Outcomes in Cardiac Surgery Based on Preoperative, Mean Intraoperative and Stratified Cerebral Oximetry Values.

INTRODUCTION

Cardiac surgery is associated with significant morbidity and longer length-of-stay (LOS) than most other surgeries. Regional cerebral oximetry (rSO) using near-infrared spectroscopy (NIRS) on the patient's forehead monitors cerebral oxygenation during surgery and cardiopulmonary bypass (CPB). Its purpose is to detect and manage periods of cerebral hypoxia which may otherwise go undetected, thereby reducing morbidity. But outcomes have been inconsistent, and not all cardiac departments have adopted this non-invasive, simple-to-use technology. We aimed to study the efficacy of our use of rSO by recording seven outcomes for each patient according to their preoperative rSO, the mean intraoperative rSO, and four ischemic thresholds during surgery.

METHOD

This is a retrospective audit of cardiac surgical patients in whom a protocol was used to maintain rSO above the preoperative value and studied seven major morbidity outcomes. Cerebral oximetry data were recorded for each patient and analyzed for six variables: preoperative baseline rSO, mean intraoperative rSO and four ischemic thresholds defined as an area under the curve (AUC) in minutes% below the baseline rSO,minus 10% below the baseline, minus 20% the below baselineand minus 50% below baseline. Outcomes examined were: delirium, stroke, postoperative rise in creatinine of 50 mmol, absolute creatinine of 200 mmol, need for new renal replacement therapy (RRT), hospital LOS and inpatient mortality.

RESULTS

Complete data were available for 166 patients. Lower mean preoperative rSO was associated with stroke (p=0.031), mild and severe renal dysfunction (p=0.045 and p=0.036), death-in-hospital (p=0.027) and prolonged hospital LOS (p=0.005). Lower mean intraoperative rSO during surgery was associated with the outcomes of renal dysfunction, mild (p=0.027), moderate (p=0.003) or severe (p=0.002), death-in-hospital (p=0.003) and prolonged hospital LOS (p=0.015). Of the four ischemic thresholds defined, only new RRT occurring at minus 20% and minus 50% below baseline was significant.

CONCLUSION

Lower preoperative rSO and mean intraoperative rSO were associated with poor outcomes, notably leading to a significant increase in hospital LOS. Mild degrees of cerebral ischemia below the baseline and minus 10% of the baseline during surgery were well tolerated.