Jugular Bulb Desaturation Research Articles

Jugular bulb desaturation during off-pump coronary artery bypass surgery

Off-pump coronary artery bypass grafting surgery (OPCAB) frequently results in significant jugular bulb desaturation. Although jugular bulb desaturation during OPCAB may be associated with postoperative cerebral injury, routine jugular bulb oximetry appears to be invasive and expensive. We hypothesized that intraoperative hemodynamic compromise during OPCAB due to cardiac displacement is associated with jugular bulb desaturation which correlates with specific hemodynamic and physiological changes. Hemodynamic and physiological data were measured at the following points: (1) before anastomosis of the coronary artery (baseline); (2) during anastomosis of the left anterior descending artery; (3) during anastomosis of the circumflex branch or posterior descending artery; and (4) after chest closure. Arterial, mixed venous, and jugular venous bulb blood gas analyses were performed serially. Jugular bulb desaturation (<or=50%) frequently occurred during surgical displacement of the heart. Mixed venous oxygen saturation (S(VO2)), partial pressure of carbon dioxide (Pa(CO2)), and central venous pressure (CVP) showed a significant relationship with jugular bulb oxygen saturation (r = 0.45) by multivariate linear regression analysis. Multivariate logistic regression analysis also demonstrated that S(VO2) <or= 70%, Pa(CO2) <or= 40 mmHg, and CVP >or= 8 mmHg were likely predictors of the occurrence of jugular bulb desaturation. Changes in S(VO2) and Pa(CO2) were associated with jugular bulb oxygen saturation, and S(VO2) <or= 70%, Pa(CO2) <or= 40 mmHg, and CVP >or= 8 mmHg had a significant odds ratio for jugular bulb desaturation. We suggest that achieving normal values of S(VO2), Pa(CO2) and CVP may be important to prevent cerebral desaturation during OPCAB.

Intraoperative jugular bulb desaturation during acute aneurysmal rupture

To describe an episode of acute jugular venous desaturation during intraoperative rupture of a cerebral aneurysm. A 57-yr-old patient was scheduled for clipping of a large unruptured basilar tip aneurysm. Abrupt bulging of the brain was observed after bone flap removal, but before dura was opened. This was associated with concurrent development of systemic hypertension to 200/120 mmHg and jugular venous bulb (S(jv)O(2)) desaturation to 13%. Rupture of aneurysm was confirmed by frank blood in cerebrospinal fluid drainage from the lumbar subarachnoid catheter. Abrupt S(jv)O(2) desaturation prior to dural opening may suggest an acute increase in intracranial pressure, which in our case followed aneurysmal rupture; the systemic response to increased intracranial pressure (Cushing's response) may be ineffective in maintaining cerebral perfusion.

Venous jugular bulb desaturation episodes during functional hemispherotomies

Fàbregas, N.1; Bel, I.1; Salvador, L.1; Valero, R.1; Carrero, E.1; Rumià, J.2 Author Information

Critical appraisal of Perez et al: Jugular venous oxygen saturation or arteriovenous difference of lactate content and outcome in children with severe traumatic brain injury

To review the findings and discuss the implications of jugular venous bulb oxygenation monitoring in children with severe traumatic brain injury. A critical appraisal of Perez et al, Jugular venous oxygen saturation or arteriovenous difference of lactate content and outcome in children with severe traumatic brain injury. Two episodes of jugular venous bulb desaturation and abnormal values of arteriovenous difference in lactate content are associated with poor neurologic outcome in children with severe traumatic brain injury-risk ratio 6.6 (95% confidence interval, 1.5-29.7) and risk ratio 17.6 (95% confidence interval, 2.5-122.5), respectively. This confirms the findings of previously reported adult studies. This study is the first to demonstrate that jugular venous monitoring may aid in predicting the neurologic outcome of children with severe traumatic brain injury. More studies need to be performed (particularly on safety) before adopting jugular venous bulb oxygenation monitoring as a prediction tool or, ultimately, as a therapeutic intervention to help manage and improve outcome for children with severe traumatic brain injury.

Jugular bulb desaturation during coronary artery surgery: a comparison of off-pump and on-pump procedures

Conventional coronary artery bypass surgery has been associated with cerebral injury attributed to cardiopulmonary bypass (CPB) and surgical manipulation of the ascending aorta. Off-pump coronary artery surgery avoids these factors and could prevent cerebral injury. However, moving the heart from its natural position affects the circulation and could compromise cerebral oxygenation and perfusion. We set out to compare episodes of poor global cerebral oxygenation, defined as a jugular bulb saturation less than 50%, between patients randomized to off-pump or (conventional) on-pump coronary artery surgery. One hundred and eighty-seven patients were assigned randomly to off-pump or on-pump coronary artery surgery. Oxygen saturation in the jugular bulb (SjO2) was measured during revascularization of the three main coronary vessels in the off-pump group, and at the start of CPB, before rewarming, and after rewarming in the on-pump group. We compared samples with jugular bulb with desaturation (SjO2) < or = 50%) between treatment groups. One hundred and seventy-five patients (81 in the off-pump group [93%] and 94 in the on-pump group [94%]) had complete jugular oxygen saturation data. Thirty-nine patients in the off-pump group (48%) and 25 patients in the on-pump group (27%) had one or more samples with desaturation during revascularization or CPB (odds ratio after adjustment for other factors, 0.39; 95% confidence interval, 0.21-0.73, P<0.01). Jugular bulb desaturation occurs more frequently during off-pump coronary artery surgery than during conventional coronary artery surgery.

A reply

We appreciate the interest of Dr Alston in our review article on jugular bulb oximetry during cardiac surgery [1]. We agree with him that bench oximetry, not fibreoptic catheters, is the gold standard for the measurement of jugular bulb oxygen saturation (Sjo2) during cardiopulmonary bypass (CPB). Dr Alston provides a perfectly valid explanation of why Sjo2 less than 50% occurs during cardiopulmonary bypass and why, postoperatively, hyperventilation leads to reduced arterial carbon dioxide tension (Paco2), cerebral vasoconstriction, decreased cerebral perfusion and hence increase in oxygen extraction and reduced Sjo2. We recently studied the effect of Paco2 on Sjo2[2], but found that it explains only 34% of the variance of Sjo2 during warm CPB. Recently, Robson and colleagues found that cognitive dysfunction at 3 months after CPB was not related to jugular bulb desaturation (Sjo2 < 50%) during or after CPB [3]. In their study, the authors did not report the early cognitive changes in the first week after CPB or its relation to Sjo2, which was reported by Croughwell et al. [4]. It would be very interesting to confirm this finding because it seems that jugular bulb desaturation may affect only short-term cognitive dysfunction. Low Sjo2 is a symptom of reduced oxygen availability to the brain and if values < 50% do not lead to long-term cerebral damage, we must presume that the brain can still function under this condition. However, there must be some lower limit of Sjo2 (20%, 30%, 40%?) below which cerebral damage will occur. Another factor might be cerebral damage arising from embolism, which would be minimised by reduced cerebral perfusion. We have tried to explain in our review article that Sjo2 does reflect global cerebral oxygenation but does not detect regional cerebral oxygenation. This was confirmed in our recent paper [5] where we found that Sjo2 did not reflect impairment of regional cerebral oxygenation detected by near-infrared spectroscopy (NIRS). Therefore, if brain injury is due to regional ischaemia, it may or may not be reflected by Sjo2. Thus, in attempting to optimise cerebral oxygenation during CPB, it is important to determine whether the aim should be to maintain good oxygenation of the brain or to minimise cerebral perfusion and hence the risk of embolism (while still maintaining adequate oxygenation – whatever this may be).

Jugular venous oximetry and oxygen tension during hypothermic cardiopulmonary bypass

Introduction. In patients undergoing cardiopulmonary bypass (CPB), jugular bulb desaturation may be associated with postoperative neurocognitive dysfunction. We examined jugular bulb oximetry (SjvO2) and oxygen tension (PjvO2) in patients undergoing CPB with pH-stat perfusion management.Methods. Jugular bulb catheters were inserted in 12 patients undergoing hypothermic CPB for coronary artery bypass. Jugular bulb temperature was monitored continuously. Jugular venous blood was sampled at intervals during cooling, rewarming, and after bypass. SjvO2 was measured by cooximeter (AVOX System 4000). PjvO2 was measured by gas analyzer (Nova Stat Profile Ultra) and recorded both uncorrected at 37°C (stat) and temperature corrected (pH-stat).Results. SjvO2 decreased as jugular bulb temperature increased. However, only 2 patients demonstrated jugular bulb desaturation (<50%) during rewarming, both when jugular venous temperature exceeded 37.5°C. Desaturation during rewarming was not consistently associated with low PjvO2 values (<27 mm Hg). During cooling and hypothermia, PjvO2 (pH-stat values) were lower than PjvO2 (stat values) and may reflect a more accurate measure of brain oxygenation.Conclusions. During CPB, SjvO2 decreased as jugular bulb temperature increased, with desaturation noted during hypothermia. Therefore, brain oxygenation may be jeopardized in the presence of marked hypothermia. We also noted that, during cooling and hypothermia, PjvO2 measured with pH-stat technique was much lower than that measured with a stat technique. The significance of this finding requires further investigation. [1Croughwell N. Newman M. Blumenthal J. et al.Ann Thor Surg. 1994; 58: 1702-1708Abstract Full Text PDF PubMed Scopus (214) Google Scholar]Issues. Suboptimal brain oxygenation during hypothermia: stat versus pH-stat blood gases. Introduction. In patients undergoing cardiopulmonary bypass (CPB), jugular bulb desaturation may be associated with postoperative neurocognitive dysfunction. We examined jugular bulb oximetry (SjvO2) and oxygen tension (PjvO2) in patients undergoing CPB with pH-stat perfusion management. Methods. Jugular bulb catheters were inserted in 12 patients undergoing hypothermic CPB for coronary artery bypass. Jugular bulb temperature was monitored continuously. Jugular venous blood was sampled at intervals during cooling, rewarming, and after bypass. SjvO2 was measured by cooximeter (AVOX System 4000). PjvO2 was measured by gas analyzer (Nova Stat Profile Ultra) and recorded both uncorrected at 37°C (stat) and temperature corrected (pH-stat). Results. SjvO2 decreased as jugular bulb temperature increased. However, only 2 patients demonstrated jugular bulb desaturation (<50%) during rewarming, both when jugular venous temperature exceeded 37.5°C. Desaturation during rewarming was not consistently associated with low PjvO2 values (<27 mm Hg). During cooling and hypothermia, PjvO2 (pH-stat values) were lower than PjvO2 (stat values) and may reflect a more accurate measure of brain oxygenation. Conclusions. During CPB, SjvO2 decreased as jugular bulb temperature increased, with desaturation noted during hypothermia. Therefore, brain oxygenation may be jeopardized in the presence of marked hypothermia. We also noted that, during cooling and hypothermia, PjvO2 measured with pH-stat technique was much lower than that measured with a stat technique. The significance of this finding requires further investigation. [1Croughwell N. Newman M. Blumenthal J. et al.Ann Thor Surg. 1994; 58: 1702-1708Abstract Full Text PDF PubMed Scopus (214) Google Scholar] Issues. Suboptimal brain oxygenation during hypothermia: stat versus pH-stat blood gases.

Jugular bulb desaturation during rewarming from cardiopulmonary bypass is influenced by isoflurane

Jugular bulb oxyhaemoglobin desaturation (SjO2≤ 50%) during the rewarming phase of cardiopulmonary bypass (CPB) is associated with postoperative cognitive deficits [1]. Isoflurane effects cerebral blood flow and cerebral metabolic rate, both of which affect SjO2 [2]. We report the effect of isoflurane on the incidence of desaturation during rewarming from CPB for coronary artery surgery.

Hypercapnia Prevents Jugular Bulb Desaturation During Rewarming from Hypothermic Cardiopulmonary Bypass

UNLABELLED BACKGROUND. The rewarming period of hypothermic cardiopulmonary bypass (CPB) is associated with reduced jugular bulb venous oxygen saturation (SjO2). This study investigates the effects of normocapnia vs. hypercapnia on changes in SjO2 during rewarming from hypothermic CPB for coronary artery bypass graft in patients classified as American Society of Anesthesiologists physical status 111. METHODS Anesthesia was induced and maintained with fentanyl, midazolam, and continuous infusion of etomidate. Hypothermic CPB (27 degrees C) was managed according to alpha-stat conditions. The SjO2 percentage was measured using a fiberoptic catheter placed in the right jugular bulb via the right internal jugular vein. Data were recorded before and during the rewarming period. Patients were assigned to a normocapnic (PaCO2: 36-40 mmHg, n = 10) or hypercapnic (PaCO2: 45-50 mmHg, n = 10) PaCO2 regimen during rewarming. RESULTS The maximum reduction of SjO2 occurred during rewarming with the jugular bulb temperature at 35-36 degrees C. In contrast, SjO2 did not change during rewarming from hypothermia in hypercapnic patients. CONCLUSIONS These results show that mild hypercapnia prevents the desaturation of SjO2 seen with the normocapnic group during the rewarming period from hypothermic CPB. These data suggest that mild hypercapnia during rewarming from CPB is associated with a better balance between cerebral oxygen supply and demand.

Magnetic resonance spectroscopy of high-energy phosphates and lactate immediately after coronary artery bypass surgery.

Hypothermic cardiopulmonary bypass (CPB) is associated with a high incidence of neuropsychological defects, marked cerebral swelling immediately after surgery and jugular bulb desaturation during rewarming. This suggests cerebral ischaemia may occur, but evidence is indirect. We studied four patients with 31P magnetic resonance spectroscopy (MRS) and four with 1H MRS before and immediately after coronary surgery. There was no visible lactate in 1H MR spectra. In 31P MR spectra, the ratio of phosphocreatine to adenosine triphosphate was maintained (before: 2.13 +/- 0.86 vs after: 2.57 +/- 1.31; mean +/- 1 SD) and there was no intracellular acidosis (intracellular pH: 7.1 +/- 0.04 vs 7.16 +/- 0.08), while phosphocreatine/inorganic phosphate was increased immediately after the operation (2.92 +/- 0.37 vs 6.39 +/- 2.67, p = 0.03). This suggests rebound replacement of energy stores following recovery from temporary cerebral ischaemia during CPB: intra-operative studies would be needed to test this hypothesis further.

Hypercapnia prevents jugular bulb desaturation during rewarming from hypothermic cardiopulmonary bypass.

BACKGROUND. The rewarming period of hypothermic cardiopulmonary bypass (CPB) is associated with reduced jugular bulb venous oxygen saturation (SjO2). This study investigates the effects of normocapnia vs. hypercapnia on changes in SjO2 during rewarming from hypothermic CPB for coronary artery bypass graft in patients classified as American Society of Anesthesiologists physical status 111. Anesthesia was induced and maintained with fentanyl, midazolam, and continuous infusion of etomidate. Hypothermic CPB (27 degrees C) was managed according to alpha-stat conditions. The SjO2 percentage was measured using a fiberoptic catheter placed in the right jugular bulb via the right internal jugular vein. Data were recorded before and during the rewarming period. Patients were assigned to a normocapnic (PaCO2: 36-40 mmHg, n = 10) or hypercapnic (PaCO2: 45-50 mmHg, n = 10) PaCO2 regimen during rewarming. The maximum reduction of SjO2 occurred during rewarming with the jugular bulb temperature at 35-36 degrees C. In contrast, SjO2 did not change during rewarming from hypothermia in hypercapnic patients. These results show that mild hypercapnia prevents the desaturation of SjO2 seen with the normocapnic group during the rewarming period from hypothermic CPB. These data suggest that mild hypercapnia during rewarming from CPB is associated with a better balance between cerebral oxygen supply and demand.

Accuracy of continuous jugular bulb oximetry in the intensive care unit.

To address the accuracy of a bedside jugular bulb oxygen saturation (SjO2) catheter monitor (Baxter-Edwards, Santa Ana, CA) versus in vitro co-oximetry measurements in the intensive care unit (ICU). By prospective protocol, we compared blood gas measurements with simultaneously recorded continuous bedside oximetric monitor values for 31 ICU patients with traumatic brain injury undergoing jugular bulb catheter monitoring. For suboptimal fiberoptic light signal quality indices, the catheter was repositioned, flushed, or both before drawing the sample for in vitro measurement. Laboratory and bedside monitor data were examined for association using the chi2 and paired t tests and a linear regression model. We assessed 195 samples (median, 5 per patient; range, 1-14) who were monitored an average of 3.4 (range, 1-6) days. The in vivo monitor (range, 32-94%) and in vitro co-oximetry (range, 38-93%) values had acceptable correlation (y = 0.94x + 4.4, r2 = 0.80). For bedside monitor detection of jugular bulb desaturation (SjO2 < 50% for 10 min), the kappa statistic was 0.35, the sensitivity was 45 to 50%, and the specificity was 98 to 100%. Continuous ICU SjO2 monitoring correlates significantly with in vitro values, but less so than previously described during intracranial surgery. Although sensitivity of the bedside monitor to detect confirmed desaturations remains an issue, the high specificity indicates that it is less of a concern that patients may be misdiagnosed as having desaturations resulting in unnecessary interventions. Nonetheless, suspected jugular bulb desaturation should be verified before taking therapeutic actions.

Cerebral oxygenation monitoring by near-infrared spectroscopy is not clinically useful in patients with severe closed-head injury

To compare continuous jugular venous bulb oximetry and cerebral near-infrared spectroscopy in patients with severe closed head injury. A prospective observational study. Intensive care unit of a major teaching hospital. Adults (n = 10) with severe closed-head injury (Glasgow Coma Scale score of < or = 8). None. Jugular venous bulb oximetry, cerebral near-infrared spectroscopy, and cerebral perfusion pressure were measured continuously. A total of 3,691 paired measurements of near-infrared spectroscopy and jugular venous bulb oximetry were analyzed. Poor correlation (r2 = .04) between paired measurements and wide limits of agreement (-13% to +21%) were demonstrated. The mean difference between measurements was +/- 4% and the standard deviation of the mean difference was +/- 8.69%. The data were subsequently grouped according to three clinically significant subgroups of jugular venous bulb oxygen saturation reflecting low ( < 55%), normal (55% to 75%) and high ( > 75%) saturation values. Poor correlation and wide limits of agreement between the two methods of measurement were observed in all groups. Values recorded by near-infrared spectroscopy did not significantly change between the groups, and 14 clinically significant episodes of jugular venous bulb desaturation were not detected by near-infrared spectroscopy. Tissue oxygen saturation determined by near-infrared spectroscopy does not reflect significant changes in cerebral oxygenation detected by the global measurement of jugular venous bulb oximetry. This finding may be explained by inadequate signal detection and inaccuracies in the algorithm used to filter out extracranial components. Until these technical difficulties are addressed, near-infrared spectroscopy, as measured by the machine assessed in this study, cannot be routinely recommended for assessment of cerebral oxygenation in patients with acute head injury.

Analysis of very early jugular bulb oximetry data after severe head injury: implications for the emergency management?

Jugular bulb oximetry provides the first bedside available information on cerebral oxygen utilization. An extensive analysis was made of all initial jugular bulb oximetry data obtained in 150 patients within the first 12 h after severe traumatic brain injury. These data revealed initial abnormal jugular bulb saturation values in 57 patients (= 38% of study population), with a predominance of jugular bulb desaturation (observed in 45 patients). This confirms earlier reports that revealed a high incidence of disturbed and inadequate cerebral perfusion in the first hours after brain injury. Jugular bulb desaturation was especially related to systemic causes (such as a lowered cerebral perfusion pressure observed in 29 patients, and a lowered arterial carbon dioxide tension in 24 patients). These findings could have important implications for the emergency management of severely head-injured patients, as outcome might possibly be improved by better attention to all systemic factors that might reduce cerebral perfusion in the early hours after traumatic insult.

Warming during cardiopulmonary bypass is associated with jugular bulb desaturation

The objective of this study was to characterize cerebral venous effluent during normothermic nonpulsatile cardiopulmonary bypass. Thirty-one (23%) of 133 patients met desaturation criteria (defined as jugular bulb venous oxygen saturation ≤ 50% or jugular bulb venous oxygen tension ≤ 25 mm Hg) during normothermic cardiopulmonary bypass (after hypothermic cardiopulmonary bypass at 27 ° to 28 °C). Cerebral blood flow, calculated using xenon 133 clearance methodology, was significantly ( p < 0.005) higher in the saturated group (33.7 ± 10.3 mL · 100 g −1 · min −1) than in the desaturated group (26.2 ± 6.9 mL · 100 g −1 · min −1), whereas the cerebral metabolic rate for oxygen was significantly lower ( p < 0.005) in the saturated group (1.28 ± 0.39 mL · 100 g −1 · min −1) than in the desaturated group (1.52 ± 0.36 mL · 100 g −1 · min −1) at normothermia. The arteriovenous oxygen difference at normothermia was lower in the saturated group (3.92 ± 1.12 mL/dL) than in the desaturated group (5.97 ± 1.05 mL/dL). Neuropsychological testing was performed in 74 of the 133 patients preoperatively and on day 7 postoperatively. There was a general decline in mean scores of all tests postoperatively in both groups with no significant difference between the groups. We conclude that cerebral venous desaturation represents a global imbalance in cerebral oxygen supply-demand that occurs during normothermic cardiopulmonary bypass and may represent transient cerebral ischemia. These episodes, however, are not associated with impared neuropsychological test performance as compared with the performance of patients with no evidence of desaturation.