Cerebral and Systemic Stress Parameters in Correlation with Jugulo-Arterial CO2 Gap as a Marker of Cerebral Perfusion during Carotid Endarterectomy.

Zoltán Kovács-Ábrahám,Lajos Nagy,Tihamér Molnár,Péter Szabó,Bálint Nagy,Timea Aczél,Ildikó Tóth,Zoltán Horváth-Szalai,Gábor Jancsó

doi:10.3390/jcm10235479

Zoltán Kovács-Ábrahám, Lajos Nagy + Show 7 more

Open Access

https://doi.org/10.3390/jcm10235479

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Abstract

Intraoperative stress is common to patients undergoing carotid endarterectomy (CEA); thus, impaired oxygen and metabolic balance may appear. In this study, we aimed to identify new markers of intraoperative cerebral ischemia, with predictive value on postoperative complications during CEA, performed in regional anesthesia. A total of 54 patients with significant carotid stenosis were recruited and submitted to CEA. Jugular and arterial blood samples were taken four times during operation, to measure the jugulo-arterial carbon dioxide partial pressure difference (P(j-a)CO2), and cortisol, S100B, L-arginine, and lactate levels. A positive correlation was found between preoperative cortisol levels and all S100B concentrations. In addition, they are positively correlated with P(j-a)CO2 values. Conversely, postoperative cortisol inversely correlates with P(j-a)CO2 and postoperative S100B values. A negative correlation was observed between maximum systolic and pulse pressures and P(j-a)CO2 after carotid clamp and before the release of clamp. Our data suggest that preoperative cortisol, S100B, L-arginine reflect patients’ frailty, while these parameters postoperatively are influenced by intraoperative stress and injury. As a novelty, P(j-a)CO2 might be an emerging indicator of cerebral blood flow during CEA.

Highlights

Carotid endarterectomy (CEA) is a widely accepted method for the treatment of severe carotid stenosis and stroke prevention
CEA is often associated with increased intraoperative stress [2,3]
To adequately monitor cerebral function, CEA is often performed in regional anesthesia, most frequently by cervical plexus block [10]

Summary

Introduction

Carotid endarterectomy (CEA) is a widely accepted method for the treatment of severe carotid stenosis and stroke prevention. During CEA, carotid cross-clamping is performed [1]. CEA is often associated with increased intraoperative stress [2,3]. Patients with vascular disease are especially sensitive to distress. During cross-clamping, the risk of cerebral hypoperfusion is present [5]. Symptomatic ischemia is most certainly detected on vigilant patients by evaluating the verbal and contralateral motor functions [6,7,8]. To adequately monitor cerebral function, CEA is often performed in regional anesthesia, most frequently by cervical plexus block [10]. Besides the general advantages [11], operating on awake patients offers hemodynamic benefits, e.g., fewer hypotensive episodes, and less vasopressor usage, and better cerebral perfusion [12,13,14,15]

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