Monitoring Regional Oxygen Saturation

Assessing the Value of NIRS in Clinical Practice

Outline

1 Intervening to reverse desaturation and improved outcomes

2 NIRS monitoring outside of the CVOR

 Why Measure Regional Oximetry?

ADEQUATE SYSTEMIC SAT DOES NOT MEAN REGIONAL SAT DEPENDS ON SUPPLY,
ADEQUATE REGIONAL SAT (rSO2) DEMAND, AND CONTENT

• SaO2 – systemic arterial oxygen availability • NIRS rSO2 – measures post-extraction oxygen
saturation (ie, what’s left over when the tissue
• SpO2 – used to determine adequate has extracted what it needs)
content, but does not indicate adequate
delivery to tissues • Low/decreasing rSO2 can indicate a low
oxygen content, inadequate flow to the tissue,
• Invasive SvO2 – global picture of oxygen or high demand (ie, the brain is too active)
usage, but does indicate adequate delivery
to tissues

.
Cerebral rSO2 Distribution in Healthy Subjects
Percent

Wide Static Normative Cerebral rSO2 Range

Wide Static Normative Distribution of SjvO2

Years
Data on file at Medtronic, Boulder, CO
LINK BETWEEN INTERVENING ON
INTRAOPERATIVE DESATURATION AND
IMPROVED OUTCOMES
 Cerebral Desaturation

Bilateral reduction One-sided

of 20%
Verify head position reduction of 20%
1
Inspection of central, aortic and
superior vena catheters
2
Reposition or removal
Treat and find etiology If hypotension Mean arterial pressure? No Yes
catheter or cannula
If MAP
No
normal
3
Treat and find etiology If SaO2 abnormal Systemic saturation?
If SaO2
4 normal 7 8
Correct hyperventilation < 35 mmHg PaCO2? Hypothermia/
Reduce ICHT
anti-epileptic medication
If PaCO2
normal
5 Cerebral
Consider blood cell Yes
edema
< 7 - 8 gm Hemoglobin?
transfusion
If Hb normal Convulsions Cerebral imaging
or > 10gm Hyperthermia (CT Scan/MRI)
6
Hemodynamic and Cardiac function and
If SvO2 <60%
echocardiography evaluation venous O2 Saturation(SvO2)?
Normal Increased Increased
SvO2 (>65%)
Optimize cardiac function or
venous return. Cerebral O2 consumption? Normal Intracranial pressure

Deschamps A, Lambert J, Couture P, et al. Reversal of decreases in cerebral saturation in high-risk cardiac surgery. J Cardiothorac Vasc Anesth. 2013;27(6):1260-1266
 Interventions are Effective at Reversing Intraoperative
Desaturation
• Multicenter (US)
EFFICACY OF INTERVENTIONS TO CORRECT DESATURATIONS • Prospective pilot
FOR 340 CLINICIAN-IDENTIFIED EVENTS
• CABG +/- valve
% Efficacy • N=235
Intervention- (vs all events that
corrected responded to any
Intervention desaturations intervention) In 8% of patients,
Treat hypotension 67 29.8 desaturations
Increase FiO2 35 15.6
recognized by the
Normalize CPB flow 32 14.2
RBC transfusion 31 13.8
clinician and
Decrease CPB sweep speed 25 11.1 intervened upon could
Deepen anesthesia 24 10.7 not be reversed
Adjusted CPB cannula 18 8
Reposition head to midline 6 2.7

Subramanian B, Nyman C, Fritock M, et al. A multicenter pilot study assessing regional cerebral oxygen desaturation frequency during cardiopulmonary bypass and responsiveness to an intervention algorithm. Anesth Analg. 2016;122(6):1786-1793.
 Monitoring and Intervening Reduces the Burden of Hypoxia

When cardiac surgery patients were monitored and

intervened upon during desaturation, compared to
the control group:

Fewer patients
Total AUC was
experienced
lower
prolonged
(154.3%mins vs
desaturation
729.7%mins)2
(0% vs 6%)1

1 Murkin JM, Adams S, Novick R, et al. Monitoring Brain Oxygen Saturation During Coronary Bypass Surgery: A Randomized, Prospective Study. International Anesth Analg. 2007;104(1):51-58.
2 Deschamps A, Lambert J, Couture P, et al. Reversal of decreases in cerebral saturation in high-risk cardiac surgery. J Cardiothorac Vasc Anesth. 2013;27(6):1260-1266
 Interventions Reduce the Incidence of Morbidity and
Mortality
• Single Center (Canada)
MAJOR ORGAN MORBIDITY AND MORTALITY • RCT
16
• CABG
STS reported rate
14 Control
• N=200
12 INVOS
13.4
* p < 0.048
10
11
Compared to the
8 control group, the
%

6
intervention group
spent ½ day less in the
4
ICU (1.25 vs 1.87 days,
2 3 p=0.029)
0
MOMM

Murkin JM, Adams S, Novick R, et al. Monitoring Brain Oxygen Saturation During Coronary Bypass Surgery: A Randomized, Prospective Study. International Anesth Analg. 2007;104(1):51-58.
 Interventions Reduce the Incidence of Neurocognitive
Decline
• Single Center (Croatia)
NEUROCOGNITIVE DECLINE • Prospective
60
Control • CABG
INVOS
50 • N=200
52
40 * p < 0.002
Compared
Monitoringtoandthe
30 control group,was
intervention the
%

intervention group
associated with a 46%
28
20 spend
reduced½ day
risk less
of in the
ICU (1.25 vs 1.87 days,
postop
10
p=0.029)
neurocognitive
0 decline
POCD

Colak Z, Borojevic M, Bogovic A, et al. Influence of intraoperative cerebral oximetry monitoring on neurocognitive function after coronary artery bypass surgery: a randomized, prospective study. Eur J Cardiothorac Surg. 2015;47(3):447-554.
 Combined rSO2 and Hct Thresholds in a Transfusion Protocol
Can Reduce Blood Use
• Single Center (Greece)
PATIENTS TRANSFUSED • RCT
100
Hct only • Cardiac
90 Hct and rSO2
• N=150
80
82.1 p < 0.029
70

60 Fewer RBC units per

65.7
50 patient were
%

40 transfused in the OR
p < 0.048
30 (1.27 vs 1.75 units;
20 29.8 p=0.021) and overall
10 (1.32 vs 1.82 units;
15.7
0 p=0.024)
OR Hospital Stay

Vretzakis G, Georgopoulou S, Stamoulis K, et al. Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial. J Cardiothorac Surg. 2013; 8:145.
Guidelines and Recommendations

INTERNATIONAL GUIDELINES REGARDING USE OF CEREBRAL OXIMETRY

SOCIETY/GUIDELINE STATEMENT
2013 AmSECT: Standards and Guidelines for “Cerebral oximetry should be used during cardiopulmonary bypass”
Perfusion Practice
2011 ACCF/AHA: Clinical Practice Guideline: “The effectiveness of routine use of intraoperative or early postoperative monitoring of
CABG Surgery CNS Monitoring cerebral oxygen saturation via near-infrared spectroscopy to detect cerebral
hypoperfusion in patients undergoing CABG is uncertain.”
2012 STS: Clinical Practice Guideline: “The data concerning NIRS and neurodevelopmental outcomes are limited in quality.
Protecting the Infant Brain During Cardiac There is no consistent evidence that the use of NIRS is associated with improved
Surgery neurodevelopmental outcomes. NIRS may be considered as a monitoring methodology.”
2015 ANZCA: Guidelines on Monitoring “When clinically indicated, equipment to monitor other physiological variables (…cerebral
During Anaesthesia oximetry…) should be available.”
2015 ASA: Practice Guidelines for “Additional monitoring may include…cerebral monitoring (i.e., cerebral oximetry and
Perioperative Blood Management near infrared spectroscopy [NIRS])”
ADDITIONAL USES
Other Applications of Cerebral Oximetry in the OR

• Carotid endarterectomy – shunt selection

• Shoulder – blood pressure management during beach chair position

• Spinal – cerebral desaturation in the prone position

• Thoracoabdominal aortic aneurysm – monitoring spinal collateral network

• Minimally invasive cardiac surgery– cerebral desaturation during rapid

pacing, somatic monitoring for limb ischemia from cannulation
RECENT META-ANALYSES
2018 YU COCHRANE REVIEW1 2018 ZORRILLA-VACA2
Population 15 RCTs 15 RCTs
1,822 patients 2,057 patients
Any surgery, adult and pediatric Any adult surgery
Intervention NIRS monitoring plus intervention

Comparison Blinded/no NIRS monitoring

Primary Outcomes Stroke POCD

Delirium
Postoperative cognitive dysfunction (POCD)
Mortality (intraop or postop)
Results POCD (46% - 82% risk reduction) POCD (40% risk reduction)
ICU length of stay (- 0.29 days) Delirium (12% risk reduction)
MOMM (73% risk reduction) ICU length of stay (-0.21 days)
“Complications” (24% risk reduction)
OR desaturation (19% risk reduction)
Conclusions “The effects of perioperative active cerebral NIRS monitoring of brain “…intraoperative cerebral oximetry-guided
oxygenation in adults for reducing the occurrence of short-term, mild management is associated with significant reduction in the incidence
POCD are uncertain due to the low quality of the evidence.” of POCD…our findings suggest that simple intraoperative maneuvers
based upon cerebral oximetry may provide clear benefit.”

1 Yu Y, Zhang K, Zhang L, Zong H, Meng L, Han R. Cerebral near-infrared spectroscopy (NIRS) for perioperative monitoring of brain oxygenation in children and adults. Cochrane Database Syst Rev. 2018, 17;1:CD010947.
2 Zorrilla-Vaca A, Healy R, Grant MC, Joshi B, Rivera-Lara L, Brown C, Mirski MA. Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: a meta-analysis of randomized controlled trials. Can J Anaesth. 2018 [epub ahead of print].
THANK YOU!