Cerebral Monitoring Research Articles

The Use of Cerebral Oximetry in Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The evidence on the use of cerebral oximetry during surgery to minimize postoperative neurologic complications remains uncertain in the literature. The present authors aimed to assess the value of cerebral oximetry in the prevention of postoperative cognitive dysfunction, postoperative delirium, and postoperative stroke in adults undergoing surgery. A systematic review and meta-analysis. The surgery room. Adult patients (ages ≥18 years) undergoing surgery. Cerebral oximetry monitoring. Databases of Ovid MEDLINE, Ovid EMBASE, and CENTRAL were systematically searched from their inception until December 2020 for randomized controlled trials comparing cerebral oximetry monitoring with either blinded or no cerebral oximetry monitoring in adults undergoing surgery. Observational studies, case reports, and case series were excluded. Seventeen studies (n=2,120 patients) were included for quantitative meta-analysis. Patients who were randomized to cerebral oximetry monitoring had a lower incidence of postoperative cognitive dysfunction (studies=seven, n=969, odds ratio [OR] 0.23, 95% confidence interval [CI] 0.11-0.48, p=0.0001; evidence=very low). However, no significant differences were observed in the incidence of postoperative delirium (studies=five, n=716, OR 0.81, 95% CI 0.53-1.25, p=0.35; evidence=high), and postoperative stroke (studies=seven, n=1,087, OR 0.72, 95% CI 0.30-1.69, p=0.45; evidence=moderate). Adult patients with cerebral oximetry monitoring were associated with a significant reduction of postoperative cognitive dysfunction. However, given the low certainty of evidence and substantial heterogeneity, more randomized controlled trials using standardized assessment tools for postoperative cognitive dysfunction and interventions of correcting cerebral desaturation are warranted to improve the certainty of evidence and homogeneity.

Thoracoscopic Repair of Esophageal Atresia.

Background: Esophageal atresia (EA) is a rare congenital malformation of the esophagus. Surgical treatment is required to restore the continuity of the esophagus. This can be performed through thoracotomy. However, an increasing number of hospitals is performing minimal invasive surgery (MIS). In this article, we describe the technique of thoracoscopic repair of EA in neonates in more detail and show the outcome of a patient cohort operated by young pediatric surgeons in training. Methods: Between 2014 and 2019 correction was performed in 64 EA type C patients at the UMC Utrecht, Wilhelmina Children's Hospital, mainly by young pediatric surgeons in training. Results: All patients were corrected through MIS, 3 days after birth. The median operation duration was 181 (127-334) minutes. Nasogastric tube feeding was started on the first postoperative day, and oral feeding 6 days postop. Postoperative complications included leakage (14.1%), stenosis (51.1%), and recurrent tracheoesophageal fistula (7.8%). Conclusion: Thoracoscopic repair of EA can be performed safely, with good outcome and all the benefits of MIS. However, it remains a challenging procedure and should be performed only in pediatric centers with a vast experience in MIS, especially when training young pediatric surgeons. These centers must have access to a multidisciplinary team of neonatologists, pediatric anesthesiologists, surgeons, and ENT specialists to ensure the best possible care in hemodynamic, respiratory, and cerebral monitoring and gastrointestinal and developmental outcome.

THE ANESTHETIC MANAGEMENT OF EXTENSIVE AORTIC THORACIC ANEURYSM REPAIR WITH CLAMSHELL INCISION

Introduction Surgical repair of extensive thoracic aorta disease represents an interesting challenge, both surgical and anesthetic. We describe the surgical repair of an acute aortic dissection beginning in the aortic arch in relation with aortic coartation and a post coartation aneurism, and the aspects related to planning, management and perioperative care. The clamshell incision is associated with respiratory complications, bleeding and post-operative severe pain. Interruption of spinal cord blood supply is one of the causes of spinal cord injury after thoracic aortic aneurism repair. Aortic arch surgery requiring circulatory arrest bears significant risk of brain injury. Methods Descending aorta cannulation and perfusion, preservation of its posterior wall, lumbar paravertebral NIRS and femoral arterial invasive pressure monitoring were used as spinal cord protective strategies. Cerebral antegrade perfusion, initially unilateral and then bilateral, with BIS and cerebral NIRS monitoring were the key components of the cerebral protection strategy. A bilateral erector spinae plane block (BESPB) was performed to allow good pain control in the postoperative period, early extubation and rehabilitation. Intravenous antifibrinolytic, goal directed transfusion therapy and maintaining a coagulation friendly environment were the mainstays of the non-surgical hemostasis strategy. Results The patient was successfully extubated in the operating room presenting no neurological deficits. The surgical drains were removed on the fifth day; on the following day it was necessary to surgically remove part of the left thoracic drain, under combined anesthesia with the ipsilateral ESPB catheter. The remaining postoperative period was uneventful and the patient was discharged home in the 10th postoperative day. Discussion No subarachnoid catheter was placed (to drain cerebrospinal fluid to protect the spinal cord from ischemia), after discussing it in advance with the surgical team, given the risks associated with it and the protective strategy to be adopted: direct perfusion of the descending aorta, preservation of its posterior wall, lumbar paravertebral NIRS ant femoral arterial invasive pressure monitoring., in the intraoperative period, on table extubation and direct neurological monitoring, together with adequate systemic arterial pressures, in the immediate postoperative period. Good pain control with BESPB and on table extubation allowed for early rehabilitation

Interventions Triggered During Routine Use of NIRS Cerebral Oxygenation Monitoring in Cardiac Surgical Patients

The purpose of this study was to determine the incidence and types of interventions triggered during a drop of baseline near-infraredspectroscopy (NIRS) values in consecutive cardiac surgical patients. A single-center, retrospective observational study. A university-affiliated tertiary care center. Three thousand three hundred two consecutive cardiac surgical patients from October 2016 to August 2017 Interventions: None. Of the 1,972 patients who met the inclusion criteria, 576 (29.2%) patients showed NIRS deviation of -20% from baseline. Interventions performed during the drop of baseline NIRS values were documented in 285 (14.4%) patients, with a total of 391 interventions. Three hundred fifteen (80%) interventions were triggered by a deviation in NIRS and concomitant changes in standard monitoring parameters. Seventy-six (20%) interventions were triggered by NIRS deviation alone, with no concomitant pathologic deviation in standard monitoring. A total of 279 (71%) interventions were performed on patients who had no recommendation for NIRS monitoring by current national guidelines. Out of these, 30 (7.7%) interventions (1.3% of all patients) were performed based on NIRS monitoring alone. The higher risk deviation group had longer intensive care unit and hospital lengths of stays (one and 15 days) and postoperative delirium when compared with the no-deviation group (zero and 13 days) Conclusions: The authors' data suggested that most interventions triggered during the drop of baseline values during routine use of NIRS would have also been triggered by the concomitant changes in standard monitoring parameters. Routine use of NIRS for all cardiac surgical patients still is debatable and needs to be evaluated in a large prospective trial.

Entropy Detects Cerebral Hypoperfusion During Off-Pump Coronary Artery Bypass Graft Surgery

Background: Hypotension during off pump coronary artery bypass graft (CABG) surgery is commonly due to positioning of the heart or due to intraoperative ischemia, but sometimes, it is deliberate and controlled during aortic clamping. Due to hypotension, the risk of cerebral hypoperfusion or stroke is high during CABG surgery in patients with bilateral carotid artery stenosis. Methods: Various cerebral monitoring techniques are recommended to detect cerebral hypoperfusion during CABG. Results: Entropy is used for the assessment of depth of anesthesia. In our patient for CABG with associated bilateral carotid artery disease, entropy helped in timely detection of cerebral hypoperfusion. Conclusion: The best management approach of carotid artery disease associated with coronary artery disease still remains debatable.

Systemic inflammation alters the neuroinflammatory response: a prospective clinical trial in traumatic brain injury

BackgroundNeuroinflammation following traumatic brain injury (TBI) has been shown to be associated with secondary injury development; however, how systemic inflammatory mediators affect this is not fully understood. The aim of this study was to see how systemic inflammation affects markers of neuroinflammation, if this inflammatory response had a temporal correlation between compartments and how different compartments differ in cytokine composition.MethodsTBI patients recruited to a previous randomised controlled trial studying the effects of the drug anakinra (Kineret®), a human recombinant interleukin-1 receptor antagonist (rhIL1ra), were used (n = 10 treatment arm, n = 10 control arm). Cytokine concentrations were measured in arterial and jugular venous samples twice a day, as well as in microdialysis-extracted brain extracellular fluid (ECF) following pooling every 6 h. C-reactive protein level (CRP), white blood cell count (WBC), temperature and confirmed systemic clinical infection were used as systemic markers of inflammation. Principal component analyses, linear mixed-effect models, cross-correlations and multiple factor analyses were used.ResultsJugular and arterial blood held similar cytokine information content, but brain-ECF was markedly different. No clear arterial to jugular gradient could be seen. No substantial delayed temporal associations between blood and brain compartments were detected. The development of a systemic clinical infection resulted in a significant decrease of IL1-ra, G-CSF, PDGF-ABBB, MIP-1b and RANTES (p < 0.05, respectively) in brain-ECF, even if adjusting for injury severity and demographic factors, while an increase in several cytokines could be seen in arterial blood.ConclusionsSystemic inflammation, and infection in particular, alters cytokine levels with different patterns seen in brain and in blood. Cerebral inflammatory monitoring provides independent information from arterial and jugular samples, which both demonstrate similar information content. These findings could present potential new treatment options in severe TBI patients, but novel prospective trials are warranted to confirm these associations.Graphical abstract

Intracranial Pressure and Cerebral Hemodynamic Monitoring After Cardiac Arrest in Pediatric Pigs Using Contrast Ultrasound-Derived Parameters.

We explore the correlation of contrast-enhanced ultrasound (CEUS) parameters to intracranial pressure (ICP) in a porcine experimental model of pediatric cardiac arrest. Eleven pediatric pigs underwent electrically induced cardiac arrest followed by cardiopulmonary resuscitation. ICP was measured using intracranial bolt monitor and CEUS was monitored through a cranial window. Various CEUS parameters were monitored at baseline, immediately post return of spontaneous circulation (ROSC), 1 hour-post ROSC, and 3 hours post-ROSC. There was significant ICP correlation with wash-out slope assessed by CEUS time intensity curve analysis at immediate post-ROSC. At 3 hours post-ROSC there was also significant negative correlation between ICP and peak enhancement which may be due to the evolution of anoxic injury. The use of CEUS in assessing disruption of cerebral hemodynamics and ICP post cardiac arrest will need future validation and comparison to other imaging modalities. The correlation between CEUS parameters and ICP may be due to the alterations in cerebral autoregulation that result from anoxic brain injury.

Cerebral monitoring in surgical ICU patients

To give an overview of cerebral monitoring techniques for surgical ICU patients. As the burden of postsurgical neurological and neurocognitive complications becomes increasingly recognized, cerebral monitoring in the surgical ICU might gain a relevant role in detecting and possibly preventing adverse outcomes. However, identifying neurological alterations in surgical ICU patients, who are often sedated and mechanically ventilated, can be challenging. Various noninvasive and invasive techniques are available for cerebral monitoring, providing an assessment of cortical electrical activity, cerebral oxygenation, blood flow autoregulation, intracranial pressure, and cerebral metabolism. These techniques can be used for the diagnosis of subclinical seizures, the assessment of sedation depth and delirium, the detection of an impaired cerebral blood flow, and the diagnosis of neurosurgical complications. Cerebral monitoring can be a valuable tool in the early detection of adverse outcomes in surgical ICU patients, but the evidence is limited, and clear clinical indications are still lacking.

Improving Compliance and Quality of Documentation of Cerebral Function Monitoring in a Neonatal Neurocritical Care Unit.

Neonates admitted to neurocritical care units frequently undergo continuous bedside cerebral function monitoring (CFM). Documentation of CFM findings that are complete and accurate can augment the quality of care through improved communication. We aimed to increase the compliance with and quality of CFM documentation in the electronic medical records by 50% in our neonatal intensive care unit over 6 months. We used the Plan-Do-Study-Act methodology, process mapping, and fishbone analysis. We implemented interventions, including the development of standardized EMR templates, face-to-face reminders at staff meetings and clinical handover sessions, and teaching on CFM interpretation. We evaluated 50 and 161 charts pre (August-October 2018) and postintervention (December 2018-July 2019), respectively. We improved compliance with documentation from 72% to 89% (P = 0.004); and the quality of documentation from 10% to 61% (P < 0.001). Multimodal reminders to document and educational sessions to increase familiarity with CFM interpretation effectively improved the quality of documentation. We improved the compliance with and the quality of CFM documentation using targeted quality improvement interventions with case-focused educational sessions, reference tools, and standardized templates. Barriers to compliance with documentation were adverse effects on the workflow that changes in the EMR system may address. A significant challenge to sustainability was the high frequency of rotating trainees. We addressed this challenge by developing mandatory electronic teaching modules that include reminders to document and a case-focused teaching curriculum; to increase awareness of the importance of CFM documentation and increase confidence in CFM interpretation.

Noninvasive measurement of cerebral cortex hemoglobin oxygenation with Near-Infrared spectroscopy

Near-Infrared (NIR) is the region of light with wavelength from 650 nm to 1100 nm. In this region light can penetrate into higher depth compared to visible light in biological tissues. In NIR region there is a special optical window from 700 nm to 900 nm in which dominant absorber chromophores inside the brain are oxy-hemoglobin and deoxy-hemoglobin. non-invasive Functional Near-Infrared Spectroscopy (fNIRS) is a portable low-cost efficient method for monitoring hemodynamic change in cerebral cortex. Since fNIRS and Functional Magnetic Resonance Imaging (fMRI) both measure hemoglobin oxygenation, it is acceptable to compare these two methods for cortex related cognitive task studies and drug addiction studies. in cases that other diagnostic techniques like fMRI are not applicable and might be harmful for example in case of a patient with cardiac pacemaker, or when fMRI is not available or for claustrophobic patient an alternative method should be available. in many studies for specific tasks because of subject’s positioning limits inside fMRI, an inexpensive method that allows data acquisition from a sitting or standing subject fNIRS is a reliable alternative. When it’s about cerebral cortex fNIRS can be an alternative for fMRI considering that fNIRS price is much lower and for many cognitive task designs subject’s mobility and position are important factors and with fNIRS we do not have to be that concerned about these issues. In this article Principles and equations for this technology will be described and as an example we designed a cognitive task and used fNIRS device to measure cerebral activity in left prefrontal cortex of healthy male adult to show accuracy and efficiency of this device for cerebral cortex activity monitoring. Also, Value of this method in attention & cognitive disorders specially in children thanks to higher depth of light penetration in their brain compared to adults will briefly be discussed.

Variation in perioperative cerebral and hemodynamic monitoring during carotid endarterectomy

Hemodynamic disturbances cause half of the perioperative strokes following carotid endarterectomy (CEA). Guidelines strongly recommend strict pre- and postoperative blood pressure (BP) monitoring in CEA patients, but do not provide firm practical recommendations. Although in the Netherlands 50 centres perform CEA, no national protocol on perioperative hemodynamic, and cerebral monitoring exists. To assess current monitoring policies of all Dutch CEA-centres, a national survey was conducted. Between May and July 2017 all 50 Dutch CEA-centres were invited to complete a 42-question survey addressing perioperative hemodynamic and cerebral monitoring during CEA. Nonresponders received a reminder after 1 and 2 months. By November 2017 the survey was completed by all centres. Preoperative baseline BP was based on a single bilateral BP-measurement at the outpatient-clinic in the majority of centres (n = 28). In 43 centres (86%) pre-operative monitoring (transcranial Doppler (TCD, n = 6), electroencephalography (EEG, n = 11), or TCD+EEG (n = 26)) was performed as a baseline reference. Intraoperatively, large diversity for type of anaesthesia (general: 45 vs. local [LA]:5) and target systolic BP (>100 mm hg - 160 mm hg [n = 12], based on preoperative outpatient-clinic or admission BP [n = 18], other [n = 20]) was reported. Intraoperative cerebral monitoring included EEG+TCD (n = 28), EEG alone (n = 13), clinical neurological examination with LA (n = 5), near-infrared spectroscopy with stump pressure (n = 1), and none due to standard shunting (n = 3). Postoperatively, significant variation was reported in standard duration of admission at a recovery or high-care unit (range 3-48 hr, mean:12 hr), maximum accepted systolic BP (range >100 mm hg - 180 mm Hg [n = 32]), postoperative cerebral monitoring (standard TCD [n = 16], TCD on indication [n = 5] or none [n = 24]) and in timing of postoperative cerebral monitoring (range directly postoperative - 24 hr postoperative; median 3 hr). In Dutch centres performing CEA the perioperative hemodynamic and cerebral monitoring policies are widely diverse. Diverse policies may theoretically lead to over- or under treatment. The results of this national audit may serve as the baseline dataset for development of a standardized and detailed (inter)national protocol on perioperative hemodynamic and cerebral monitoring during CEA.

A Review of Monitoring Methods for Cerebral Blood Oxygen Saturation.

In recent years, cerebral blood oxygen saturation has become a key indicator during the perioperative period. Cerebral blood oxygen saturation monitoring is conducive to the early diagnosis and treatment of cerebral ischemia and hypoxia. The present study discusses the three most extensively used clinical methods for cerebral blood oxygen saturation monitoring from different aspects: working principles, relevant parameters, current situations of research, commonly used equipment, and relative advantages of different methods. Furthermore, through comprehensive comparisons of the methods, we find that near-infrared spectroscopy (NIRS) technology has significant potentials and broad applications prospects in terms of cerebral oxygen saturation monitoring. Despite the current NIRS technology, the only bedside non-invasive cerebral oxygen saturation monitoring technology, still has many defects, it is more in line with the future development trend in the field of medical and health, and will become the main method gradually.

Optimization of time domain diffuse correlation spectroscopy parameters for measuring brain blood flow.

.Significance: Time domain diffuse correlation spectroscopy (TD-DCS) can offer increased sensitivity to cerebral hemodynamics and reduced contamination from extracerebral layers by differentiating photons based on their travel time in tissue. We have developed rigorous simulation and evaluation procedures to determine the optimal time gate parameters for monitoring cerebral perfusion considering instrumentation characteristics and realistic measurement noise.Aim: We simulate TD-DCS cerebral perfusion monitoring performance for different instrument response functions (IRFs) in the presence of realistic experimental noise and evaluate metrics of sensitivity to brain blood flow, signal-to-noise ratio (SNR), and ability to reject the influence of extracerebral blood flow across a variety of time gates to determine optimal operating parameters.Approach: Light propagation was modeled on an MRI-derived human head geometry using Monte Carlo simulations for 765- and 1064-nm excitation wavelengths. We use a virtual probe with a source–detector separation of 1 cm placed in the pre-frontal region. Performance metrics described above were evaluated to determine optimal time gate(s) for different IRFs. Validation of simulation noise estimates was done with experiments conducted on an intralipid-based liquid phantom.Results: We find that TD-DCS performance strongly depends on the system IRF. Among Gaussian pulse shapes, pulse length appears to offer the best performance, at wide gates (500 ps and larger) with start times 400 and 600 ps after the peak of the TPSF at 765 and 1064 nm, respectively, for a 1-s integration time at photon detection rates seen experimentally (600 kcps at 765 nm and 4 Mcps at 1064 nm).Conclusions: Our work shows that optimal time gates satisfy competing requirements for sufficient sensitivity and sufficient SNR. The achievable performance is further impacted by system IRF with quasi-Gaussian pulse obtained using electro-optic laser shaping providing the best results.

Combined multimodal cerebral monitoring and focused hemodynamic assessment in extremely low birth weight infants – Potential benefits or potential costs?

Combined multimodal cerebral monitoring and focused hemodynamic assessment in extremely low birth weight infants – Potential benefits or potential costs?

Central data monitoring in the multicentre randomised SafeBoosC-III trial \u2013 a pragmatic approach

BackgroundData monitoring of clinical trials is a tool aimed at reducing the risks of random errors (e.g. clerical errors) and systematic errors, which include misinterpretation, misunderstandings, and fabrication. Traditional ‘good clinical practice data monitoring’ with on-site monitors increases trial costs and is time consuming for the local investigators. This paper aims to outline our approach of time-effective central data monitoring for the SafeBoosC-III multicentre randomised clinical trial and present the results from the first three central data monitoring meetings.MethodsThe present approach to central data monitoring was implemented for the SafeBoosC-III trial, a large, pragmatic, multicentre, randomised clinical trial evaluating the benefits and harms of treatment based on cerebral oxygenation monitoring in preterm infants during the first days of life versus monitoring and treatment as usual. We aimed to optimise completeness and quality and to minimise deviations, thereby limiting random and systematic errors. We designed an automated report which was blinded to group allocation, to ease the work of data monitoring. The central data monitoring group first reviewed the data using summary plots only, and thereafter included the results of the multivariate Mahalanobis distance of each centre from the common mean. The decisions of the group were manually added to the reports for dissemination, information, correcting errors, preventing furture errors and documentation.ResultsThe first three central monitoring meetings identified 156 entries of interest, decided upon contacting the local investigators for 146 of these, which resulted in correction of 53 entries. Multiple systematic errors and protocol violations were identified, one of these included 103/818 randomised participants. Accordingly, the electronic participant record form (ePRF) was improved to reduce ambiguity.DiscussionWe present a methodology for central data monitoring to optimise quality control and quality development. The initial results included identification of random errors in data entries leading to correction of the ePRF, systematic protocol violations, and potential protocol adherence issues. Central data monitoring may optimise concurrent data completeness and may help timely detection of data deviations due to misunderstandings or fabricated data.

A One-Day Prospective National Observational Study on Sedation-Analgesia of Patients with Brain Injury in French Intensive Care Units: The SEDA-BIP-ICU (Sedation-Analgesia in Brain Injury Patient in ICU) Study.

Sedation/analgesia is a daily challenge faced by intensivists managing patients with brain injury (BI) in intensive care units (ICUs). The optimization of sedation in patients with BI presents particular challenges. A choice must be made between the potential benefit of a rapid clinical evaluation and the potential exacerbation of intracranial hypertension in patients with impaired cerebral compliance. In the ICU, a pragmatic approach to the use of sedation/analgesia, including the optimal titration, management of multiple drugs, and use of any type of brain monitor, is needed. Our research question was as follows: the aim of the study is to identify what is the current daily practice regarding sedation/analgesia in the management of patients with BI in the ICU in France? This study was composed of two parts. The first part was a descriptive survey of sedation practices and characteristics in 30 French ICUs and 27 academic hospitals specializing in care for patients with BI. This first step validates ICU participation in data collection regarding sedation-analgesia practices. The second part was a 1-day prospective cross-sectional snapshot of all characteristics and prescriptions of patients with BI. On the study day, among the 246 patients with BI, 106 (43%) had a brain monitoring device and 74 patients (30%) were sedated. Thirty-nine of the sedated patients (53%) suffered from intracranial hypertension, 14 patients (19%) suffered from agitation and delirium, and 7 patients (9%) were sedated because of respiratory failure. Fourteen patients (19%) no longer had a formal indication for sedation. In 60% of the sedated patients, the sedatives were titrated by nurses based on sedation scales. The Richmond Agitation Sedation Scale was used in 80% of the patients, and the Behavioral Pain Scale was used in 92%. The common sedatives and opioids used were midazolam (58.1%), propofol (40.5%), and sufentanil (67.5%). The cerebral monitoring devices available in the participating ICUs were transcranial Doppler ultrasound (100%), intracranial and intraventricular pressure monitoring (93.3%), and brain tissue oxygenation (60%). Cerebral monitoring by one or more monitoring devices was performed in 62% of the sedated patients. This proportion increased to 74% in the subgroup of patients with intracranial hypertension, with multimodal cerebral monitoring in 43.6%. The doses of midazolam and sufentanil were lower in sedated patients managed based on a sedation/analgesia scale. Midazolam and sufentanil are frequently used, often in combination, in French ICUs instead of alternative drugs. In our study, cerebral monitoring was performed in more than 60% of the sedated patients, although that proportion is still insufficient. Future efforts should stress the use of multiple monitoring modes and adherence to the indications for sedation to improve care of patients with BI. Our study suggests that the use of sedation and analgesia scales by nurses involved in the management of patients with BI could decrease the dosages of midazolam and sufentanil administered. Updated guidelines are needed for the management of sedation/analgesia in patients with BI.

The Use of the Comma Sign and Tissue for Recognition, Reduction, and Stability During Arthroscopic Repair of Combined Anterosuperior Cuff Tears

Background: The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear. Indications: Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct. Technique Description: Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months). Results: Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%). Conclusion: Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.

Hemodynamic changes of anesthesia, pneumoperitoneum, and head-down tilt during laparoscopic surgery in elderly patients.

BackgroundThe hemodynamic variations of cardiac and cerebral blood monitoring during pneumoperitoneum and head-down tilt position in general anesthetized elderly patients remain unresolved. We evaluated the time course of cerebral tissue oxygen saturation (SctO2) and cardiac output (CO) and investigated how the changes in hemodynamic values during the surgery would affect cerebral perfusion in elderly patients.MethodsIn this prospective observational study of 47 elderly patients (≥65 years old, American Society of Anesthesiologists Physical status I to III) undergoing laparoscopic colorectal radical resection with head-down position, SctO2 by near-infrared spectroscopy and arterial pressure-based cardiac output (APCO), Cardiac index (CI), stroke volume (SV), and SV index (SVI) according to FloTrac/Vigileo were measured at 9 time points. Heart rate (HR), mean arterial blood pressure (MAP), end-tidal carbon dioxide (ETCO2), bispectral index (BIS), central venous pressure (CVP), and ventilator settings were recorded. Results are reported as medians [95% confidence interval (CI)].ResultsHeart Rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), MAP, CO, CI, SV, SVI, and SctO2 before incision decreased significantly compared with the waking state (P<0.05). SBP, CO, CI, SV, and SVI before incision decreased significantly compared with induction and intubation (P<0.05). SBP, DBP, MAP, and CVP increased significantly after pneumoperitoneum and head-down tilt, and then decreased during the following hour. CO and SVI decreased, while CI and SV increased after pneumoperitoneum and head-down tilt. CO, CI, SV and SVI decreased at the following 20, 40, and 60 minutes respectively. SctO2 increased after pneumoperitoneum and head-down tilt and remained stable during the following hour. CVP decreased while CO, CI, SV, and SVI increased significantly at the end of pneumoperitoneum and head-down tilt (P<0.05). HR and MAP increased significantly at the end of surgery compared to at the end of pneumoperitoneum and head-down tilt (P<0.05). CI was associated with SctO2 as indicated by a Pearson r of 0.035 (P<0.05).ConclusionsAnesthesia, pneumoperitoneum, and head-down tilt affect cardiac function and cerebral perfusion in elderly patients. cardiac index independently affects elderly patients’ cerebral blood flow.

A novel modification of frozen elephant trunk technique: unique protocol from one institution.

We aim to present a novel surgical technique of Frozen Elephant Trunk (FET) to treat complex thoracic aortic diseases in one stage and report its short-term outcomes. Between December 2019 and 30 April 2021, twenty-five patients underwent FET operation at Viet Duc University Hospital. The mean age of the patients was 55.9 (±9.9, range 33-72) years. Eighteen (72%) of the patients were men. Thoracic aortic aneurysm was presented in three (12%) patients. Among seventeen (68%) of the patients undergoing the aortic dissection, eleven (44%) were treated acute type A aortic dissection. Type A intramural hematoma was presented in three (12%) patients. Four (16%) of the patients had undergone previous aortic operations, four (16%) of them had Marphan syndrome and two (11.1%) of them had stage 3 chronic kidney disease. All patients underwent FET procedure by unique protocol. Brain protection was achieved by antegrade bilateral selective cerebral perfusion and moderate hypothermia (28°C) in all cases; besides cerebral tissue oximetry monitoring was used to control brain oxygenation. There were no perioperative deaths, and all patients are still alive during mild-term follow-up period. Sixteen (88.9%) patients received isolated FET, while a Bentall procedure during FET was performed in two (8%) patients and right coronary artery bypass was in one (4%) case. The duration of cardiopulmonary bypass, cross-clamping, circulatory arrest, and total operation were 176.7 (±48.1, range 102-330), 106 (±39.8, range 63-205), 32.7 (±9.6, range 20-58), and 365.6 (±53.6, range 270-480) min, respectively. There was no bleeding following surgery. Prolonged ventilation required tracheotomy was documented in two (8%) patients, hemodialysis caused acute renal failure was in five (20%) patients, cerebral shock was in one (4%) patient, and type 1A endoleak in 2 (8%) patients. Our modification of FET technique was feasible, effective, and safe, with good postoperative outcomes.

Intraoperative cerebral oximetry in open heart surgeries reduced postoperative complications: A retrospective study

Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.