Abstract
The article by Phelps and colleagues [1Phelps H.M. Mahle W.T. Kim D. et al.Postoperative cerebral oxygenation in hypoplastic left heart syndrome after the Norwood procedure.Ann Thorac Surg. 2009; 87: 1490-1494Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar] adds to a growing body of literature regarding the clinical application of cerebral oximetric monitoring to the perioperative care of both pediatric and adult cardiac surgical patients. For a monitoring technology to be useful, it must be accurate and reproducible, and it should prompt correlated interventions that impact clinical outcome. Debate continues over whether current cerebral oximetry technology satisfies these requirements. Experience with devices that render absolute values for cerebral oxygen content is limited, and relative values can be affected by various factors, such as cerebral blood volume, hematocrit, acid-base status, and cranial anatomy. Areas of the brain remote from the monitored frontal cortex are at risk of undetected injury, potentially limiting the usefulness of the technology in avoiding significant central nervous system insult. There is significant inter-patient variability of rSO2 values, and a lack of a well-defined normative range. This is particularly true among children with congenital heart disease in which arterial desaturation and parallel circulatory arrangements further complicate our understanding of monitored values.These limitations notwithstanding, the association between lower mean rSO2 values and adverse events after Norwood palliation described by the authors are consistent with a large number of prior reports that impute clinical utility to continuous cerebral oximetry monitoring. In light of our increasing awareness of perioperative cerebral injury and its subsequent neuro-developmental impact, mechanisms to accurately surveil the cerebral environment are needed. Systemic measures of oxygen delivery such as SvO2 or lactate are poor predictors of cerebral insult. The clinical benefit of cerebral oximetric monitoring is intuitive, and the supporting evidence is compelling. Although weaknesses of the present design and understanding of the technology require the clinician to place rSO2 values in proper context, further design improvements and clinical understanding of its role represent a significant opportunity to improve care and outcomes. The article by Phelps and colleagues [1Phelps H.M. Mahle W.T. Kim D. et al.Postoperative cerebral oxygenation in hypoplastic left heart syndrome after the Norwood procedure.Ann Thorac Surg. 2009; 87: 1490-1494Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar] adds to a growing body of literature regarding the clinical application of cerebral oximetric monitoring to the perioperative care of both pediatric and adult cardiac surgical patients. For a monitoring technology to be useful, it must be accurate and reproducible, and it should prompt correlated interventions that impact clinical outcome. Debate continues over whether current cerebral oximetry technology satisfies these requirements. Experience with devices that render absolute values for cerebral oxygen content is limited, and relative values can be affected by various factors, such as cerebral blood volume, hematocrit, acid-base status, and cranial anatomy. Areas of the brain remote from the monitored frontal cortex are at risk of undetected injury, potentially limiting the usefulness of the technology in avoiding significant central nervous system insult. There is significant inter-patient variability of rSO2 values, and a lack of a well-defined normative range. This is particularly true among children with congenital heart disease in which arterial desaturation and parallel circulatory arrangements further complicate our understanding of monitored values. These limitations notwithstanding, the association between lower mean rSO2 values and adverse events after Norwood palliation described by the authors are consistent with a large number of prior reports that impute clinical utility to continuous cerebral oximetry monitoring. In light of our increasing awareness of perioperative cerebral injury and its subsequent neuro-developmental impact, mechanisms to accurately surveil the cerebral environment are needed. Systemic measures of oxygen delivery such as SvO2 or lactate are poor predictors of cerebral insult. The clinical benefit of cerebral oximetric monitoring is intuitive, and the supporting evidence is compelling. Although weaknesses of the present design and understanding of the technology require the clinician to place rSO2 values in proper context, further design improvements and clinical understanding of its role represent a significant opportunity to improve care and outcomes. Postoperative Cerebral Oxygenation in Hypoplastic Left Heart Syndrome After the Norwood ProcedureThe Annals of Thoracic SurgeryVol. 87Issue 5PreviewCerebral near-infrared spectroscopy (NIRS) is being used with increasing frequency in the care of pediatric patients after surgery for congenital heart disease. Near-infrared spectroscopy provides a means of evaluating regional cerebral oxygen saturation (cSaO2) noninvasively, with correlations to cardiac output and central venous saturation. Prior studies have demonstrated that systemic venous saturation can predict outcome after the Norwood procedure. With this in mind, we sought to determine whether regional cSaO2 by NIRS technology could predict risk of adverse outcome after the Norwood procedure. Full-Text PDF
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