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Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation: A Novel Approach to Clinical Diagnosis

  • Kristen K. Burton
    Affiliations
    Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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  • Elizabeth A. Valentine
    Correspondence
    Address reprint requests to Elizabeth A. Valentine MD, Hospital of the University of Pennsylvania, Department of Anesthesiology and Critical Care, 3400 Spruce Street, 6 Dulles Building, Philadelphia, PA 19104.
    Affiliations
    Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Search for articles by this author
Published:November 07, 2017DOI:https://doi.org/10.1053/j.jvca.2017.08.047
      NEAR INFRARED SPECTROSCOPY (NIRS) is a noninvasive continuous monitor of the balance between tissue oxygen delivery and consumption.
      • Deschamps A.
      • Hall R.
      • Grocott H.
      • et al.
      Cerebral oximetry monitoring to maintain normal cerebral oxygen saturation during high-risk cardiac surgery: A randomized controlled feasibility trial.
      • Sorensen H.
      Near infrared spectroscopy evaluated cerebral oxygenation during anesthesia.
      NIRS reflects real-time changes in the microcirculatory tissue perfusion, and as such, allows for rapid feedback on tissue perfusion for a patient who otherwise may appear adequately resuscitated from a macrohemodynamic perspective.
      • Iyegha U.P.
      • Conway T.
      • Pokorney K.
      • et al.
      Low StO2 measurements in surgical intensive care unit patients is associated with poor outcomes.
      • Creteur J.
      Muscle StO2 in critically ill patients.
      • Leone M.
      • Blidi S.
      • Antonini F.
      • et al.
      Oxygen tissue saturation is lower in nonsurvivors than in survivors after early resuscitation of septic shock.
      NIRS is a nonspecific diagnostic tool that must be interpreted within the appropriate clinical context. Abnormal values merely suggest a problem may exist; it is incumbent upon the clinician to interpret the data to make a diagnosis and an intervention. In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Hu et al.

      Hu T, Collin Y, Carrier FM, et al. Case Series of a Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation. J Cardiothorc Vasc Anesthesia. https://doi.org/10.1053/j.jvca.2017.07.019

      describe a novel application of combined cerebral and somatic oximetry monitoring during orthotopic liver transplantation (OLT).
      It is important to understand the rationale for the use of NIRS, particularly as it relates to OLT. Cerebral oximetry has been widely employed in cardiac surgery, where evidence increasingly supports an association between intraoperative cerebral desaturation and adverse postoperative outcomes including stroke, myocardial infarction, death, impaired cognition, and increased hospital length of stay.
      • Deschamps A.
      • Hall R.
      • Grocott H.
      • et al.
      Cerebral oximetry monitoring to maintain normal cerebral oxygen saturation during high-risk cardiac surgery: A randomized controlled feasibility trial.
      • Murkin J.M.
      • Adams S.J.
      • Novick R.J.
      • et al.
      Monitoring brain oxygen saturation during coronary bypass surgery: A randomized, prospective study.
      • Slater J.P.
      • Guarino T.
      • Stack J.
      • et al.
      Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery.
      • Yao F.S.
      • Tseng C.C.
      • Ho C.Y.
      • et al.
      Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery.
      • Deschamps A.
      • Lambert J.
      • Couture P.
      • et al.
      Reversal of decreases in cerebral saturation in high-risk cardiac surgery.
      • de Tournay-Jette E.
      • Dupuis G.
      • Bherer L.
      • et al.
      The relationship between cerebral oxygen saturation changes and postoperative cognitive dysfunction in elderly patients after coronary artery bypass graft surgery.
      Use of cerebral oximetry also has been described in major vascular surgery,
      • Jonsson M.
      • Lindstrom D.
      • Wanhainen A.
      • et al.
      Near infrared spectroscopy as a predictor for shunt requirement during carotid endarterectomy.
      • Vernieri F.
      • Tibuzzi F.
      • Pasqualetti P.
      • et al.
      Transcranial Doppler and near-infrared spectroscopy can evaluate the hemodynamic effect of carotid artery occlusion.
      neurosurgery,
      • Trafidlo T.
      • Gaszynski T.
      • Gaszynski W.
      • et al.
      Intraoperative monitoring of cerebral NIRS oximetry leads to better postoperative cognitive performance: A pilot study.
      • Dunham C.M.
      • Sosnowski C.
      • Porter J.M.
      • et al.
      Correlation of noninvasive cerebral oximetry with cerebral perfusion in the severe head injured patient: A pilot study.
      • Badenes R.
      • Garcia-Perez M.L.
      • Bilotta F.
      Intraoperative monitoring of cerebral oximetry and depth of anaesthesia during neuroanesthesia procedures.
      trauma and critical care,
      • Kessel B.
      • Alfici R.
      • Korin A.
      • et al.
      Real time cerebral perfusion monitoring in acute trauma patients: A preliminary study.
      • Green M.S.
      • Sehgal S.
      • Tariq R.
      Near-infrared spectroscopy: The new must have tool in the intensive care unit?.
      and transplant surgery.
      • Nissen P.
      • Pacino H.
      • Frederiksen H.J.
      • et al.
      Near-infrared spectroscopy for evaluation of cerebral autoregulation during orthotopic liver transplantation.
      • Zheng Y.
      • Villamayor A.J.
      • Merritt W.
      • et al.
      Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation.
      Cerebral oximetry may be especially useful in OLT, which can be associated with significant hemodynamic perturbations, which may cause intraoperative cerebral ischemia and contribute to postoperative neuropsychiatric complications.
      • Zheng Y.
      • Villamayor A.J.
      • Merritt W.
      • et al.
      Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation.
      • Larsen F.S.
      • Ejlersen E.
      • Strauss G.
      • et al.
      Cerebrovascular metabolic autoregulation is impaired during liver transplantation.
      • Panzera P.
      • Greco L.
      • Carravetta G.
      • et al.
      Alteration of brain oxygenation during "piggy back" liver transplantation.
      Impaired autoregulation has been seen in up to 25% of OLT patients and may be a risk factor for adverse neurologic events.
      • Nissen P.
      • Pacino H.
      • Frederiksen H.J.
      • et al.
      Near-infrared spectroscopy for evaluation of cerebral autoregulation during orthotopic liver transplantation.
      • Zheng Y.
      • Villamayor A.J.
      • Merritt W.
      • et al.
      Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation.
      Patients undergoing OLT frequently demonstrate abnormal cerebral tissue oxygenation in the perioperative period. In one study, cerebral deoxygenation occurred in about 35% of cases (typically during the anhepatic phase) and hyperoxygenation in about 15% of cases (typically during the neohepatic phase).
      • Sorensen H.
      • Grocott H.P.
      • Secher N.H.
      Near infrared spectroscopy for frontal lobe oxygenation during non-vascular abdominal surgery.
      Plachky et al
      • Plachky J.
      • Hofer S.
      • Volkmann M.
      • et al.
      Regional cerebral oxygen saturation is a sensitive marker of cerebral hypoperfusion during orthotopic liver transplantation.
      noted a correlation between decreased cerebral oximetry during the anhepatic phase of OLT with elevated levels of neuron specific enolase and S-100, two biochemical markers of neurologic insult.
      In addition to monitoring cerebral oxygenation, NIRS can be employed to monitor somatic tissue oxygenation. Decreased somatic tissue oxygenation has been associated with severity of shock
      • Crookes B.A.
      • Cohn S.M.
      • Bloch S.
      • et al.
      Can near-infrared spectroscopy identify the severity of shock in trauma patients?.
      • Cohn S.M.
      • Nathens A.B.
      • Moore F.A.
      • et al.
      Tissue oxygen saturation predicts the development of organ dysfunction during traumatic shock resuscitation.
      as well as mortality
      • Leone M.
      • Blidi S.
      • Antonini F.
      • et al.
      Oxygen tissue saturation is lower in nonsurvivors than in survivors after early resuscitation of septic shock.
      in critically ill patients. In a prospective study, Lima et al
      • Lima A.
      • van Bommel J.
      • Jansen T.C.
      • et al.
      Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients.
      demonstrated that abnormalities in tissue oxygenation were associated with more severe organ dysfunction as indicated by statistically significant higher Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores in patients with varying shock states including septic, hypovolemic, hemorrhagic, post-traumatic, and cardiogenic shock. The role of somatic tissue oximetry in liver transplantation is not well studied; to our knowledge, this is the first study to report somatic oximetry values in this population.
      In a recent review published in this Journal, Lecluyse et al
      • Lecluyse V.
      • Couture E.J.
      • Denault A.Y.
      A proposed approach to cerebral and somatic desaturation in the intensive care unit: Preliminary experience and review.
      described a case series utilizing cerebral and somatic oximetry together as a diagnostic modality in the intensive care unit and proposed a clinical algorithm for interpretation of these data. For example: an isolated lower extremity desaturation may signify lower extremity ischemia or abdominal compartment syndrome, whereas an isolated intracranial condition may manifest as focal cerebral desaturation. A decrease in both cerebral and somatic tissue oxygenation may indicate total body malperfusion as would be seen in a profound shock state. Hu et al’s observations build upon the concept of combining cerebral and somatic oximetry data to guide perioperative decision making in OLT patients.

      Hu T, Collin Y, Carrier FM, et al. Case Series of a Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation. J Cardiothorc Vasc Anesthesia. https://doi.org/10.1053/j.jvca.2017.07.019

      Hu et al describe a prospective single-center observational case series of 10 patients undergoing OLT with the use of both cerebral and somatic oximetry monitoring.

      Hu T, Collin Y, Carrier FM, et al. Case Series of a Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation. J Cardiothorc Vasc Anesthesia. https://doi.org/10.1053/j.jvca.2017.07.019

      In this case series, the authors confirm previously reported findings, including a decreased baseline cerebral oximetry values compared with normal subjects in the setting of hyperbilirubinemia, an increase in cerebral oxygenation upon induction of general anesthesia, as well as decreased lower extremity somatic and cerebral oximetric values during caval clamping. Phlebotomy and perioperative bleeding were associated with a decrease in cerebral oxygenation, while an increase in both cerebral and somatic oximetry was seen with blood transfusion. Standard surgical technique at the author’s institution is described to be total caval clamping with vena cava resection. An interesting finding was the relatively modest decrease in cerebral oximetry with caval clamping.

      Hu T, Collin Y, Carrier FM, et al. Case Series of a Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation. J Cardiothorc Vasc Anesthesia. https://doi.org/10.1053/j.jvca.2017.07.019

      We would have expected a greater decrease in NIRS signals than reported in the absence of the use of a piggyback technique or venovenous bypass for maintenance of venous return, given the profound decrease in cardiac output that is generally associated with caval clamping.
      These data are interesting as they are the first to evaluate the feasibility of monitoring a combination of cerebral and somatic oximetry during OLT. OLT can be associated with significant hemodynamic instability, and changes in oximetry values may be evident prior to overt decompensation. Hemodynamic instability is common during OLT and may occur from a myriad of causes. Combining the information from cerebral and somatic oximetry may help refine the suspected cause of instability, leading to earlier intervention and stabilization. Whether that results in improved clinical outcomes remains to be seen.
      The authors make the observation that patients with more frequent and severe desaturation episodes experienced higher rates of postoperative complications and longer hospital lengths of stay, and the patients who did not develop perioperative complications had minimal perturbations in oximetry monitoring. However, this small, observational study lacks the power necessary to make any assertions about oximetry and postoperative outcome. The authors also describe in detail how changes in oximetry monitoring helped to confirm clinical diagnoses such as hemorrhage or abdominal compartment syndrome; it is unclear, however, whether these changes were appreciated sooner than other signs of complications (eg, hypotension or increased bladder pressure). Previous studies suggest that oximetry changes may be seen earlier than macrocirculatory dysfunction. It would be interesting to know whether oximetry changes were the first sign of an impending problem, or merely a confirmatory one. Regardless, we applaud the authors’ contribution of a proposed diagnostic algorithm for parallel and non-parallel changes in cerebral and somatic oximetry.
      Overall, this study contributes to a growing body of evidence that suggests that abnormalities in oximetry are common in the perioperative period among patients undergoing OLT. The authors are to be commended for the novel combination of cerebral and somatic oximetry in OLT, which together may serve as a useful diagnostic tool for making clinical diagnoses rapidly and in real time. The information gleaned, in turn, may allow clinicians to intervene more effectively and in a timely manner, but this remains to be seen. Recognizing the limitations of this small observational study, we hope to see a larger study, adequately powered to detect an association between NIRS and perioperative outcomes in OLT patients. Ultimately, a study evaluating whether real-time interventions based on cerebral and somatic oximetry data affect clinical outcomes is desirable.

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