Using bispectral index and cerebral oximetry to guide hemodynamic therapy in high-risk surgical patients

Perioperative Medicine

David Green¹  Audrey Tan¹  Heena Bidd¹ 

[1]King’s College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK

关键词: Goal-directed therapy;    Intraoperative optimization;    LiDCOrapid;    Triple low;    Cerebral oximetry;    Cardiac output monitoring;    Depth of anesthesia;    BIS;   

Others  :  816399
DOI  :  10.1186/2047-0525-2-11

 received in 2012-08-23, accepted in 2013-04-26,  发布年份 2013

【 摘 要 】

High-risk surgery represents 12.5% of cases but contributes 80% of deaths in the elderly population. Reduction in morbidity and mortality by the use of intervention strategies could result in thousands of lives being saved and savings of up to £400m per annum in the UK. This has resulted in the drive towards goal-directed therapy and intraoperative flow optimization of high-risk surgical patients being advocated by authorities such as the National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland.

Conventional intraoperative monitoring gives little insight into the profound physiological changes occurring as a result of anesthesia and surgery. The build-up of an oxygen debt is associated with a poor outcome and strategies have been developed in the postoperative period to improve outcomes by repayment of this debt. New monitoring technologies such as minimally invasive cardiac output, depth of anesthesia and cerebral oximetry can minimize oxygen debt build-up. This has the potential to reduce complications and lessen the need for postoperative optimization in high-dependency areas.

Flow monitoring has thus emerged as essential during intraoperative monitoring in high-risk surgery. However, evidence suggests that current optimization strategies of deliberately increasing flow to meet predefined targets may not reduce mortality.

Could the addition of depth of anesthesia and cerebral and tissue oximetry monitoring produce a further improvement in outcomes?

Retrospective studies indicate a combination of excessive depth of anesthesia hypotension and low anesthesia requirement results in increased mortality and length of hospital stay.

Near infrared technology allows assessment and maintenance of cerebral and tissue oxygenation, a strategy, which has been associated with improved outcomes. The suggestion that the brain is an index organ for tissue oxygenation, especially in the elderly, indicates a role for this technology in the intraoperative period to assess the adequacy of oxygen delivery and reduce the build-up of an oxygen debt.

The aim of this article is to make the case for depth of anesthesia and cerebral oximetry alongside flow monitoring as a strategy for reducing oxygen debt during high-risk surgery and further improve outcomes in high-risk surgical patients.

【 授权许可】

   
2013 Bidd et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]National Institute for Health and Care Excellence:: Medical Technologies Guidance MTG3: CardioQODM Oesophageal Doppler Monitor. 2011 . [http://www.nice.org.uk/MTG3 webcite]
• [2]Association of Anaesthetists of Great Britain and Ireland:: Recommendations for standards of monitoring during anaesthesia and recovery. [http://www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf webcite]
• [3]Shoemaker WC, Appel PL, Kram HB: Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest 1992, 102:208-215.
• [4]Shoemaker WC, Appel PL, Kram HB: Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Crit Care Med 1993, 21:977-990.
• [5]Gurgel ST, do Nascimento P Jr: Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011, 112:1384-1391.
• [6]Hamilton MA, Cecconi M, Rhodes A: A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011, 112:1392-1402.
• [7]Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A: Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care 2011, 15:R197. BioMed Central Full Text
• [8]Michard F: The burden of high-risk surgery and the potential benefit of goal-directed strategies. Crit Care 2011, 15:447. BioMed Central Full Text
• [9]Ghosh S, Arthur B, Klein AA: NICE guidance on CardioQ(TM) oesophageal Doppler monitoring. Anaesthesia 2011, 66:1081-1083.
• [10]Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, Leaper E, Parker M, Ridgway S, White S, Wiese M, Wilson I: Management of proximal femoral fractures 2011. Anaesthesia 2012, 67:85-98.
• [11]Mythen MG, Swart M, Acheson N, Crawford R, Jones K, Kuper M, McGrath JS, Horgan A: Perioperative fluid management: consensus statement from the Enhanced Recovery Partnership. Perioperative Medicine 2012, 1:1-4. BioMed Central Full Text
• [12]Shepherd J, Jones J, Frampton G, Bryant J, Baxter L, Cooper K: Depth of anaesthesia monitoring (E-entropy, bispectral index and narcotrend). Health Technol Assess 2012. [http://www.nice.org.uk/dg6 webcite]
• [13]Green D, Paklet L: Latest developments in peri-operative monitoring of the high-risk major surgery patient. Int J Surg 2010, 8:90-99.
• [14]Scheeren TW, Schober P, Schwarte LA: Monitoring tissue oxygenation by near infrared spectroscopy (NIRS): background and current applications. J Clin Monit Comput 2012, 26:279-287.
• [15]Highton D, Elwell C, Smith M: Noninvasive cerebral oximetry: is there light at the end of the tunnel? Curr Opin Anaesthesiol 2010, 23:576-581.
• [16]Murkin JM, Arango M: Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br J Anaesth 2009, 103(Suppl 1):i3-i13.
• [17]Murkin JM, Adams SJ, Novick RJ, Quantz M, Bainbridge D, Iglesias I, Cleland A, Schaefer B, Irwin B, Fox S: Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg 2007, 104:51-58.
• [18]Slater JP, Guarino T, Stack J, Vinod K, Bustami RT, Brown JM 3rd, Rodriguez AL, Magovern CJ, Zaubler T, Freundlich K, Parr GV: Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery. Ann Thorac Surg 2009, 87:36-44. discussion 44–45
• [19]Casati A, Fanelli G, Pietropaoli P, Proietti R, Tufano R, Danelli G, Fierro G, De Cosmo G, Servillo G: Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia. Anesth Analg 2005, 101:740-747.
• [20]Green DW: A retrospective study of changes in cerebral oxygenation using a cerebral oximeter in older patients undergoing prolonged major abdominal surgery. Eur J Anaesthesiol 2007, 24:230-234.
• [21]Heringlake M, Garbers C, Kabler JH, Anderson I, Heinze H, Schon J, Berger KU, Dibbelt L, Sievers HH, Hanke T: Preoperative cerebral oxygen saturation and clinical outcomes in cardiac surgery. Anesthesiology 2011, 114:58-69.
• [22]Rifai L, Winters J, Friedman E, Silver MA: Initial description of cerebral oximetry measurement in heart failure patients. Congest Heart Fail 2012, 18:85-90.
• [23]Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED: Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005, 9:R687-R693. BioMed Central Full Text
• [24]Myles PS, Leslie K, McNeil J, Forbes A, Chan MTV, for the B-aware trial group: Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomized controlled trial. Lancet 2004, 363:1757-1763.
• [25]Avidan MS, Jacobsohn E, Glick D, Burnside BA, Zhang L, Villafranca A, Karl L, Kamal S, Torres B, O’Connor M, Evers AS, Gradwohl S, Lin N, Palanca BJ, Mashour GA: Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med 2011, 365:591-600.
• [26]Avidan MS, Zhang L, Burnside BA, Finkel KJ, Searleman AC, Selvidge JA, Saager L, Turner MS, Rao S, Bottros M, Hantler C, Jacobsohn E, Evers AS: Anesthesia awareness and the bispectral index. N Engl J Med 2008, 358:1097-1108.
• [27]Chamoun NG: The position of aspect. Anesthesiology 2000, 92:897-898.
• [28]Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N: Bispectral Index for Improving Anaesthetic Delivery and Postoperative Recovery, Cochrane Database of Systematic Reviews. Chichester, UK: Wiley; 2007.
• [29]Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005, 100:4-10.
• [30]Kertai MD, Pal N, Palanca BJ, Lin N, Searleman SA, Zhang L, Burnside BA, Finkel KJ, Avidan MS: Association of perioperative risk factors and cumulative duration of low bispectral index with intermediate-term mortality after cardiac surgery in the B-unaware trial. Anesthesiology 2010, 112:1116-1127.
• [31]Leslie K, Myles PS, Forbes A, Chan MT: The effect of bispectral index monitoring on long-term survival in the B-aware trial. Anesth Analg 2010, 110:816-822.
• [32]Lindholm ML, Traff S, Granath F, Greenwald SD, Ekbom A, Lennmarken C, Sandin RH: Mortality within 2 years after surgery in relation to low intraoperative bispectral index values and preexisting malignant disease. Anesth Analg 2009, 108:508-512.
• [33]Kertai MD, Palanca BJ, Pal N, Burnside BA, Zhang L, Sadiq F, Finkel KJ, Avidan MS: Bispectral index monitoring, duration of bispectral index below 45, patient risk factors, and intermediate-term mortality after noncardiac surgery in the B-unaware trial. Anesthesiology 2011, 114:545-556.
• [34]Moller Petrun A, Kamenik M: Bispectral index-guided induction of general anaesthesia in patients undergoing major abdominal surgery using propofol or etomidate: a double-blind, randomized, clinical trial. Br J Anaesth 2013, 110:388-396.
• [35]Purushothaman B, O’Brien T, Green DW: The hemodynamic effects of induction and their correlation with changes in depth of anesthesia. ASA Abstracts 2010, A999.
• [36]Mashour GA, Orser BA, Avidan MS: Intraoperative awareness: from neurobiology to clinical practice. Anesthesiology 2011, 114:1218-1233.
• [37]Leslie K, Short TG: Low bispectral index values and death: the unresolved causality dilemma. Anesth Analg 2011, 113:660-663.
• [38]Monk TG, Weldon BC: Does depth of anesthesia monitoring improve postoperative outcomes? Curr Opin Anaesthesiol 2011, 24:665-669.
• [39]Chan MT, Cheng BC, Lee TM, Gin T: BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol 2013, 25:33-42.
• [40]Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L, Kurz A, Greenwald S: Hospital stay and mortality are increased in patients having a ‘Triple Low’ of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology 2012, 116:1195-1203.
• [41]Ballard C, Jones E, Gauge N, Aarsland D, Nilsen OB, Saxby BK, Lowery D, Corbett A, Wesnes K, Katsaiti E, Arden J, Amaoko D, Prophet N, Purushothaman B, Green D: Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial. PLoS One 2012, 7:e37410.
• [42]Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS: Long-term consequences of postoperative cognitive dysfunction. Anesthesiology 2009, 110:548-555.
• [43]Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F: Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003, 238:641-648.
• [44]Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I: Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005, 103:25-32.
• [45]Shires T, Williams J, Brown F: Acute change in extracellular fluids associated with major surgical procedures. Ann Surg 1961, 154:803-810.
• [46]Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M: A rational approach to perioperative fluid management. Anesthesiology 2008, 109:723-740.
• [47]Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J: Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg 2009, 96:331-341.
• [48]Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G: Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth 2012, 108:53-62.
• [49]Lobo SM, Ronchi LS, Oliveira NE, Brandao PG, Froes A, Cunrath GS, Nishiyama KG, Netinho JG, Lobo FR: Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery. Crit Care 2011, 15:R226. BioMed Central Full Text
• [50]Brandstrup B, Svensen C, Engquist A: Hemorrhage and operation cause a contraction of the extracellular space needing replacement – evidence and implications? A systematic review. Surgery 2006, 139:419-432.
• [51]Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS: Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002, 97:820-826.
• [52]Noblett SE, Snowden CP, Shenton BK, Horgan AF: Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006, 93:1069-1076.
• [53]Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC: Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005, 95:634-642.
• [54]Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SA, Hansen B, Moller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L: Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 2012, 109:191-199.
• [55]Deltex Medical, Chichester, UK; [http://www.deltexmedical.com/ webcite]
• [56]Pittman J, Bar-Yosef S, SumPing J, Sherwood M, Mark J: Continuous cardiac output monitoring with pulse contour analysis: a comparison with lithium indicator dilution cardiac output measurement. Crit Care Med 2005, 33:2015-2021.
• [57]Nordstrom J, Hallsjo-Sander C, Shore R, Bjorne H: Stroke volume optimization in elective bowel surgery: a comparison between pulse power wave analysis (LiDCOrapid) and oesophageal Doppler (CardioQ). Br J Anaesth 2012, 110:374-380.
• [58]Montenij LJ, de Waal EE, Buhre WF: Arterial waveform analysis in anesthesia and critical care. Curr Opin Anaesthesiol 2011, 24:651-656.
• [59]Mora B, Ince I, Birkenberg B, Skhirtladze K, Pernicka E, Ankersmit HJ, Dworschak M: Validation of cardiac output measurement with the LiDCO(TM) pulse contour system in patients with impaired left ventricular function after cardiac surgery. Anaesthesia 2011, 66:675-681.
• [60]Brandstrup B: Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol 2006, 20:265-283.
• [61]Prowle JR, Chua HR, Bagshaw SM, Bellomo R: Clinical review: volume of fluid resuscitation and the incidence of acute kidney injury – a systematic review. Crit Care 2012, 16:230. BioMed Central Full Text
• [62]Optimise trial[http://www.controlled-trials.com/ISRCTN04386758 webcite]
• [63]Green DW, Shephard B: Influence of depth of anaesthesia (DOA) and cerebral oximetry (rSO2) monitoring on Na and fluid requirements using the oesophageal Doppler (ODM) for targeted fluid replacement during prolonged major abdominal surgery. ASA Abstracts 2011, A277.
• [64]Wolff CB: Normal cardiac output, oxygen delivery and oxygen extraction. Adv Exp Med Biol 2007, 599:169-182.
• [65]Grocott MP, Dushianthan A, Hamilton MA, Mythen MG, Harrison D, Rowan K: Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database Syst Rev 2012, 11:CD004082.
• [66]Willars C, Dada A, Hughes T, Green D: Functional haemodynamic monitoring: the value of SVV as measured by the LiDCORapid™ in predicting fluid responsiveness in high risk vascular surgical patients. Int J Surg 2012, 10:148-152.
• [67]Gutierrez G, Brown SD: Gastrointestinal tonometry: a monitor of regional dysoxia. New Horiz 1996, 4:413-419.
• [68]Mythen MG, Webb AR: Gastrointestinal tonometry comes of age? Br J Anaesth 1998, 81:667-668.