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American Society of 

Extracorporeal Technology 

Perfusion Safety and Best Practices in 

Perfusion Meeting 

June 24 - 27, 2009 

Royal Sonesta Hotel 

New Orleans, Louisiana. USA

Session II 

Perfusion Safety: Case Reports 

Session Objective: 

To increase patient safety measures 

and decrease patient accidents. 

Can the Somanetics technology help 

us to achieve this goal l?

Cape Cod Hospital 

Cardiac Surgery Program 

in Partnership with 

Brigham & Women’s Hospital



• 2002 – 2005 

• 355 Primary CABG 

• CVA 0.0 0 (0%) 

• Mortality 2/355 (0.6%) 

• 2002 - 2009 

• 659 Primary CABG 

• CVA 1/659 (0.015%) 

• Mortality 8/659 (1.2%)

Introduction to Cerebral Oximetry

Skull 

How the INVOS System Works 

Two depths of light penetration are 

used to subtract out data from the 

skin and skull, resulting in blood 

oxygen saturation for deeper tissues 

directly underneath the sensor. 

Skin 

Light 

Emitting 

Diode 

Surface 

Photodetector 

SomaSensor 

Cerebral 

Cortex 

Deep 

Photodetector

Normative Range for rSO2 

• Adult cardiac patients 67±10 

• Left-Right differences: 5% were >10 

• 5% rSO2 baseline values < 50 

• 1.6% rSO2 baseline values < 40 

• Strong positive correlation with hemoglobin 

concentration

Transcranial Cerebral Oximetry 

On CPB 

Flow Down 

Han SH et al: The effect of bloodless pump prime on cerebral oxygenation 

in pediatric patients. Acta Anaesthesiol Scand 48:648-652, 2004

Minimal Priming Volume Strategy 

Autologus Blood Priming Technique 

Priming Volume 800 -1000 ml Normosol


On CPB

Judging the Adequacy of Perfusion 

Global Measures: 

• SVO2 Monitor 

• Mean arterial pressure 

• Blood flow index (1.8 – 2.4) 

• CVP 

• Arterial PO2, PCO2 

• Venous PO2 

• Base Deficit 

• Urine output


Reop. CABG 

Kinked Venous Cannula

Determinants of Regional 

Cerebral Oxygen Saturation (rSO2) 

• Cerebral Perfusion Pressure (CPP) 

• CPP = MAP – CVP 

• Blood flow rate 

• PaCO 2 

• PaO 2 (FIO 2 ) 

• Oxygen carrying capacity (HCT) 

• Arterial inflow temperature 

• Intact cerebral circulation 

i


Taking Venous Return


EDVH


EDVH


Anes Jet Lag


CCP Jet Lag

Baseline Asymmetry > 10 

• Carotid or Intracranial stenosis 

• Intracranial space-occupying lesion 

• Prior cerebral infarction 

• Hemangioma 

• Frontal sinus fluid 

• Skull defect 

• Subclavian steal


# 614221 Air Embolism 

Innominate Art. 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Left 

Right


• June 16, 2009 

• 73 y o Retired University President 

• Admit with USA 

• Cath; 3VD, AVA < 0.7, 5 CM AAA 

• PMH: HTN, IDDM, + Lipids, HB (Pacer) 

• Meds: ASA, HCTZ, Lipitor, Insulin 

Lisinopril.

Transcranial Cerebral Oximetry

AUC – Quantifying Risk 

O 2 

rSO 

90 

80 

70 

Baseline 

60 

50 25% from Baseline 

40 

Area Below 25% from Baseline (min%) 

30 

8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 

• AUC 

(Area Under the Curve) 

Quantifies the depth 

and duration below 

the critical i threshold 

h of 25% below baseline 

• High AUC has been 

correlated with adverse 

outcomes 

Murkin JM, et al. Anesth Analg 2007;7(6):515

Common Interventions to Correct 

Declining Cerebral Oxygen Saturation* 

• Increase blood flow rate (39pts) (67%) 

• Increase MAP (42pts) (62%) 

• Normalize PaCO 2 (34pts) (50%) 

• Deepen Anesthesia (27pts) (48%) 

• Increase FIO 2 (28pts) (43%) 

• Pulsatile Flow (6pts) (17%) 

• Check cannulas 

(both arterial & venous) 

• Increase oxygen carrying capacity 

(Murkin JM, A &A 2007 

* Intervention threshold >20% or below 50, Critical threshold > 25% or below 40

STS Database Fields 

As of January 1st, 2008 the following Cerebral Oximetry metrics 

will be collected by the STS Database: 

Pre-Induction Baseline Regional Oxygen Saturation: 

Left: ______ (%) Right _______ (%) 

Cumulative Saturation Below Threshold: 

Left: _____ (minute-%) Right _____ (minute-%) 

Cerebral Oximeter Provided The First Indication: Yes No 

Skin Closure Regional Oxygen Saturation: 

Left: _____ (%) Right _______ (%)

New rSO2 Asymmetry 

• Intraoperative Type A Dissection 

• Cannulation misadventures (art & ven) 

• Axial head rotation 

• Heart manipulation 

• Gaseous or particulate emboli 

• Subclavian steal


Anemia on CPB 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Lef t 

Right

The Effect of Age on the Brain 

• Over age 65 

15% carotid stenosis. 

> 50% 

• 30% “Silent Infarcts” 

• HTN- narrows the 

deep penetrating 

vessels. 

• Loss of Cerebral 

Autoregulation 

Sieber FE, Geriatric Anesthesia; 2007:McGraw Hill Co.

Hour rs 

200 

Control, Diabetics, n=26 

Interventions, Diabetics, n=30 

Randomized, prospective, blinded 

160 

120 

80 

40 30 

0 

9 

Ventilation* 

Study Findings 

Bringing g Diabetics in Sync with Non-Diabetics 

69 

Murkin JM, et al. Anesth Analg 2005;100:SCA101 

201.6 

Diabetic cardiac surgery patients 

monitored with the INVOS System. 

Reductions in ventilation time, ICU 

time, and LOS were statistically 

significant. 

132 “Clinical outcomes were improved to 

the point that there were no significant 

differences between diabetics i and 

non-diabetics, essentially leveling the 

playing field for patients who 

30 traditionally have had poorer 

outcomes during cardiac surgery.” 

ICU Stay* Hospital Stay* 

John M. Murkin, MD 

Professor of Anesthesiology 

University of Western Ontario, 

London, Ontario, Canada 

Murkin JM, et al. Anesth Analg 2005;100:SCA101.


3% of the rSO2 managed group experienced MOMM 

compared to 11% in the control group compared with 

13.4% for the STS database 

14 

13.4% 

12 

11% 

− Death within 30 days 

− Permanent stroke 

10 

− > 48 hours ventilation 

8 

− Renal failure requiring dialysis 

% 

6 

− Re-operation for any reason 

4 

3%* − Mediastinitis/deep sternal 

infection 

2 

0 

Morbidity 

(p

Neonatal l& Pediatric Monitoring

Benefits of Cerebral Oximetry 

• Improved Neurocognitive Function 

• Shortened ICU/ Hospital Stay 

• Decreased Stroke Rate 

• Detection of Cerebral Malperfusion 

• Early warning of Oxygen Delivery Failure 

• Detection of Cerebral Vasospasm 

• ? Transfusion Trigger

Session II 

Perfusion Safety: Case Reports 

Session Objective: 

To increase patient safety measures 

and decrease patient accidents. 

Can the Somanetics technology help 

us to achieve this goal l?


Cardiac Surgery Program

Adoption to Date 

• 645 Centers (adult & 

pediatric) nationwide 

• 185 ,000 procedures 

annually 

• 500+ Clinical 

references that speak 

to its clinical value 

• Supported by direct 

sales and clinical 

specialists coast-tocoast 

– International distributors 

Tyco Healthcare and 

Edwards LifeSciences

Intra-Operative Strategies to Avoid 

Adverse Neurologic Outcomes 

Minimize the number 

of Cerebral Emboli 

Avoid Cerebral 

Hypo-Perfusion 

Attenuate the Whole Body 

Inflammatory Response 

Epi-Aotic Scanning 

CPB Filtration. 

Single Cross Clamp 

Min. Card. Suction 

Thermal Management 

Acid Base Mgt. 

Neurologic Monitoring 

VAVD 

Surface Coatings 

Min Cardiotomy Suction 

Pharmacological Mgt. 

Anti-coagulation Mgt. 

Murkin JM, et al. Attenuation of Neurologic Injury During Cardiac Surgery. 

Ann Thorac Surg 2001;72: S1838-S1844 

Lill KJ t l O ti d P f i St t t Att t Ad 

Lilly KJ, et al. Operative and Perfusion Strategy to Attenuate Adverse 

Neurologic Outcomes. Perfusion 2006; 21:1-7


• ICU Length Of Stay for the intervention group was significantly shorter 

• Standard Deviation was also tighter, indicating fewer outlier patients 

5 

4 

Monitored 

Unmonitored 

±2.7 

Da ays 

3 

2 

1 

0 

±0.8 

1.25 1.87 

ICU Length of Stay 

(p

Study Design - Murkin 

Study Design and Hypothesis 

• Prospective, Randomized, Blinded, Cardiac Surgery Study 

• n = 200, (100 Control, 100 Intervention) 

• Data collected by an independent, blinded observer in an 

autonomous, protocol driven, “closed”, ICU 

Control Group 

n = 100, Blinded rSO2 Data Collection 

No Interventions 

R 

Intervention Group 

n = 100, rSO2 Data Collection 

Interventions per Protocol 

Murkin JM, et al. Anesth Analg 2007;7(6):515

Data Summary Page 

Data Base Summary in Run Mode

Judging the Adequacy of fPerfusion

INVOS:IN VIVO OPTICAL 

SPECTROSCOPY 

• LIGHT: NEAR- INFRARED LIGHT (NIRS) 

• WAVELENGTH 730+810 nm 

• 3 cm.depth DURA MATER+CSF 

• 4 cm. depth GRAY MATTER 

• PLACEMENT MID- FOREHEAD 

• VENOUS/ARTERIAL 75% VENOUS 

25% ART.

Post - Operative 

• Day 1, awoke with extreme agitation, 

treated with sedation (Propofol) 

• Day 3, Neuro Consult, Head CT & EEG 

Diagnosis: Metabolic Encephalopathy 

• Day 7, Propofol weaned agitation returned, 

Precedex started (1500 hrs) 

• Day 8, Woke up,followed commands, weaning 

initiated, extubated by noon, Precedex D/C 1300 

• Day 16, Discharged to rehabilitation hospital.

Perfusion Management of Acute 

Ascending Aortic Dissection: 

Does Brain Monitoring Help? 

Kevin J. Lilly CCP, Paul A. Pirudini MD, Douglas Shook MD, 

Michaela A. Smith CCP, Pam DeVellis NP, Brian Gorsach PAC, 

Bruce Campbell RPh, Pauline Philie RN , Robert J. Rizzo MD 

Division of Cardiac Surgery 

Brigham & Women’s Hospital and Cape Cod Hospital 

Harvard Medical School

AAAD 

• October 19, 2005 

• 64 yo male admitted from Falmouth Hosp to OR. 

• PMH: HTN, Hyperlipidemia, Remote Tob. 

• Pt retired 5 days PTA from Biotech. Ind. (PhD) 

• CP while building walkway, relieved with rest. 

• CP returned next day along with leg numbness, 

• Leg weakness and ataxia, drove to local ER 

• Collapsed on presentation.

AAAD 

• Admitted R/O MI, 

?TIA 

• TEE: flap ascending 

aorta. 

• 4+AI

Classification of Aortic Dissections 

Cohn LC, Edmunds LH: Cardiac Surgery in the Adult.

AAAD – Otb October 192005 19, Type I Aortic Dissection

Acute Ascending Aortic 

Dissection 

Dec 30, 2005 - 10 weeks post discharge



The Future of Cardiac Surgery

Effect of Age on Neurologic 

Outcome in CABG Surgery 

Neurologic Events 

• < 65 yrs (0.9%) 

• < 74 yrs (3.6%) 

• > 75 yrs (8.9%) 10X 

N = 2000 

Tuman KJ et al, Differential effects of age on neurologic and cardiac risks of 

coronary artery operations. J Thorac Cardiovasc Surg. 1992 Dec; 104(6): 1510-7

Risk Factors Associated with 

Adverse Neurological Events 

Type I (Focal) 

• Advanced age 

• Aortic Atherosclerosis 

• Previous Stroke 

• Diabetes 

Type II (Non-Focal) 

• Advanced Age 

• HTN 

• COPD 

• ETOH

Incidence of Type I & Type II 

Adverse Neurological Events 

• Type I,( CVA, Focal 

Injury; Coma). 31% 3.1% 

Mortality = 21% vs 2% 

LOS = 25 days vs 10 days 

• Type II, Cognitive 

Dysfunction 30% 3.0% 

LOS = 21 days 

• N = 2108

The Effect of Aging on the Brain 

• Diminuation of Brain Mass 

• Decreased Neuronal Density 

• Decreased in complexity of Neuronal 

Interconnections. 

• Increased Cerebrospinal Fluid (Hydrocephalus) 

• Reduced d production & function of 

Neurotransmitters 

Peters A, Structural changes in the normally aging cerebral cortex of primates. 

Prog Brain Res.2002;136:455-465


Physiologic changes can result in: 

• Deterioration of gait, mobility & reflexes 

• Impairment of memory, intellect & executive 

function 

• Altered sleep patterns 

• Diminished vision, hearing, taste and smell. 

Sieber FE, Geriatric Anesthesia; 2007:McGraw Hill Co.


The reduced production of Neurotransmitters: 

Acetylcholine 

Dopamine 

Norepinephrine 

Serotonin 

May be related to the development of Alzheimer’s 

Dementia, Parkinson's and may alter the brain’s 

sensitivity to volatile anesthetics




CABG Results: CVA 

Year 2002 2003 2004 2005 2006 

STS 1.9% 1.9% 2.2% 1.8% 1.65% 

Predicted 

CVA Rate 

Actual 

CVA Rate 

0% 0% 0% 0% 0%


CABG Results: Mortality 

Year 2002 2003 2004 2005 2006 

STS 2.53% 3.24% 3.43% 2.7% 3.64% 

Predicted 

Mortality 

Actual 

Mortality 

0% 0% 0% 1.9% 

(2) 

2.3% 

(2)

CCH Cardiac Surgery Program 

August 15, 2002 - August 31, 2007 

Isolated CABG 489 

Valve (all) 311 

Program 

mortality: 

16 / 844 

= 1.9% 

CABG/Other 19 

Aorta w/o CABG or Valve 7 

Tumor (+1) 5 

Other Cardiac Surgery 8 

Non pump OR cases 5 

Total lPump cases 843 

CPB assisted PCI 3 

TOTAL Cardiac surgery 

patients 

844

Cannulation Misadventures 

Cohn LC, Edmunds LH: Cardiac Surgery in the Adult.

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