• Valeur en délirium

• Cas de Benedir

• Pilote Deschamps

• Exemple Algorythme: cardio

• Revoir cours Vancouver 2012 fev

Disclosure

• Research grant

• Unrestricted research grant

• Speaker fees

Cerebral oximetry What does it predict?

André Denault MD PhD FRCPC,CSPQ, ABIM-CCM, FASE President of the CVT section of the CAS

Professeur agrégé de cliniqueDépartement d’anesthésiologie

Institut de Cardiologie de MontréalService des soins intensifs

Centre Hospitalier Universitaire de Montréal

A: « Airway »

B: « Breathing »

C: Circulatory monitor

D: Diagnostic

E: Expectency of survival

Capnography

Key questions

• Why talking about NIRS?

• What detemines the value?

• Does NIRS change outcome?

• How can we use it?

Key questions

• Why talking about NIRS?

• What detemines the value?

• Does NIRS change outcome?

• How can we use it?

Ultimate Objective of

Resuscitation

August 2011

Goal in the OR and ICU

Goal in the OR and ICU

80 year-old CABG(September 16th 2011)

Goal in the OR and ICU

"Emerging hypothesis is that SctO2 monitoring may be an index of

overall organ perfusion and injury. “

" Our finding that a statistically significant model using SctO2 data

predicted ICU and hospital LOS underscores this point

…and suggests that future studies may investigate the cost-

effectiveness of this form of monitoring and intervention. "

Invos™ 5100

Cerebral Oximetry

Equanox™

Fore-Sight™

Receptors

Transmitter

Mode of operation

• Photons with two separate wavelenght are captures by a receptor

• The photons will penetrate superficial and deep tissues down to the frontal cortex

• The superficial signal is substracted from the final signal

(“Spatially resolved NIRS”)

• The final signal originates from deeper cortical tissue

Oxygen saturation monitoring of the distal region

of the ACA and MCA (watershed)

Light SourceLight Source

Shallow

Detector

Deep

Detector

Shallow

DetectorDeep

Detector

Periosteal

Dura Matter

Skin TissueBone

Superior

Sagittal Sinus

Brain

Photons direction

ANTERIOR

CEREBRAL ARTERY

MIDDLE

CEREBRAL ARTERY

ANTERIOR

CHOROIDAL

ARTERY

POSTERIOR

CEREBRAL ARTERY

INVOS

Theory of Operation

Edmonds HL, Jr., APSF Newsletter 14(3):25-32, 1999

Awake baseline rSO2

40 50 60 70 80 90

30%

25%

20%

15%

10%

5%

0%

Cardiac surgical patients: rSO2 65 ± 9 (47 à 83, 2 SD).

Normal volunteer: rSO2 70 ± 6 (58 à 82, 2 SD).

rSO2 baseline valuesNormal healthy volunteer and cardiac surgical patients

Key questions

• Why talking about NIRS?

• What detemines the value?

• Does NIRS change outcome?

• How can we use it?

rSO2 modulation

Cerebral O2

metabolism

Cerebral O2

transport

Normal valueSaO2

PCO2

Hb

CPP

CO or VR

Brain desaturation

Cerebral O2

transport

Abnormal value

SaO2

PCO2

Hb

CPP

CO or VR

Cerebral O2

metabolism

Normal value

Cerebral O2

metabolism

Cerebral O2

transport

Temperature

monitoring

44 year-old ♀ under

cardiopulmonary bypass

Decreases in rSO2 of 20% from baseline, or below 50, are cause for concern.

Larger declines have been demonstrated to be associated with neurological

dysfunction in a variety of clinical situations.Roberts KW, Anesthesiol 89: A934, 1998.

Edmonds HL, Jr., Anesth Analg 86:SCA13, 1998.

Carlin RE, J Clin Anest 10:109-113, 1998.

Cho H, J Neurosurg 89: 533-538, 1998.

Higami T, Ann Thor Surg 67:1091-6, 1999.

85

50

40

100

80

60

40

20

0

-10%

-20%

-30%

Absolu

te V

alu

es r

SO

2

Change F

rom

Baselin

e

Baseline

Significant changes in rSO2 Below 75% of the baseline for 15 seconds

Intraoperative desaturation

Preoperative desaturation

Intraoperative desaturation

Total Population (n=1176)

Euroscore > 10 (n = 102)

Montreal Heart Institute and CHUM

experience before 2002

Courtesy of Alan Mutch

Montreal Heart Institute and CHUM

experience 2002-2012

(n ≈ 3000)• Cardiac Surgery

– 50% complex surgery– Minimally invasive surgery

• Non-Cardiac Surgery: Vascular

• Cardiology– Electrophysiology– Hemodynamic: percutaneous valve program

• Intensive Care - CHUM– Neurosurgery– Shock– Transplant

• Research: 6 publications, 3 reviews, 1 book chapter and 5 research project, online training program

Montreal Heart Institute

personal experience 2002-2012

(n ≈ 866)

• Cardiac Surgery

1464 cases since 1999

Brain oximetry available in 26 patients who died post-operatively

Overall mortality:• Significant intraoperative desaturation in 16 patients (61.5%)

Death within 48 hours:• Significant intraoperative desaturation in 10 patients (100%)

61 yo ♀ cardiogenic shock

Pulmonary venous flow

75 yo ♀ CABG and AVR

Key questions

• Why talking about NIRS?

• What detemines the value?

• Does NIRS change outcome?

• How can we use it?

Monitoring

April 14, 1912 April 14, 1912

«In high-risk surgical patients, the use of a hemodynamic

protocol to maintain tissue perfusion decreased mortality and

postoperative organ failure»

Anesth Analg 2011:112:1384-91

Anesthesia Analgesia 2007

Anesthesia Analgesia 2007

56/100 patients with episodes of

desaturation: treated with

success in 80.4%

• 48 high risk patients randomised

• 35/48 (72.9%) brain desaturation

• 89.6% success rate in correcting rSO2

• Area under the curve

– Control 729.7 ± 1260 % min

– Treatment 154.3 ± 218.3 % min

• Duration of mechanical ventilation

– Control 28.2 ± 54.3 hours

– Treatment 14.8 ± 6.3 hours

• ICU desaturation

– Control 68.4% vs treatment 37.5%

Key questions

• Why talking about NIRS?

• What detemines the value?

• Does NIRS change outcome?

• How can we use it?

Seminars of Cardiothoracic and Vascular Anesthesia 2007

8 steps approach

• Based on the determinants of brain oximetry

• Inspired by interventional studies

(Casati 2005, Murkin 2007, Slater 2009)

• Priority-based, logical and fast

(60 seconds)

andre.denault@umontreal.ca

12

3

4

5

6

7 8

Transesophageal

echocardiography

12

3

4

5

6

7 8

Acute desaturation:

true or false?

Step #4Step #4

Ventilation and rSO2

Yao et al Anesthesiology 2000

Cere

bra

l satu

ration (

%)

End-tidal CO2 (mmHg)

During hyperventilation

From hyperventilation to normal ventilation

Cardiopulmonary

bypass

82 yo ♀ scheduled for AVR:

rSO2 during CPB

pH 7.45

PCO2 32

PO2 375

During

desaturation

After

ventilation

pH 7.35 ↓

PCO2 42 ↑

PO2 294 ↓

Step #5Step #5

54 yo ♀ CABG and interatrial

mass resection

Baseline SrO2 55-51

54 yo ♀ CABG and interatrial

mass resection

Baseline SrO2 55 baseline now 48 during CPB

Step #6

74 yo ♂ before

CABG +AVR77 yo ♀ return to OR

after CABG

Hemodynamic monitor

• Baseline values determined by cardiac

function

• Better that the PA catheter to determine if

cardiac function is normal or not

• Useful in all types of shock states

• Useful to determine the efficacy of the

intervention

Before CPB CPB weaning

Hemodynamic monitor

• Baseline values determined by cardiac

function

• Better that the PA catheter to determine if

cardiac function is normal or not

• Useful in all types of shock states

• Useful to determine the efficacy of the

intervention

Right ventricular failure Left ventricular outflow

tract obstruction

A: «Airway» for true hypoxia

B: «Breathing» adequacy

C: Circulatory monitor

D: Diagnostic

E: Expectency of survival(biomarker)

Brain oximetry:

what does it predict?

In Summary• Cerebral oximetry is the monitoring of trends based on the absorption of

near-infrared light in oxygenated/non-oxygenated blood.

• Several variables will influence final values

• Baseline value before cardiac surgery has prognostic implication

• The severity of intraoperative desaturation correlates with post-operative

complications, neuro-cognitive deficiencies and the length of hospital stay

• Two randomized studies (Murkin 2007, Slater 2009) support its usefulness in

cardiac surgery

• It’s role in the ICU is promising and under current investigation

• The impact of monitoring essentially depends on:

– The use of a systematic approach and adequate training

– The comprehension and communication level of the operating room and ICU

team

L’équipe de recherche:

Denis Babin

MSc Inh

Jean-Claude Tardif

MD FRCP

Alain Deschamps

MD FRCPC PhD

Jean Lambert PhD

Biostatistique

Pierre Couture

MD FRCPC

Louis P.Perrault

MD PhD FRCSC

Les étudiants

PhD

Anne Nguyen Paul Gavra Francois Haddad MD

Hosam Ased Julián AndrésGarcía Duitama

Les étudiants

Master

Christian Ayoub MD

Maxime Laflamme MD

Éric Piette MD

L’équipe de recherche:

FEBRUARY 2009

A. Deschamps, PhD, MD

Validation of NIRS

Protocol

279 patients48:48, male:femaleMean of 63 (28-87) years of ageComplex surgeries onlyProspective - observationalAnesthesiologists follow algorithmEvents are recordedSuccess of intervention recorded

FEBRUARY 2009

A. Deschamps, PhD, MD

• AVR - 26.0% • CABG - 23.5%• Aortic - 9.9%• MVR - 8.0%• REDO - 6.8%• MVRepair - 6.8%• TVRepair - 6.2%• Other - 6.2%• Congenital - 2.5%• PVRepair - 2.2%• ASD - 1.2%• Pericardiotomy - 0.6%

Types of surgeries

FEBRUARY 2009

A. Deschamps, PhD, MD

Cerebral Desaturations

Baseline NIRS values

Right: mean 68, 35 - 86

Left: mean 68, 29 - 89

FEBRUARY 2009

A. Deschamps, PhD, MD

% Patients 487%

Pre CPB 27.3%

During CPB 56.1%

Post CPB 16.7%

FEBRUARY 2009

A. Deschamps, PhD, MD

• ↑ PA -33.3% • ↑ PaCO2 - 28.33%• ↑ PaO2 - 8.33%• Transfusion - 8.33%• Reposition Cannula - 8.33%• ↑ Cardiac Function - 8.33%• Change head position - 3.33%• ↑ Anesthesia - 1.67%

Types of interventions

FEBRUARY 2009

A. Deschamps, PhD, MD

Success rate

88.7% (70% required more than 1 intervention)

5 x ↓ cerebral sat were not attemptedAll with hypothermic cardiac arrest