Ann Thorac Surg 2006;82:325-327
© 2006 The Society of Thoracic Surgeons
Case report
Rapid Diagnosis of Cannula Migration by Cerebral Oximetry in Neonatal Arch Repair
Frank G. Scholl, MD
*
,
David Webb, CCP,
Karla Christian, MD,
Davis C. Drinkwater, MD
Division of Pediatric Cardiac Surgery, Monroe Carrell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
Accepted for publication September 12, 2005.
* Address correspondence to Dr Scholl, 5247 Doctor's Office Tower, 2200 Children's Way, Vanderbilt University Medical Center, Nashville, TN 37232-9292 (Email: frank.scholl{at}vanderbilt.edu).
 |
Abstract
|
|---|
Although it has gained much interest in other surgical specialties, the application of near-infrared spectroscopy to assess cerebral perfusion during cardiac surgery is relatively new. Regional cerebral oxygen saturation (rSO2) is a function of cerebral oxygen supply and demand. Continuous monitoring of the rSO2 permits early detection of cerebral ischemia allowing for prompt intervention. The following is a description of a repair of truncus arteriosus with type A interrupted aortic arch during which continuous cerebral oximetry assisted with the positioning of the arterial cannula avoiding a prolonged episode of cerebral ischemia.
|
Introduction
|
|---|
Cerebral oxygen saturation monitoring with near-infrared spectroscopy is an innovative method to assess brain perfusion [1–5]. This noninvasive technique is accomplished by placing a sensor on the skin over the frontal and temporal regions of the brain. By passing a low intensity near infrared light into the brain, this technique allows the capability of measuring changes in tissue chromophores such as hemoglobin [6]. As light is returned at two distances from its source (ie, the spectral absorption of oxygenated and deoxygenated hemoglobin in the brain can be measured and the relative differences can be compared with time). This measurement is displayed as an oxygen saturation index (rS02) of the mixed arterial and venous blood in the cerebral cortex [7]. Although rSO2 is affected by various physiologic measurements consistent with assessing the adequacy of perfusion of other tissues of the body, it can also be helpful in rapidly identifying mechanical perfusion issues affecting blood supply and anesthetic levels affecting demand [5].
After the birth a 3.2 kg full-term boy with the diagnosis of truncus arteriosus with interrupted aortic arch, he was intubated, placed on prostaglandins, and transferred to our institution. On arrival, oxygen saturations were 95% on room air and initial blood arterial blood gas demonstrated mild metabolic acidosis. Diagnosis was confirmed with transthoracic echocardiography. The rest of the laboratory findings were unremarkable. The patient was brought to the operating room on day 8 of his life. Anesthetic and perfusion monitoring consisted of electrocardiogram, esophageal and rectal temperatures, pulse oximetry, expired respiratory and anesthetic gas concentration, right radial artery and central venous pressures, continuous in-line blood gas monitoring (CDI 500, Terumo Cardiovascular, Ann Arbor, MI), and cerebral oximetry with a sensor placed over the right cerebral hemisphere (INVOS 5100B, Somanetics, Troy, MI).
After a median sternotomy and heparinization, the distal ascending aorta was cannulated at the base of the innominate artery with a 6-French wire wound the arterial perfusion cannula. Bi-caval cannulation was completed with two right-angle 12-French venous cannulae. After initiating cardiopulmonary bypass the patient was gradually cooled to 18°C.
The course of the operation was unremarkable and an anatomic repair was completed with a short period of low-flow regional, cerebral perfusion. Shortly after initiation of rewarming the cerebral oxygen saturation demonstrated a precipitous decline from 48 to 24 scale units (Fig 1). This was unanticipated as other measurements indicated adequate pump output to meet cerebral oxygen demand (rectal temperature, 23.6°C; confidence interval, 1.7; SvO2, 78%; mean arterial pressure, 45 mm Hg; hematocrit, 33%; pH, 7.42; pCO2, 39 mm Hg; pO2, 242 mm Hg; base excess, 2.0; FiO2, 0.40; sweep gas, 0.20 L/min; isoflurane, 1.0%). With surgeon notification, the right arm and forehead were palpated by the anesthesia team; this revealed a warm right hand and arm, and a cool forehead. This confirmed the suspicion of migration of the tip of the arterial perfusion cannula into the orifice of the right subclavian artery during the repair of the interrupted aortic arch. The cannula was pulled back and repositioned into the proximal arch, which resulted in an immediate improvement in the cerebral oxygen saturation (Fig 1). The remainder of the operation was uneventful. The patient recovered without neurologic insult and was discharged home 15 days later.
View larger version (34K):
[in this window]
[in a new window]
|
Fig 1. Graph demonstrates changes in cerebral oxygen saturation during the course of the operative procedure with letters indicating various highlights. (A = cardiopulmonary bypass initiation; B = application of the cross clamp; C = period of low-flow perfusion and deep hypothermia; D = cross clamp removed and rewarming initiated; E = indication of malpositioned arterial cannula; F = cardiopulmonary bypass termination.)
|
|
|
Comment
|
|---|
Complex neonatal cardiac surgery continues to evolve. As we continue to strive for improved outcomes, newer technologies may be of use to help achieve these goals. Cerebral oximetry monitoring can have a significant impact on the quality of patient care by allowing real time changes to be made during the course of an operation. This report highlights the importance of using neurologic monitoring in the prevention of uncommon but potentially significant injuries associated with cerebral malperfusion (Fig 1).
Regional cerebral perfusion has been proposed as a method to avoid potentially deleterious long-term effects of deep hypothermic circulatory arrest [8]. One would expect a gradual decline in the rS02 value during the rewarming phase due to increased metabolic demand. Although this decline is somewhat compensated with increased flow, we also observed an increase due in part to anesthesia. A sudden unexpected decline in the rS02 indicates inadequate cerebral oxygen delivery. This must prompt a search for the cause such as a lack of adequate anesthesia, gross air embolism, or in this case an arterial cannula malposition. In order to avoid potential neurologic injury the contributing factor must be quickly identified and treated. Cerebral oximetry allows prompt identification of the problem allowing rapid treatment.
Although it is difficult to speculate the outcome in the event that cerebral oximetry had not been used, the length of time to identify the malpositioned arterial cannula would have certainly been extended along with any associated sequela. Eventually the problem would have likely been resolved, either by tactile observation of extremities, increased arterial line pressure, or delayed rewarming. Fortunately we were able to rapidly identify and correct this complication with the use of cerebral oxygen saturation monitoring.
|
References
|
|---|
- Nemoto EM, Yonas H, Kassam A. Clinical experience with cerebral oximetry in stroke and cardiac arrest Crit Care Med 2000;28:1052-1054.[Medline]
- Janelle GM, Mnookin S, Gravenstein N, Martin TD, Urdaneta F. Unilateral cerebral oxygen desaturation during emergent repair of a DeBakey type 1 aortic dissectionpotential aversion of a major catastrophe. Anesthesiology 2002;96:1263-1265.[Medline]
- Hayashida M, Kin N, Tomiota T, et al. Cerebral ischaemia during cardiac surgery in children detected by combined monitoring of BIS and near-infrared spectroscopy Br J Anaesth 2004;92:662-669.[Abstract/Free Full Text]
- Edmonds Jr HL, Ganzel BL, Austin 3rd HE. Cerebral oximetry for cardiac and vascular surgery Semin Cardiothorac Vasc Anesth 2004;8:147-166.[Medline]
- Caruso LJ, Gravenstein N, Janelle GM, Gabrielli A. Detection of oxygen delivery failure during cardiopulmonary bypassan even earlier warning technique. J Cardiothorac Vasc Anesth 2002;16:789.[Medline]
- Jobsis FF. Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters Science 1977;198:1264-1267.[Abstract/Free Full Text]
- Nollert G, Shin'oka T, Jonas RA. Near-infrared spectrophotometry of the brain in cardiovascular surgery Thorac Cardiovasc Surg 1998;46:167-175.[Medline]
- Kilpack VD, Stayer SA, McKenzie ED, Fraser Jr CD, Andropoulos DB. Limiting circulatory arrest using regional low flow perfusion J Extra Corpor Technol 2004;36:133-138.[Medline]
This article has been cited by other articles:
|
|
|
|
 
S. Chakravarti, S. Srivastava, and A. J. C. Mittnacht
Near Infrared Spectroscopy (NIRS) in Children
Seminars in Cardiothoracic and Vascular Anesthesia,
March 1, 2008;
12(1):
70 - 79.
[Abstract]
[PDF]
|
|
|
Top
Abstract
Introduction
