Correlation and agreement of regional cerebral oxygen saturation measured from sensor sites at frontal and temporal areas in adult patients undergoing cardiovascular anesthesia.

Background: The function and viability of the brain depend on adequate oxygen supply. A decrease in cerebral blood supply causing cerebral desaturation may lead to many neurological complications. Direct measurement of regional cerebral oxygen saturation (rScO2) assists in early detection and management. Near-infrared spectroscopy (NIRS) has been introduced for measuring rScO2. A pair of sensors are attached to the right and left forehead. However, there are some situations where the forehead of the patient is not accessible for sensor attachment (e.g., neurosurgery involving the frontal area; a bispectral index (BIS) sensor already attached, or a wound to the forehead); therefore, alternate sites for sensor attachment are required. The temporal area was proposed as an alternate site. The objective of this study was to assess the correlation and agreement of rScO2 measured at the forehead vs. the temporal area. Methods: Adult patients undergoing cardiothoracic or vascular surgery were monitored for rScO2 using two pairs of ForeSight sensors. The first pair (A1 and A2) were attached to the right and left forehead, while the second pair (B1 and B2) were attached to the right and left temporal area. The rScO2 values measured from A1 vs. B1 and A2 vs. B2 were assessed for correlation and agreement using the Bland-Altman analysis. Results: Data from 19 patients with 14,364 sets of data were analyzed. The data from A1 vs. B1 and A2 vs. B2 showed moderate positive correlation (r = 0.627; P < 0.0001 and r = 0.548; P < 0.0001). The biases of A1 vs. B1 and A2 vs. B2 were -2.3% (95% CI [-2.5 to -2.2]; P < 0.0001) and 0.7% (95% CI [0.6-0.8]; P < 0.0001). The lower and upper limits of agreement of A1 vs. B1 were -17.5% (95% CI [-17.7 to -17.3]) and 12.8% (95% CI [12.6-13.0]). The lower and upper limits of agreement of A2 vs. B2 were -14.6% (95% CI [-14.8 to -14.4]) and 16.0% (95% [CI 15.8-16.3]). Conclusions: The rScO2 values measured from sensors at the frontal and temporal areas show a moderate correlation with sufficiently good agreement. The temporal area may be an alternative to the frontal area for cerebral oximetry monitoring.

Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial.

BACKGROUND: Early goal-directed therapy (EGDT) using FloTrac reduced length of stay (LOS) in intensive care (ICU) and hospital among patients undergoing coronary artery bypass graft (CABG) with a cardiopulmonary bypass. However, this platform in off-pump CABG (OPCAB) has received scant attention, so we evaluated the efficacy of EGDT using FloTrac/EV1000 as a modality for improving postoperative outcomes in patients undergoing OPCAB. METHODS: Forty patients undergoing OPCAB were randomized to the EV1000 or Control group. The Control group received fluid, inotropic, or vasoactive drugs (at the discretion of the attending anesthesiologist) to maintain a mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥ 0.5 mL kg-1 h-1; SpO2 > 95%; and hematocrit ≥ 30%. The EV1000 group achieved identical targets using information from the FloTrac/EV1000. The goals included stroke volume variation < 13%; cardiac index (CI) of 2.2-4.0 L min-1 m-2; and systemic vascular resistance index of 1500-2500 dynes s-1 cm-5 m-2. RESULTS: The EV1000 group had a shorter LOS in ICU (mean difference - 1.3 d, 95% CI - 1.8 to - 0.8; P < 0.001). The ventilator time for both groups was comparable (P = 0.316), but the hospital stay for the EV1000 group was shorter (mean difference - 1.4 d, 95% CI - 2.1 to - 0.6; P < 0.001). CONCLUSIONS: EGDT using FloTrac/EV1000 compared to conventional protocol reduces LOS in ICU and hospital among patients undergoing OPCAB. Trial registration This study was retrospectively registered at www. CLINICALTRIALS: gov (NCT04292951) on 3 March 2020.

Validation of Open-Heart Intraoperative Risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass.

BACKGROUND: A prolonged stay in an intensive care unit (ICU) after cardiac surgery with cardiopulmonary bypass (CPB) increases the cost of care as well as morbidity and mortality. Several predictive models aim at identifying patients at risk of prolonged ICU stay after cardiac surgery with CPB, but almost all of them involve a preoperative assessment for proper resource management, while one - the Open-Heart Intraoperative Risk (OHIR) score - focuses on intra-operative manipulatable risk factors for improving anesthetic care and patient outcome. OBJECTIVE: We aimed to revalidate the OHIR score in a different context. MATERIALS AND METHODS: The ability of the OHIR score to predict a prolonged ICU stay was assessed in 123 adults undergoing cardiac surgery (both coronary bypass graft and valvular surgery) with CPB at two tertiary university hospitals between January 2013 and December 2014. The criteria for a prolonged ICU stay matched a previous study (ie, a stay longer than the median). RESULTS: The area under the receiver operating characteristic curve of the OHIR score to predict a prolonged ICU stay was 0.95 (95% confidence interval 0.90-1.00). The respective sensitivity, specificity, positive predictive value, and accuracy of an OHIR score of ≥3 to discriminate a prolonged ICU stay was 93.10%, 98.46%, 98.18%, and 95.9%. CONCLUSION: The OHIR score is highly predictive of a prolonged ICU stay among intraopera-tive patients undergoing cardiac surgery with CPB. The OHIR comprises of six risk factors, five of which are manipulatable intraoperatively. The OHIR can be used to identify patients at risk as well as to improve the outcome of those patients.

A fatal adverse effect of cefazolin administration: severe brain edema in a patient with multiple meningiomas.

Cefazolin is commonly administered before surgery as a prophylactic antibiotic. Hypersensitivity to cefazolin is not uncommon, and the symptoms mostly include urticaria, skin reaction, diarrhea, vomiting, and transient neutropenia, which are rarely life threatening. We present a rare case of fatal cefazolin hypersensitivity in a female who was diagnosed with multiple meningiomas and scheduled for craniotomy and tumor removal. Immediately after cefazolin IV administration, the patient developed acute hypertensive crisis, which resolved within 10 minutes after the treatment. This was followed by unexplained metabolic acidosis. The patient then developed severe brain edema 100 minutes later. The patient had facial edema when her face was exposed for the next 30 minutes. A computed tomography scan revealed global brain edema with herniation. She was admitted to the intensive care unit for symptomatic treatment and died 10 days after surgery from multiorgan failure. The serum IgE level was very high (734 IU/mL). Single-dose administration of cefazolin for surgical prophylaxis may lead to rare, fatal adverse reaction. The warning signs are sudden, unexplained metabolic acidosis, hypertensive crisis, tachycardia, and facial angioedema predominating with or without cutaneous symptoms like urticaria.