Monitoring Cardiac Surgical Patients with the INVOS™ Cerebral Oximetry System

Intraoperative cerebral oxygen desaturation in cardiac surgical patients is surprisingly common and associated with worsened postoperative outcome.^2,3  Multiple controlled trials have demonstrated that INVOS™ cerebral oximetry-guided care can reverse cerebral desaturation and improve postoperative outcome.^1,2

The burden of cerebral desaturation in cardiac surgical patients

 The incidence of cerebral desaturation ranges from 69.9-76% in high-risk cardiac surgery patients.³ The implication of these desaturation events is significant, as multiple clinical trials have demonstrated the adverse influence of these events on postoperative patient outcome. 

• de Tournay-Jetté et al.  determined that CABG patients who suffered cerebral desaturation is associated with early and late post-operative cognitive dysfunction⁴
• Murkin et al. found that among CABG patients suffering postoperative major organ morbidity and mortality had lower cerebral oximetry values.²
• Schoen et al. found that elective cardiac surgery patients with intraoperative cerebral desaturation were at greater risk for worsened early postoperative cognitive function scores⁵
• Slater et al. determined that CABG patients with prolonged desaturation are more than 2.5 times more likely to stay in the hospital > 6 days⁶

Reversing cerebral desaturation

In 2007, Denault and Murkin et al. published an interventional algorithm to assist clinicians in reversing cerebral desaturation events.^2,7 The interventions in the algorithm target factors that regularly influence cerebral oxygen supply and demand such as perfusion pressure, cardiac output, arterial oxygen content, partial pressure of carbon dioxide (PaCO2), and cerebral metabolic rate.  Studies have demonstrated that an interventional algorithm coupled with cerebral oximetry monitoring can reverse 88% of all desaturation events, resulting in a 78% reduction in burden of intraoperative cerebral desaturation.³

Improving outcome with INVOS™ cerebral oximetry guided care

In controlled trials, interventions delivered based on cerebral oximetry resulted in improved outcome in cardiac surgical patients.

• Colak et al. randomized 200 CABG surgical patients to receive either cerebral oximetry monitoring coupled with an interventional algorithm or standard practice.¹  The cerebral oximetry group demonstrated a 56% decrease reduction in the incidence of postoperative cognitive decline.¹ Learn more about controlled trials evaluating cerebral oximetry in CABG and valve patients
• Vretzakis et al. randomized 150 cardiac surgery patients receive transfusions either based on cerebral oximetry or hemoglobin measurements.  Forty-seven percent fewer patients in the cerebral oximetry group required transfusions.  Of the patients who received transfusions, cerebral oximetry group patients received 37% fewer RBC unit on average.⁸ Learn more about cerebral oximetry guided management of transfusions in cardiac surgery
• Anastasiadia et al randomized 120 cardiac surgery patients to receive either a “physiological approach” (a goal-directed strategy using cardiac index, SvO2, DO2i, DO2i/VCO2i, and cerebral oximetry with minimally invasive extracorporeal circulation) or standard anesthetic regimen.  Patients who received the “physiology approach” experience few strokes, less acute kidney injury and required intraoperative blood transfusions.⁹ Learn more about utilizing cerebral oximetry to improve patient outcome in adult cardiac surgery patients

References:
1. Colak Z, Borojevic M, Bogovic A, Ivancan V, Biocina B, Majeric-Kogler V. 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):447-454.
2. Murkin JM, Adams SJ, Novick RJ, et al. Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg. 2007;104(1):51-58.
3. 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.
4. de Tournay-Jette E, Dupuis G, Bherer L, Deschamps A, Cartier R, Denault A. The relationship between cerebral oxygen saturation changes and postoperative cognitive dysfunction in elderly patients after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2011;25(1):95-104.
5. Schoen J, Husemann L, Tiemeyer C, et al. Cognitive function after sevoflurane- vs propofol-based anaesthesia for on-pump cardiac surgery: a randomized controlled trial. Br J Anaesth. 2011;106(6):840-850.
6. Slater JP, Guarino T, Stack J, et al. Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery. Ann Thorac Surg. 2009;87(1):36-44; discussion 44-35.
7. Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Semin Cardiothorac Vasc Anesth. 2007;11(4):274-281.
8. 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.
9. Anastasiadis K, Antonitsis P, Deliopoulos A, Argiriadou H. A multidisciplinary perioperative strategy for attaining "more physiologic" cardiac surgery. Perfusion. 2017;32(6):446-453.

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TOPIC: INVOS™ Cerebral/Somatic Oximetry, Operating Room