valeur en délirium cas de benedir pilote deschamps exemple ... · • cerebral oximetry is the...
TRANSCRIPT
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• Valeur en délirium
• Cas de Benedir
• Pilote Deschamps
• Exemple Algorythme: cardio
• Revoir cours Vancouver 2012 fev
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Disclosure
• Research grant
• Unrestricted research grant
• Speaker fees
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Cerebral oximetry What does it predict?
André Denault MD PhD FRCPC,CSPQ, ABIM-CCM, FASE President of the CVT section of the CAS
Professeur agrégé de cliniqueDépartement d’anesthésiologie
Institut de Cardiologie de MontréalService des soins intensifs
Centre Hospitalier Universitaire de Montréal
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A: « Airway »
B: « Breathing »
C: Circulatory monitor
D: Diagnostic
E: Expectency of survival
Capnography
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Key questions
• Why talking about NIRS?
• What detemines the value?
• Does NIRS change outcome?
• How can we use it?
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Key questions
• Why talking about NIRS?
• What detemines the value?
• Does NIRS change outcome?
• How can we use it?
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Ultimate Objective of
Resuscitation
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August 2011
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Goal in the OR and ICU
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Goal in the OR and ICU
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80 year-old CABG(September 16th 2011)
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Goal in the OR and ICU
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"Emerging hypothesis is that SctO2 monitoring may be an index of
overall organ perfusion and injury. “
" Our finding that a statistically significant model using SctO2 data
predicted ICU and hospital LOS underscores this point
…and suggests that future studies may investigate the cost-
effectiveness of this form of monitoring and intervention. "
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Invos™ 5100
Cerebral Oximetry
Equanox™
Fore-Sight™
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Receptors
Transmitter
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Mode of operation
• Photons with two separate wavelenght are captures by a receptor
• The photons will penetrate superficial and deep tissues down to the frontal cortex
• The superficial signal is substracted from the final signal
(“Spatially resolved NIRS”)
• The final signal originates from deeper cortical tissue
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Oxygen saturation monitoring of the distal region
of the ACA and MCA (watershed)
Light SourceLight Source
Shallow
Detector
Deep
Detector
Shallow
DetectorDeep
Detector
Periosteal
Dura Matter
Skin TissueBone
Superior
Sagittal Sinus
Brain
Photons direction
ANTERIOR
CEREBRAL ARTERY
MIDDLE
CEREBRAL ARTERY
ANTERIOR
CHOROIDAL
ARTERY
POSTERIOR
CEREBRAL ARTERY
INVOS
Theory of Operation
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Edmonds HL, Jr., APSF Newsletter 14(3):25-32, 1999
Awake baseline rSO2
40 50 60 70 80 90
30%
25%
20%
15%
10%
5%
0%
Cardiac surgical patients: rSO2 65 ± 9 (47 à 83, 2 SD).
Normal volunteer: rSO2 70 ± 6 (58 à 82, 2 SD).
rSO2 baseline valuesNormal healthy volunteer and cardiac surgical patients
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Key questions
• Why talking about NIRS?
• What detemines the value?
• Does NIRS change outcome?
• How can we use it?
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rSO2 modulation
Cerebral O2
metabolism
Cerebral O2
transport
Normal valueSaO2
PCO2
Hb
CPP
CO or VR
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Brain desaturation
Cerebral O2
transport
Abnormal value
SaO2
PCO2
Hb
CPP
CO or VR
Cerebral O2
metabolism
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Normal value
Cerebral O2
metabolism
Cerebral O2
transport
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Temperature
monitoring
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44 year-old ♀ under
cardiopulmonary bypass
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Decreases in rSO2 of 20% from baseline, or below 50, are cause for concern.
Larger declines have been demonstrated to be associated with neurological
dysfunction in a variety of clinical situations.Roberts KW, Anesthesiol 89: A934, 1998.
Edmonds HL, Jr., Anesth Analg 86:SCA13, 1998.
Carlin RE, J Clin Anest 10:109-113, 1998.
Cho H, J Neurosurg 89: 533-538, 1998.
Higami T, Ann Thor Surg 67:1091-6, 1999.
85
50
40
100
80
60
40
20
0
-10%
-20%
-30%
Absolu
te V
alu
es r
SO
2
Change F
rom
Baselin
e
Baseline
Significant changes in rSO2 Below 75% of the baseline for 15 seconds
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Intraoperative desaturation
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Preoperative desaturation
Intraoperative desaturation
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Total Population (n=1176)
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Euroscore > 10 (n = 102)
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Montreal Heart Institute and CHUM
experience before 2002
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Courtesy of Alan Mutch
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Montreal Heart Institute and CHUM
experience 2002-2012
(n ≈ 3000)• Cardiac Surgery
– 50% complex surgery– Minimally invasive surgery
• Non-Cardiac Surgery: Vascular
• Cardiology– Electrophysiology– Hemodynamic: percutaneous valve program
• Intensive Care - CHUM– Neurosurgery– Shock– Transplant
• Research: 6 publications, 3 reviews, 1 book chapter and 5 research project, online training program
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Montreal Heart Institute
personal experience 2002-2012
(n ≈ 866)
• Cardiac Surgery
1464 cases since 1999
Brain oximetry available in 26 patients who died post-operatively
Overall mortality:• Significant intraoperative desaturation in 16 patients (61.5%)
Death within 48 hours:• Significant intraoperative desaturation in 10 patients (100%)
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61 yo ♀ cardiogenic shock
Pulmonary venous flow
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75 yo ♀ CABG and AVR
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Key questions
• Why talking about NIRS?
• What detemines the value?
• Does NIRS change outcome?
• How can we use it?
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Monitoring
April 14, 1912 April 14, 1912
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«In high-risk surgical patients, the use of a hemodynamic
protocol to maintain tissue perfusion decreased mortality and
postoperative organ failure»
Anesth Analg 2011:112:1384-91
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Anesthesia Analgesia 2007
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Anesthesia Analgesia 2007
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56/100 patients with episodes of
desaturation: treated with
success in 80.4%
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• 48 high risk patients randomised
• 35/48 (72.9%) brain desaturation
• 89.6% success rate in correcting rSO2
• Area under the curve
– Control 729.7 ± 1260 % min
– Treatment 154.3 ± 218.3 % min
• Duration of mechanical ventilation
– Control 28.2 ± 54.3 hours
– Treatment 14.8 ± 6.3 hours
• ICU desaturation
– Control 68.4% vs treatment 37.5%
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Key questions
• Why talking about NIRS?
• What detemines the value?
• Does NIRS change outcome?
• How can we use it?
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Seminars of Cardiothoracic and Vascular Anesthesia 2007
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8 steps approach
• Based on the determinants of brain oximetry
• Inspired by interventional studies
(Casati 2005, Murkin 2007, Slater 2009)
• Priority-based, logical and fast
(60 seconds)
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6
7 8
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Transesophageal
echocardiography
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12
3
4
5
6
7 8
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Acute desaturation:
true or false?
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Step #4Step #4
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Ventilation and rSO2
Yao et al Anesthesiology 2000
Cere
bra
l satu
ration (
%)
End-tidal CO2 (mmHg)
During hyperventilation
From hyperventilation to normal ventilation
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Cardiopulmonary
bypass
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82 yo ♀ scheduled for AVR:
rSO2 during CPB
pH 7.45
PCO2 32
PO2 375
During
desaturation
After
ventilation
pH 7.35 ↓
PCO2 42 ↑
PO2 294 ↓
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Step #5Step #5
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54 yo ♀ CABG and interatrial
mass resection
Baseline SrO2 55-51
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54 yo ♀ CABG and interatrial
mass resection
Baseline SrO2 55 baseline now 48 during CPB
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Step #6
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74 yo ♂ before
CABG +AVR77 yo ♀ return to OR
after CABG
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Hemodynamic monitor
• Baseline values determined by cardiac
function
• Better that the PA catheter to determine if
cardiac function is normal or not
• Useful in all types of shock states
• Useful to determine the efficacy of the
intervention
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Before CPB CPB weaning
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Hemodynamic monitor
• Baseline values determined by cardiac
function
• Better that the PA catheter to determine if
cardiac function is normal or not
• Useful in all types of shock states
• Useful to determine the efficacy of the
intervention
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Right ventricular failure Left ventricular outflow
tract obstruction
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A: «Airway» for true hypoxia
B: «Breathing» adequacy
C: Circulatory monitor
D: Diagnostic
E: Expectency of survival(biomarker)
Brain oximetry:
what does it predict?
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In Summary• Cerebral oximetry is the monitoring of trends based on the absorption of
near-infrared light in oxygenated/non-oxygenated blood.
• Several variables will influence final values
• Baseline value before cardiac surgery has prognostic implication
• The severity of intraoperative desaturation correlates with post-operative
complications, neuro-cognitive deficiencies and the length of hospital stay
• Two randomized studies (Murkin 2007, Slater 2009) support its usefulness in
cardiac surgery
• It’s role in the ICU is promising and under current investigation
• The impact of monitoring essentially depends on:
– The use of a systematic approach and adequate training
– The comprehension and communication level of the operating room and ICU
team
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L’équipe de recherche:
Denis Babin
MSc Inh
Jean-Claude Tardif
MD FRCP
Alain Deschamps
MD FRCPC PhD
Jean Lambert PhD
Biostatistique
Pierre Couture
MD FRCPC
Louis P.Perrault
MD PhD FRCSC
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Les étudiants
PhD
Anne Nguyen Paul Gavra Francois Haddad MD
Hosam Ased Julián AndrésGarcía Duitama
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Les étudiants
Master
Christian Ayoub MD
Maxime Laflamme MD
Éric Piette MD
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L’équipe de recherche:
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FEBRUARY 2009
A. Deschamps, PhD, MD
Validation of NIRS
Protocol
279 patients48:48, male:femaleMean of 63 (28-87) years of ageComplex surgeries onlyProspective - observationalAnesthesiologists follow algorithmEvents are recordedSuccess of intervention recorded
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FEBRUARY 2009
A. Deschamps, PhD, MD
• AVR - 26.0% • CABG - 23.5%• Aortic - 9.9%• MVR - 8.0%• REDO - 6.8%• MVRepair - 6.8%• TVRepair - 6.2%• Other - 6.2%• Congenital - 2.5%• PVRepair - 2.2%• ASD - 1.2%• Pericardiotomy - 0.6%
Types of surgeries
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FEBRUARY 2009
A. Deschamps, PhD, MD
Cerebral Desaturations
Baseline NIRS values
Right: mean 68, 35 - 86
Left: mean 68, 29 - 89
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FEBRUARY 2009
A. Deschamps, PhD, MD
% Patients 487%
Pre CPB 27.3%
During CPB 56.1%
Post CPB 16.7%
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FEBRUARY 2009
A. Deschamps, PhD, MD
• ↑ PA -33.3% • ↑ PaCO2 - 28.33%• ↑ PaO2 - 8.33%• Transfusion - 8.33%• Reposition Cannula - 8.33%• ↑ Cardiac Function - 8.33%• Change head position - 3.33%• ↑ Anesthesia - 1.67%
Types of interventions
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FEBRUARY 2009
A. Deschamps, PhD, MD
Success rate
88.7% (70% required more than 1 intervention)
5 x ↓ cerebral sat were not attemptedAll with hypothermic cardiac arrest