Cerebral Oximetry Monitoring Clinical Protocol - Casecag.com

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Once the baselines have been set it is very important to start capturing the Society of Thoracic Surgery (STS)data. This is accomplished by entering the BASELINE + EVENTS menu and selecting INDUCTION. Thiswill start the collection of Area Under the Curve (AUC expressed in min %) data which is captured by ourcenter and reported to the STS. At the end of the case it is imperative to return to the BASELINE + EVENTSmenu and select SKIN CLOSURE to give the AUC an end point for its calculations.Clinical Use of Cerebral Oximetry in Cardiac SurgeryTwo separate clinical strategies are presently accepted related to the use of intraoperative cerebral oximetry incardiac surgical patients.Strategy IIf the baseline rSO 2 values are >50% then one must strive to maintainthe patient’s rSO 2 values no less than25% of the preoperatively establishedroom air baseline.Strategy IIIf the baseline rSO 2 values are ≤50% then one must strive to maintain thepatient’s rSO 2 values ≥ 50% 5 .If a significant cerebral desaturation ٭event is noted then follow the establishedtreatment algorithm presented below.II. Defined٭ as a drop of ≥ 8%, or a drop below a saturation of 50% if using Strategy
Cerebral Desaturation Treatment Algorithm1) Assess patient head position to insure that the head has not been inadvertently turned ormoved into any other potential anatomical malposition that may adversely affect cerebral orfacial tissue perfusion.Correct any potential anatomical malposition (e.g., head rotated or steep Trendelenburgposition as the surgical conditions permit)2) Inspect the face to detect plethora, redness or other signs of vascular congestion which mayalso be related to anatomical malposition (e.g., release any pressure on the neck from thesurgical field) and should be corrected as surgical conditions allow.Correct any potential anatomical malposition3) Assess ETCO 2 and/or PaCO 2 .If ETCO 2 or PaCO 2 are < 35 mmHg then adjust mechanical ventilation strategy to allowPaCO2 to climb to a value ≥ 40 mmHg. This can also be done on CPB by adjusting freshgas flow sweep speed in cooperation with the perfusion team.4) Assess mean arterial blood pressure (MAP).If MAP has decreased below 50 mmHg (or below approximately 20% of their baselineMAP) then administer phenylephrine (or other vasoconstrictors as appropriate) to raise theMAP to a value > 60 mmHg or higher as indicated by the patient’s preoperative MAP. Dothis in conjunction with the surgical team so that the pressure is not increased at a timewhen relative hypertension may threaten a surgical complication.5) Assess the CVP to determine if CPB cannula malposition may be impeding jugular venousdrainage or if the position of the heart may be causing a similar phenomenon.If the CVP is > 10 mmHg with a clinical suspicion that one of the above scenarios is theculprit then ask the surgeon to adjust the venous cannula position or reposition the heart asappropriate.6) Assess the cardiac index (CI).If the CI is < 2.0 L/min/m 2 in the setting of what is interpreted to be adequate cerebralperfusion pressure then administer appropriate inotropic support, or work with the perfusionteam if on CPB, to increase the CI to a value > 2.5 L/min/m 2 .7) Assess the FiO 2In patients with persistent and significant desaturations increase the FiO 2 to 100% or a valuethat increases the observed rSO 2 values to a more appropriate level (e.g., within 75% ofroom air baseline or ≥ 50% if employing Strategy II).8) If significant desaturations persist despite the above measures then consider the following:If on CPB, work with the surgical and perfusion teams to reduce the systemictemperature to effect a decrease in CMRO 2If on CPB with an IABP in situ, consider instituting pulsatile perfusion by running theIABP at a fixed rate while on CPBDeepen the anesthetic by administration of additional volatile or intravenous anestheticsto effect a decrease in CMRO 29) Assess the Hemoglobin concentrationIf the hemoglobin concentration is assessed as critically low (e.g., < 7 g/dL) consider earlyadministration of acute normovolemic whole blood if employing an acute normovolemichemodilution (ANH) technique during the case, or administer banked allogeneic red bloodcells to increase the hemoglobin concentration in an effort to improve oxygen carryingcapacity/delivery.
Page 1 and 2: Clinical Protocol †Cardiac Surgic
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Cerebral Oximetry Monitoring Clinical Protocol - Casecag.com

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