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Table of Contents
INVITED COMMENTARY  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 392-393
Should cerebral oximetry be used as routine monitoring for cardiovascular surgical cases?


Department of Cardiac Anaesthesiology, Salalah Heart Center, Salalah, Sultanate of Oman

Click here for correspondence address and email

Date of Web Publication6-Jul-2016
 

How to cite this article:
Rawat RS. Should cerebral oximetry be used as routine monitoring for cardiovascular surgical cases?. Ann Card Anaesth 2016;19:392-3

How to cite this URL:
Rawat RS. Should cerebral oximetry be used as routine monitoring for cardiovascular surgical cases?. Ann Card Anaesth [serial online] 2016 [cited 2020 Aug 7];19:392-3. Available from: http://www.annals.in/text.asp?2016/19/3/392/185516


The Editor,

We appreciate Dr. Murat Cetin article [1] for monitoring cerebral oxygenation and presenting a study during cardiac catheterization cases.

The neurological outcome remains problematic in cardiac and vascular surgery and is associated with prolonged hospitalization, excessive operative morbidity/mortality, and higher hospital costs. The brain injury after cardiac surgery is multifactorial. The ischemia is the main factor leading to brain injury, which results from cerebral hypoperfusion and embolization that is exacerbated by inflammatory processes evoked from cardiopulmonary bypass injury, inflammatory responses, disorders in oxygen delivery resulting from anemia and postoperative cerebral hyperthermia, cardiac arrhythmias, and genetic predisposition. [2] The magnetic resonance imaging of the brain has revealed that brain infarction occurs in 45% of patients after cardiac surgery. It is found that 1-3% of patients with coronary artery bypass grafting develop strokes. [3]

To recognize cerebral ischemia different monitoring modalities are used in practice. One of them is cerebral oximetry, based on near-infrared spectroscopy (NIRS). It determines regional hemoglobin oxygen saturation (rSO 2 ) in the frontal lobes. Two probes are applied over the forehead. These probes contain diodes (light-emitting diode) or laser light sources which emit photons in the NIR spectrum. This light is partly reflected, partly redirected, scattered, and absorbed. Contact with hemoglobin molecules results in a change of light spectrum depending on the oxygenation status of hemoglobin. A fraction of this resultant light returns toward the surface and is captured by detectors. Monitor differentiates two forms of oxygenated and deoxygenated hemoglobin and determines the rSO 2 in the frontal lobes. A value of 60-80% is considered normal. [4] A decrease in baseline cerebral oximetry value is reported to cause the neurological deficit. [5] With cardiac and vascular surgery the unexpected fall in regional brain oxygen level may be the consequences of hemodynamic instability and anemia. The mechanical causes include malpositioned heart, obstruction in perfusion cannula, vascular clamp, or cardiac vent. [6],[7] The volatile halogenated anesthetic agents, barbiturate, and propofol have profound cortical suppressant activity. A sudden decrease in cerebral rSO 2 may signify anesthetic effects.

During anesthesia, an absolute rSO 2 value <50% or a >20% drop from individual baseline rSO 2 is commonly considered as intervention trigger. Anesthesiologist using NIRS monitoring can intervene at the earliest. The proposed algorithm to treat low-rSO 2 events includes head and vascular cannula repositioning and an increase in the fraction of inspired oxygen. In addition, optimization of pump flow, mean arterial pressure, hemoglobin concentration, arterial oxygen, and carbon dioxide content are warranted. Furthermore, reduction in intracranial pressure, cerebral metabolism, and cerebral oxygen demand would help in improvement of cerebral oxygen saturation. [8]

NIRS-based cerebral oximetry permits early detection of cerebral hypoxia, and it would enable us to bring early interventions to avert a likely catastrophe. Monitoring of cerebral oxygenation and intervening to restore parameters during cardiac surgery is associated with a decrease in the incidence of neurological damage. [9] It improves clinician outcome, shortens Intensive Care Unit, and hospital stay. [10],[11] It helps us to decrease total financial expenses. Considering these factors, use of this technique seems to be cost effective.

 
   References Top

1.
Cetin M, Birbicer H, Hallioglu O, Orekeci G. Comparative study between the effects of dexmedetomidine and propofol on cerebral oxygenation during sedation at pediatric cardiac catheterization. Ann Card Anaesth 2016;19:20-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Vretzakis G, Georgopoulou S, Stamoulis K, Stamatiou G, Tsakiridis K, Zarogoulidis P, et al. Cerebral oximetry in cardiac anesthesia. J Thorac Dis 2014;6 Suppl 1:S60-9.  Back to cited text no. 2
    
3.
Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001;72:S1838-44.  Back to cited text no. 3
    
4.
Colak Z, Borojevic M, Ivancan V, Gabelica R, Biocina B, Majeric-Kogler V. The relationship between prolonged cerebral oxygen desaturation and postoperative outcome in patients undergoing coronary artery bypass grafting. Coll Antropol 2012;36:381-8.  Back to cited text no. 4
    
5.
Moritz S, Kasprzak P, Arlt M, Taeger K, Metz C. Accuracy of cerebral monitoring in detecting cerebral ischemia during carotid endarterectomy: A comparison of transcranial Doppler sonography, near-infrared spectroscopy, stump pressure, and somatosensory evoked potentials. Anesthesiology 2007;107:563-9.  Back to cited text no. 5
    
6.
Gottlieb EA, Fraser CD Jr., Andropoulos DB, Diaz LK. Bilateral monitoring of cerebral oxygen saturation results in recognition of aortic cannula malposition during pediatric congenital heart surgery. Paediatr Anaesth 2006;16:787-9.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Semin Cardiothorac Vasc Anesth 2007;11:274-81.  Back to cited text no. 8
    
9.
Murkin JM, Adams SJ, Novick RJ, Quantz M, Bainbridge D, Iglesias I, et al. Monitoring brain oxygen saturation during coronary bypass surgery: A randomized, prospective study. Anesth Analg 2007;104:51-8.  Back to cited text no. 9
    
10.
Fischer GW, Silvay G. Cerebral oximetry in cardiac and major vascular surgery. HSR Proc Intensive Care Cardiovasc Anesth 2010;2:249-56.  Back to cited text no. 10
    
11.
Aktuerk D, Mishra PK, Luckraz H, Garnham A, Khazi FM. Cerebral oxygenation monitoring in patients with bilateral carotid stenosis undergoing urgent cardiac surgery: Observational case series. Annals of Cardiac Anaesthesia 2016;19:59-62.  Back to cited text no. 11
    

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Correspondence Address:
Rajinder Singh Rawat
Department of Cardiac Anaesthesiology, Salalah Heart Center, Post Box 98, Postal Code 211, Salalah
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.185516

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