedly three times. Near infrared spectroscopy values recorded were both the tissue oxygenation index and the tissue haemoglobin index as well as relative changes of chromophores (haemoglobin and cytochrome oxidase). Four animals served as control and were measured with both near infrared spectroscopy optodes mounted on the intact skin of the forehead, while in the remaining eight animals, one near infrared spectroscopy optode was implanted directly on the skull. RESULTS Near infrared spectroscopy readings at the skin or at the skull differed consistently throughout the study period. After arginine vasopressin administration, near infrared spectroscopy values at the different locations showed a transient dissociation. In contrast to near infrared spectroscopy measured on intact skin, near infrared spectroscopy readings obtained from skull showed a significant correlation to brain tissue oxygen partial pressure values (r = 0.67, P < 0.001). CONCLUSION Near infrared spectroscopy readings obtained from skin and skull differed largely after vasopressor administration. Near infrared spectroscopy optode placement therefore may have an important influence on the tissue region investigated.
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Affiliation(s)
- B Bein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany.
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Olsson C, Thelin S. Regional cerebral saturation monitoring with near-infrared spectroscopy during selective antegrade cerebral perfusion: Diagnostic performance and relationship to postoperative stroke. J Thorac Cardiovasc Surg 2006; 131:371-9. [PMID: 16434267 DOI: 10.1016/j.jtcvs.2005.08.068] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 08/15/2005] [Accepted: 08/31/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate whether regional cerebral tissue oxygen saturation monitoring during hypothermic selective antegrade cerebral perfusion in surgery involving the aortic arch can predict neurologic sequelae and to evaluate the diagnostic performance of near-infrared spectroscopy monitoring in this setting. METHODS Data from 46 consecutive patients were analyzed. Selective antegrade cerebral perfusion was established by perfusion of the right subclavian artery (with or without left carotid artery perfusion) or by separate concomitant perfusion of the innominate and the left carotid arteries. The bilateral regional cerebral tissue oxygen saturation index was monitored by using near-infrared spectroscopy equipment (INVOS 4100). Stroke was the primary clinical end point, along with the indices of diagnostic performance. RESULTS Six patients died in the hospital, and 6 patients (13%) experienced a perioperative stroke. In patients with stroke, regional cerebral tissue oxygen saturation values were significantly lower during selective antegrade cerebral perfusion, and regional cerebral tissue oxygen saturation tended to be lower in the affected hemisphere. In receiver operating characteristic curve analysis, the area under the curve for relative regional cerebral tissue oxygen saturation values ranged from 0.72 to 0.87. During selective antegrade cerebral perfusion, regional cerebral tissue oxygen saturation between 76% and 86% of baseline had a sensitivity up to 83% and a specificity up to 94% in identifying individuals with stroke. The associated odds ratio for stroke was 5.6 (95% confidence interval, 0.5-144) to 21 (95% confidence interval, 1.8-566). CONCLUSIONS Monitoring of regional cerebral tissue oxygen saturation by using near-infrared spectroscopy during selective antegrade cerebral perfusion allows detection of clinically important cerebral desaturation. It can help predict perioperative neurologic sequelae. Its performance as a diagnostic instrument is satisfying and supports its use as a noninvasive trend monitor of cerebral saturation.
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Affiliation(s)
- Christian Olsson
- Uppsala University Hospital, Department of Surgical Sciences, Division of Cardiothoracic Surgery, Uppsala, Sweden.
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Hagino I, Anttila V, Zurakowski D, Duebener LF, Lidov HGW, Jonas RA. Tissue oxygenation index is a useful monitor of histologic and neurologic outcome after cardiopulmonary bypass in piglets. J Thorac Cardiovasc Surg 2005; 130:384-92. [PMID: 16077403 DOI: 10.1016/j.jtcvs.2005.02.058] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Tissue oxygenation index is a novel monitoring indicator derived by near-infrared spectroscopy. We hypothesized that tissue oxygenation index could predict a minimum safe flow rate for specific bypass conditions. METHODS Thirty-six piglets (age, 43 +/- 5 days; weight, 9.0 +/- 1.1 kg) underwent cardiopulmonary bypass with cerebral near-infrared spectroscopy (NIRO-300; Hamamatsu Photonics K.K., Hamamatsu City, Japan). Animals were cooled for 40 minutes to 15 degrees C, 25 degrees C, or 34 degrees C (pH-stat, hematocrit value of 20% or 30%, and pump flow of 100 mL . kg -1 . min -1), followed by low-flow perfusion (10, 25, or 50 mL . kg -1 . min -1) for 2 hours. Neurologic and behavioral evaluations were determined for 4 days. The brain was then fixed for histologic assessment. Tissue oxygenation index was defined as the average signal during low-flow bypass. RESULTS Animals with an average tissue oxygenation index of less than 55% showed cerebral injury, whereas animals with an index of greater than 55% showed minimal or no evidence of injury. Correlations were found between average tissue oxygenation index and histologic score (Spearman rho = -0.65, P < .001) and neurologic deficit score (Pearson r = -0.50, P = .002) on the first postoperative day. Temperature (P < .001), flow rate (P < .001), and hematocrit value (P = .002) were multivariable predictors of tissue oxygenation index, as determined by means of multivariable analysis of variance. CONCLUSION Tissue oxygenation index is a useful monitor for defining the minimum safe flow rate during cardiopulmonary bypass. An index value of less than 55% is a strong predictor of neurologic injury.
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Affiliation(s)
- Ikuo Hagino
- Department of Cardiovascular Surgery, Children's Hospital Boston, Harvard Medical School, MA, USA
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Shum-Tim D, MacDonald D, Takayuki S, Laliberté E, Chen J, Jamal AM, Philip A, Platt R. Low postoperative hematocrit increases cerebrovascular damage after hypothermic circulatory arrest. Pediatr Crit Care Med 2005; 6:319-26. [PMID: 15857532 DOI: 10.1097/01.pcc.0000161070.63957.e1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the systemic and cerebral effects of different postoperative hematocrit management following cardiopulmonary bypass and deep hypothermic circulatory arrest. DESIGN Animal case study. SETTING Laboratory. SUBJECTS Four-week-old Yorkshire piglets. INTERVENTIONS Twelve piglets were subjected to cardiopulmonary bypass (hematocrit = 25%) and 100 mins of deep hypothermic circulatory arrest (15 degrees C). After weaning cardiopulmonary bypass, they were randomized to either group L or H, in which the postoperative hematocrit was maintained approximately 20% vs. approximately 30%, respectively, and survived for 6 hrs. MEASUREMENTS AND MAIN RESULTS Changes in body weight, bioimpedance, and colloid oncotic pressure were assessed. Near-infrared spectroscopy and immunohistochemical assays for cerebral transforming growth factor-beta(1) and caspase-3 were performed. Postoperative weight gain (kg) and decreases in bioimpedance (ohms) were significantly less in group H (1.5 +/- 0.2 [H] vs. 2.4 +/- 0.6 [L], p = .01; 39.3 +/- 15.5 [H] vs. 89.1 +/- 29.6 [L], p = .01). Mean colloid oncotic pressure (mm Hg) was significantly higher in group H (10.8 +/- 1.6 [H] vs. 8.2 +/- 0.8 [L], p = .01) at 6 hrs postoperatively. Oxyhemoglobin, oxidized cytochrome aa(3) (muM x differential path-length factor), and tissue oxygenation index (%) were significantly better in group H (65.7 +/- 31.8 [H] vs. -104.7 +/- 55.2 [L], p = .0001; 0.52 +/- 4.1 [H] vs. -12.8 +/- 6.1 [L], p = .0001, and 55.7 +/- 4.6% [H] vs. 45.3 +/- 6.4% [L], p = .004, respectively). Cerebral transforming growth factor-beta(1) and caspase-3 scores were significantly better in group H (3.0 +/- 0.6 [H] vs. 1.9 +/- 0.9 [L], p = .04 and 1.8 +/- 0.5 [H] vs. 3.2 +/- 0.8 [L], p = .02, respectively). Mean arterial pressure (mm Hg) was consistently higher with group H (94.7 +/- 13.0 [H] vs. 78.3 +/- 11.5 [L], p = .003) despite comparable central venous pressure ( approximately 11 mm Hg). CONCLUSIONS Lower postoperative hematocrit was associated with increased fluid retention, lower perfusion pressure, and worse cerebrovascular injury following deep hypothermic circulatory arrest. Postoperative hematocrit management may have profound systemic and cerebral effects after deep hypothermic circulatory arrest and merits further investigation.
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Affiliation(s)
- Dominique Shum-Tim
- Divisions of Cardiac Surgery, The Montreal Children's Hospital, McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec H3G 1AM, Canada.
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Bein B, Cavus E, Dörges V, Stadlbauer KH, Tonner PH, Steinfath M, Scholz J. Arginine vasopressin reduces cerebral oxygenation and cerebral blood volume during intact circulation in swine---a near infrared spectroscopy study. Eur J Anaesthesiol 2005; 22:62-6. [PMID: 15816576 DOI: 10.1017/s026502150500013x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of the present study was to investigate the impact of arginine vasopressin (AVP), a drug currently under investigation for use during cardiopulmonary resuscitation, on cerebral oxygenation and cerebral blood volume (CBV) in pigs with intact systemic circulation using near infrared spectroscopy. METHODS Nine healthy pigs were anaesthetized and subjected to invasive haemodynamic monitoring as well as to non-invasive determination (with near infrared spectroscopy) of changes in the Tissue Oxygenation Index (TOI is the ratio of oxygenated to total tissue haemoglobin), Tissue Haemoglobin Index (THI, representing CBV) and cytochrome oxidase (deltaCytOx, representing the balance of intracellular oxygen supply). RESULTS At both 3 and 5 min after AVP administration, TOI, THI and deltaCytOx were significantly (P < 0.001) reduced compared to baseline, while cerebral perfusion pressure increased significantly (P < 0.001). The effects of AVP on TOI and THI lasted longer than on deltaCytOx. There were no significant changes with respect to the intracranial pressure throughout the study period. CONCLUSIONS No improvement of cerebral oxygenation was detected after AVP administration in swine with an intact systemic circulation. In contrast to recently published investigations, AVP provoked a sustained drop in indices of cerebral oxygenation and CBV.
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Affiliation(s)
- B Bein
- University Hospital Schleswig-Holstein, Department of Anaesthesiology and Intensive Care Medicine, Campus Kiel, Germany.
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Hofer A, Haizinger B, Geiselseder G, Mair R, Rehak P, Gombotz H. Monitoring of selective antegrade cerebral perfusion using near infrared spectroscopy in neonatal aortic arch surgery. Eur J Anaesthesiol 2005; 22:293-8. [PMID: 15892408 DOI: 10.1017/s0265021505000499] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE To prevent neurological complications, low-flow antegrade cerebral perfusion (ACP) is used during repair of complex congenital heart defects. To overcome technical problems, continuous monitoring of cerebral blood flow and oxygenation is mandatory. The aim of the study was to evaluate the effect of different ACP flow rates on cerebral oxygen saturation obtained by near infrared spectroscopy. METHODS Ten consecutive neonates undergoing Norwood stage I were included. In addition to near infrared spectroscopy (Invos 5100; Somanetics Corp., USA) on both hemispheres, mean arterial pressure and transcranial Doppler flow velocity were measured continuously and arterial and jugular venous oxygen saturation intermittently. Cerebral oxygen extraction ratio was calculated. Measurement points were obtained after starting bypass, during ACP with flow rates of 30, 20 and 10 mL kg(-1) min(-1) and immediately after ACP. ANOVA and Tukey-Kramer multiple comparison test were used for statistics. RESULTS The near infrared spectroscopy signal could be obtained in all children at all measurement points, whereas transcranial Doppler failed in 1 neonate at a flow rate of 30 mL kg(-1)min(-1), in 3 neonates at 20 mL kg(-1) min(-1) and in 4 neonates at 10 mL kg(-1)min(-1). With the reduction of flow there was a significant decrease of cerebral oxygen saturation on both hemispheres (right: 78+/-8 to 72+/-9 and 66+/-8, P < 0.001; left: 71+/-7 to 65+/-7 and 60+/-7, P < 0.001), of jugular venous oxygen saturation (94+/-6 to 89+/-13 and 83+/-15, P < 0.001) and a significant increase in oxygen extraction ratio (9.1+/-8 to 14.8+/-14 and 21+/-16, P < 0.001) respectively, for 30, 20, 10 mL kg(-1)min(-1). CONCLUSION Near infrared spectroscopy reliably detects flow alterations during ACP with profound hypothermia.
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Affiliation(s)
- A Hofer
- General Hospital Linz, Departments of Anaesthesiology and Intensive Care, Linz, Austria.
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Ferrari M, Mottola L, Quaresima V. Principles, techniques, and limitations of near infrared spectroscopy. ACTA ACUST UNITED AC 2005; 29:463-87. [PMID: 15328595 DOI: 10.1139/h04-031] [Citation(s) in RCA: 597] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In the last decade the study of the human brain and muscle energetics underwent a radical change, thanks to the progressive introduction of noninvasive techniques, including near-infrared (NIR) spectroscopy (NIRS). This review summarizes the most recent literature about the principles, techniques, advantages, limitations, and applications of NIRS in exercise physiology and neuroscience. The main NIRS instrumentations and measurable parameters will be reported. NIR light (700-1000 m) penetrates superficial layers (skin, subcutaneous fat, skull, etc.) and is either absorbed by chromophores (oxy- and deoxyhemoglobin and myoglobin) or scattered within the tissue. NIRS is a noninvasive and relatively low-cost optical technique that is becoming a widely used instrument for measuring tissue O2 saturation, changes in hemoglobin volume and, indirectly, brain/muscle blood flow and muscle O2 consumption. Tissue O2 saturation represents a dynamic balance between O2 supply and O2 consumption in the small vessels such as the capillary, arteriolar, and venular bed. The possibility of measuring the cortical activation in response to different stimuli, and the changes in the cortical cytochrome oxidase redox state upon O2 delivery changes, will also be mentioned.
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Affiliation(s)
- Marco Ferrari
- Department of Biomedical Sciences and Technologies, University of L'Aquila, Italy
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Ijichi S, Kusaka T, Isobe K, Islam F, Okubo K, Okada H, Namba M, Kawada K, Imai T, Itoh S. Quantification of cerebral hemoglobin as a function of oxygenation using near-infrared time-resolved spectroscopy in a piglet model of hypoxia. JOURNAL OF BIOMEDICAL OPTICS 2005; 10:024026. [PMID: 15910099 DOI: 10.1117/1.1899184] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Near-infrared spectroscopy (NIRS) has been used for measurement of cerebral hemoglobin (Hb) concentrations in neonates to study cerebral oxygenation and hemodynamics. We perform measurements by portable three-wavelength NIR time-resolved spectroscopy (TRS) in a piglet hypoxia model with various degrees of oxygenation to estimate the absorption coefficient (mu(a)) and reduced scattering coefficient (mu(s)') of the head. Measurements of absolute values of mu(a) at three wavelengths enable estimation of Hb concentration and Hb oxygen saturation in the head (SO2). However, there is a problem concerning which background absorption should be used to estimate Hb concentration in the head derived from mu(a) at three wavelengths because it is different from a simple in vitro model. Therefore, we use two different background absorption values with the assumption that background absorption is due only to 85% (by volume) water or that background absorption is equal to absorption of the piglet head with blood exchange transfusion by fluorocarbon (FC), and we compared SO2 measured by TRS with arterial Hb oxygen saturation (SaO2) and sagittal sinus venous Hb oxygen saturation (SvO2) measured by a co-oximeter at several inspired fractional O2(FI(O2)) concentrations. We find that SO2 values using the absorption (abs) of the piglet head with blood exchange transfusion (BET) by FC are not significantly different from SO2 values using the water-only background at FI(O2) in the range of 15 to 100%, but that the values using abs of the head with BET by FC are lower than the values using the water-only background at FI(O2) in the range of 12 to 4%. The SO2 values calculated from the water-only background are higher than those of SaO2 at FI(O2) in the range of 10 to 4%. However, SO2 values using the abs of the head with BET by FC are between those of SaO2 and SvO2 over the whole range of FI(O2). Therefore, abs of the head with BET by FC is more useful for estimation of the absolute values of oxyHb and deoxyHb of the piglet head.
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Affiliation(s)
- Sonoko Ijichi
- Kagawa University, Department of Pediatrics, Faculty of Medicine, Mikicho 1750-1, Kitagun, Kagawa 761-0793, Japan
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Arginine vasopressin reduces cerebral oxygenation and cerebral blood volume during intact circulation in swine - a near infrared spectroscopy study. Eur J Anaesthesiol 2005. [DOI: 10.1097/00003643-200501000-00013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The incidence of neurological complications after pediatric cardiac surgery ranges from 2% to 25%. The causes are multifactorial and include preoperative brain malformations, perioperative hypoxemia and low cardiac output states, sequelae of cardiopulmonary bypass, and deep hypothermic circulatory arrest. Neurological monitoring devices are readily available and the anesthesiologist can now monitor the brain during pediatric cardiac surgery. In this review we discuss near-infrared cerebral oximetry, transcranial Doppler ultrasound, and electroencephalographic monitors for use during congenital heart surgery. After review of the basic principles of each monitoring modality, we discuss their uses during pediatric heart surgery. We present evidence that multimodal neurological monitoring in conjunction with a treatment algorithm may improve neurological outcome for patients undergoing congenital heart surgery and present one such algorithm.
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Affiliation(s)
- Dean B Andropoulos
- Department of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Departments of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston Texas, Department of Pediatric Cardiac Anesthesiology, Lucile Packard Children's Hospital at Stanford, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
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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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Uludağ K, Steinbrink J, Kohl-Bareis M, Wenzel R, Villringer A, Obrig H. Cytochrome-c-oxidase redox changes during visual stimulation measured by near-infrared spectroscopy cannot be explained by a mere cross talk artefact. Neuroimage 2004; 22:109-19. [PMID: 15110001 DOI: 10.1016/j.neuroimage.2003.09.053] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Revised: 09/22/2003] [Accepted: 09/26/2003] [Indexed: 10/26/2022] Open
Abstract
The detection of redox changes in cytochrome-c-oxidase ([Cyt-ox]) in response to cerebral activation by non-invasive NIRS is hampered by methodological spectroscopic issues related to the modification of the Beer-Lambert law. Also, the question whether a change in the enzyme's redox-state is elicited by functional stimulation is unresolved. In a previous study, we found physiological evidence in favour of an activation-induced increase in oxidation of the enzyme [J. Cereb. Blood Flow Metab. 19 (1999) 592], while in a second study on spectroscopic cross talk, we found that the [Cyt-ox] changes to potentially be an artefact of the spectroscopic approach [J. Biomed. Opt. 7 (2002) 51]. Here, we use two different stimuli which differentially activate areas either rich or poor in [Cyt-ox] content (blob/interblob in visual cortex V1 and pale/thin stripes in V2) to further clarify this apparent discrepancy. In a first experiment, two stimuli were presented in an alternating fashion for 20 s and all stimulation periods were separated by resting periods of 40 s. We observed similar changes in [Cyt-ox] for both stimuli. To become more sensitive to the potentially very small optical changes related to changes in [Cyt-ox], we tried to minimise global haemodynamic and metabolic effects in a second experiment by omitting the resting periods. Our hypothesis was that [Cyt-ox] changes could be fully explained by cross talk as it is predicted from our last study [J. Biomed. Opt. 7 (2002) 51]. However, in more than half of the experiments, we were not able to model the changes in Cyt-ox calculated from measured attenuation spectra as a cross talk artefact. We interpret this finding as an argument in favour of the existence of [Cyt-ox] changes in response to functional stimulation. This finding, however, does not lessen the liability of the [Cyt-ox] changes to cross talk and calls for great caution when [Cyt-ox] changes are derived from NIRS measurements based on the modified Beer-Lambert approach. Further (invasive) validation studies are required.
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Affiliation(s)
- Kâmil Uludağ
- Department of Neurology, Charité, Humboldt University, Berlin 10117, Germany.
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Han SH, Kim CS, Kim SD, Bahk JH, Park YS. The effect of bloodless pump prime on cerebral oxygenation in paediatric patients. Acta Anaesthesiol Scand 2004; 48:648-52. [PMID: 15101864 DOI: 10.1111/j.0001-5172.2004.00374.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In paediatric patients, crystalloid prime for cardiopulmonary bypass (CPB) causes further haemodilution in comparison with blood-containing prime. Thus it may affect the cerebral oxygen supply/demand balance. The purpose of the study was to compare the effect of bloodless pump prime with that of blood-containing prime on cerebral oxygenation in children. METHODS Thirty-six paediatric patients scheduled for elective repair of atrial or ventricular septal defect were enrolled. In Group C (n = 18), the CPB circuit was primed only with crystalloid. In Group B (n = 18), red blood cells were added to achieve a haematocrit (Hct) of 20% during CPB. The regional cerebral oxygen saturation (rSO(2)) value measured by near-infrared spectroscopy was compared between the two groups. RESULTS In both groups, rSO(2) decreased below baseline at the start of CPB and during rewarming (P < 0.001, for both groups during each period). At the start of CPB, haemodilution was greater in Group C than in Group B (Hct 16.1 +/- 0.7% vs. 20.7 +/- 0.5%; P < 0.01), and there was a greater reduction in rSO(2) in Group C (49.0 +/- 5.4% vs. 59.2 +/- 7.0%; P < 0.01). During rewarming, rSO(2) was significantly lower in Group C than in Group B (57.8 +/- 5.3% vs. 62.8 +/- 6.2%; P < 0.01). CONCLUSIONS In paediatric patients, the haemodilution associated with crystalloid priming causes a greater reduction in rSO(2) than with blood-containing prime at the starting period of CPB and the rewarming period.
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Affiliation(s)
- S H Han
- Department of Anaesthesiology, Seoul National University, Bundang Hospital, Seoul, Korea
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Kobayashi N, Hoshi Y, Tamura M. A perfused rat brain model maintaining the connection between the central and peripheral nervous systems. J Neurosci Methods 2004; 132:191-8. [PMID: 14706717 DOI: 10.1016/j.jneumeth.2003.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We have developed a new perfused brain model in rats. In this model, the cerebral circulation is separated from the systemic circulation, while the connections between the central and peripheral nervous systems are preserved. After bilateral common carotid, external carotid and vertebral artery ligation, bilateral common carotid arteries were cannulated to infuse rinsed human type O red blood cells mixed with modified Ringer's solution. To drain cerebral venous blood, external jugular veins were cannulated. Normal electrocortical activities were observed on electroencephalograms (EEGs) for more than 1h after the beginning of the perfusion. Somatosensory evoked potentials (SEPs) were also recorded. Direct infusion of pentylenetetrazol (PTZ) into the brain induced epileptic discharges on the EEGs and active dilation of cerebral arterioles, which was accompanied by an increase in systemic blood pressure (BP). The present model, in which we can change cerebral blood flow (CBF) and/or cerebral metabolism without directly affecting the systemic circulation, will provide a new approach to brain research.
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Affiliation(s)
- Norio Kobayashi
- Biophysics Group, Institute for Electronic Science, Hokkaido University, Sapporo 060-0812, Japan
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Erecinska M, Thoresen M, Silver IA. Effects of hypothermia on energy metabolism in Mammalian central nervous system. J Cereb Blood Flow Metab 2003; 23:513-30. [PMID: 12771566 DOI: 10.1097/01.wcb.0000066287.21705.21] [Citation(s) in RCA: 291] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This review analyzes, in some depth, results of studies on the effect of lowered temperatures on cerebral energy metabolism in animals under normal conditions and in some selected pathologic situations. In sedated and paralyzed mammals, acute uncomplicated 0.5- to 3-h hypothermia decreases the global cerebral metabolic rate for glucose (CMR(glc)) and oxygen (CMRo(2)) but maintains a slightly better energy level, which indicates that ATP breakdown is reduced more than its synthesis. Intracellular alkalinization stimulates glycolysis and independently enhances energy generation. Lowering of temperature during hypoxia-ischemia slows the rate of glucose, phosphocreatine, and ATP breakdown and lactate and inorganic phosphate formation, and improves recovery of energetic parameters during reperfusion. Mild hypothermia of 12 to 24-h duration after normothermic hypoxic-ischemic insults seems to prevent or ameliorate secondary failures in energy parameters. The authors conclude that lowered head temperatures help to protect and maintain normal CNS function by preserving brain ATP supply and level. Hypothermia may thus prove a promising avenue in the treatment of stroke and trauma and, in particular, of perinatal brain injury.
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Affiliation(s)
- Maria Erecinska
- Department of Anatomy, University of Bristol, Bristol, United Kingdom.
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Kakihana Y, Kuniyoshi T, Isowaki S, Tobo K, Nagata E, Okayama N, Kitahara K, Moriyama T, Omae T, Kawakami M, Kanmura Y, Tamura M. Re-Evaluation of the Reliability of Cytochrome Oxidase—Signal Study of Cardiopulmonary Bypass. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 540:71-5. [PMID: 15174604 DOI: 10.1007/978-1-4757-6125-2_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Yasuyuki Kakihana
- Division of Intensive Care Medicine, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
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Abstract
Combining a wireless telemetry system and a portable near-infrared instrument, we developed a movable optical spectroscopy system for monitoring cerebral hemodynamic changes. The patient carries a miniaturized near-infrared spectroscopy instrument on the back, and data are sent by a wireless telemetry system to a computer, without restricting patient movement. We used this system to detect hemodynamic changes associated with being startled, anticipation, and pleasant and unpleasant emotions in the bilateral prefrontal cortices of 16 right-handed 4- to 6-year-old preschool children while they were watching a 21-minute video clip consisting of various scenes that elicited emotional responses, interpolated with neutral scenes for comparison. The children were relaxed and cooperative when they were studied. Anticipation was associated with increases in cerebral blood flow in the left prefrontal cortex of the 6-year-old children, and unpleasant emotion was associated with decreases in cerebral blood flow bilaterally compared with neutral emotion, irrespective of age. No hemodynamic changes associated with the startle response were observed. Although this study should be considered preliminary, it is suggested that the emotional response is age-dependent and that the left prefrontal cortex participates in anticipation. Our newly developed system will open a window into brain physiology in children.
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Affiliation(s)
- Yoko Hoshi
- Department of Integrated Neuroscience, Tokyo Institute of Psychiatry, Tokyo, Japan
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Reents W, Muellges W, Franke D, Babin-Ebell J, Elert O. Cerebral oxygen saturation assessed by near-infrared spectroscopy during coronary artery bypass grafting and early postoperative cognitive function. Ann Thorac Surg 2002; 74:109-14. [PMID: 12118739 DOI: 10.1016/s0003-4975(02)03618-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cerebral oxygen saturation (ScO2) can be assessed by near-infrared spectroscopy. We investigated the correlation between early postoperative cognitive performance and intraoperative ScO2 in a prospective observational setting. METHODS Forty-seven patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass underwent preoperative and postoperative neuropsychological evaluation. Patients were classified according to the presence or absence of postoperative cognitive dysfunction. Cognitive dysfunction was defined as an individual test score decrease of more than one standard deviation in two or more of the five tests. During operation ScO2 was continuously measured using an INVOS 4100 device. Cerebral oxygen saturation values were analyzed with reference to two cutoff points, which should reflect low cerebral oxygenation: an ScO2 less than 40% and a drop of more than 25% from individual baseline values. The duration and extent of ScO2 values below these two cutoff points was compared between the patients with and without cognitive dysfunction. RESULTS Sixteen patients (34%) showed postoperative cognitive dysfunction. Cerebral oxygen saturation values less than 40% occurred in 17 patients for a mean (+/- standard error of the mean) of 17.2 +/- 6.5 minutes, whereas a decrease of more than 25% from baseline values occurred in 37 patients for 52.7 +/- 7.8 minutes. The duration and extent below the two cutoff ScO2 values was similar in patients with and without cognitive dysfunction. CONCLUSIONS Intraoperative regional ScO2 as assessed by near-infrared spectroscopy with the INVOS 4100 device is not predictive for postoperative cognitive performance in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.
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Affiliation(s)
- Wilko Reents
- Department of Cardiothoracic Surgery, University Hospital, Würzburg, Germany.
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Sakamoto T, Zurakowski D, Duebener LF, Hatsuoka S, Lidov HGW, Holmes GL, Stock UA, Laussen PC, Jonas RA. Combination of alpha-stat strategy and hemodilution exacerbates neurologic injury in a survival piglet model with deep hypothermic circulatory arrest. Ann Thorac Surg 2002; 73:180-9; discussion 189-90. [PMID: 11837244 DOI: 10.1016/s0003-4975(01)03274-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal pH strategy and hematocrit during cardiopulmonary bypass with deep hypothermic circulatory arrest (DHCA) remain controversial. We studied the interaction of pH strategy and hematocrit and their combined impact on cerebral oxygenation and neurological outcome in a survival piglet model including monitoring by near-infrared spectroscopy (NIRS). METHODS Thirty-six piglets (9.2+/-1.1 kg) underwent DHCA under varying conditions with continuous monitoring by NIRS (pH-stat or alpha-stat strategy, hematocrit 20% or 30%, DHCA time 60, 80, or 100 minutes). Neurological recovery was evaluated daily. The brain was fixed in situ on postoperative day 4 and a histological score (HS) for neurological injury was assessed. RESULTS Oxygenated hemoglobin (HbO2) and total hemoglobin signals detected by NIRS were significantly lower with alpha-stat strategy during cooling (p < 0.001), suggesting insufficient cerebral blood supply and oxygenation. HbO2 declined to a plateau (nadir) during DHCA. Time to nadir was significantly shorter in lower hematocrit groups (p < 0.01). Significantly delayed neurologic recovery was seen with alpha-stat strategy compared with pH-stat (p < 0.05). The alpha-stat group had a worse histological score compared with those assigned to pH-stat (p < 0.001). Neurologic impairment was estimated to be over 10 times more likely for animals randomized to alpha-stat compared with pH-stat strategy (odds ratio = 10.7, 95% confidence interval = 3.8 to 25.2). CONCLUSIONS Combination of alpha-stat strategy and lower hematocrit exacerbates neurological injury after DHCA. The mechanism of injury is inadequate cerebral oxygenation during cooling and a longer plateau period of minimal O2 extraction during DHCA.
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Affiliation(s)
- Takahiko Sakamoto
- Department of Cardiac Surgery, Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Sakamoto T, Hatsuoka S, Stock UA, Duebener LF, Lidov HG, Holmes GL, Sperling JS, Munakata M, Laussen PC, Jonas RA. Prediction of safe duration of hypothermic circulatory arrest by near-infrared spectroscopy. J Thorac Cardiovasc Surg 2001; 122:339-50. [PMID: 11479508 DOI: 10.1067/mtc.2001.115242] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Hypothermic circulatory arrest is widely used for adults with aortic arch disease as well as for children with congenital heart disease. At present, no method exists for monitoring safe duration of circulatory arrest. Near-infrared spectroscopy is a new technique for noninvasive monitoring of cerebral oxygenation and energy state. In the current study, the relationship between near-infrared spectroscopy data and neurologic outcome was evaluated in a survival piglet model with hypothermic circulatory arrest. METHODS Thirty-six piglets (9.36 +/- 0.16 kg) underwent circulatory arrest under varying conditions with continuous monitoring by near-infrared spectroscopy (temperature 15 degrees C or 25 degrees C, hematocrit value 20% or 30%, circulatory arrest time 60, 80, or 100 minutes). Each setting included 3 animals. Neurologic recovery was evaluated daily by neurologic deficit score and overall performance category. Brain was fixed in situ on postoperative day 4 and examined by histologic score. RESULTS Oxygenated hemoglobin signal declined to a plateau (nadir) during circulatory arrest. Time to nadir was significantly shorter with lower hematocrit value (P <.001) and higher temperature (P <.01). Duration from reaching nadir until reperfusion ("oxygenated hemoglobin signal nadir time") was significantly related to histologic score (r (s) = 0.826), neurologic deficit score (r (s) = 0.717 on postoperative day 1; 0.716 on postoperative day 4), and overall performance category (r (s) = 0.642 on postoperative day 1; 0.702 on postoperative day 4) (P <.001). All animals in which oxygenated hemoglobin signal nadir time was less than 25 minutes were free of behavioral or histologic evidence of brain injury. CONCLUSION Oxygenated hemoglobin signal nadir time determined by near-infrared spectroscopy monitoring is a useful predictor of safe duration of circulatory arrest. Safe duration of hypothermic circulatory arrest is strongly influenced by perfusate hematocrit value and temperature during circulatory arrest.
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Affiliation(s)
- T Sakamoto
- Departments of Cardiac Surgery, Pathology, Neurology, and Anesthesia and Intensive Care, The Children's Hospital and Harvard Medical School, Boston, MA, USA
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