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Original Articles: Pediatric Cardiac

Invited Commentary

Division of Cardiac Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, 2545 Chicago Ave, South, Suite 106, Minneapolis, MN 55404

(Email: doverman{at}chc-pa.or).

The article by Phelps and colleagues [1] adds to a growing body of literature regarding the clinical application of cerebral oximetric monitoring to the perioperative care of both pediatric and adult cardiac surgical patients. For a monitoring technology to be useful, it must be accurate and reproducible, and it should prompt correlated interventions that impact clinical outcome. Debate continues over whether current cerebral oximetry technology satisfies these requirements. Experience with devices that render absolute values for cerebral oxygen content is limited, and relative values can be affected by various factors, such as cerebral blood volume, hematocrit, acid-base status, and cranial anatomy. Areas of the brain remote from the monitored frontal cortex are at risk of undetected injury, potentially limiting the usefulness of the technology in avoiding significant central nervous system insult. There is significant inter-patient variability of rSO₂ values, and a lack of a well-defined normative range. This is particularly true among children with congenital heart disease in which arterial desaturation and parallel circulatory arrangements further complicate our understanding of monitored values.

These limitations notwithstanding, the association between lower mean rSO₂ values and adverse events after Norwood palliation described by the authors are consistent with a large number of prior reports that impute clinical utility to continuous cerebral oximetry monitoring. In light of our increasing awareness of perioperative cerebral injury and its subsequent neuro-developmental impact, mechanisms to accurately surveil the cerebral environment are needed. Systemic measures of oxygen delivery such as SvO₂ or lactate are poor predictors of cerebral insult. The clinical benefit of cerebral oximetric monitoring is intuitive, and the supporting evidence is compelling. Although weaknesses of the present design and understanding of the technology require the clinician to place rSO₂ values in proper context, further design improvements and clinical understanding of its role represent a significant opportunity to improve care and outcomes.

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1. Phelps HM, Mahle WT, Kim D, et al. Postoperative cerebral oxygenation in hypoplastic left heart syndrome after the Norwood procedure Ann Thorac Surg 2009;87:1490-1494.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David M. Overman Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Overman, D. M. Search for Related Content PubMed PubMed Citation Articles by Overman, D. M. Related Collections Congenital - cyanotic Related Article