TY - JOUR
T1 - American society for enhanced recovery and perioperative quality initiative joint consensus statement on the role of neuromonitoring in perioperative outcomes
T2 - Cerebral near-infrared spectroscopy
AU - The Perioperative Quality Initiative (POQI) 6 Workgroup
AU - Thiele, Robert H.
AU - Shaw, Andrew D.
AU - Bartels, Karsten
AU - Brown, Charles H.
AU - Grocott, Hilary
AU - Heringlake, Matthias
AU - Gan, Tong Joo
AU - Miller, Timothy E.
AU - McEvoy, Matthew D.
AU - Hughes, Christopher G.
AU - Boncyk, Christina S.
AU - Culley, Deborah J.
AU - Fleisher, Lee A.
AU - Leung, Jacqueline M.
AU - McDonagh, David L.
AU - Chan, Matthew T.V.
AU - Hedrick, Traci L.
AU - Egan, Talmage D.
AU - Garcia, Paul
AU - Koch, Susanne
AU - Purdon, Patrick L.
AU - Ramsay, Michael A.
N1 - Funding Information:
Name: Robert H. Thiele, MD. Contribution: This author helped served as the chair of NIRS workgroup and helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: R. H. Thiele has received funding from NIH/NIGMS (K08GM115861). Name: Andrew D. Shaw, MB, FRCA, FFICM, FCCM, MMHC. Contribution: This author helped served as cochair of NIRS workgroup and helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: A. D. Shaw is a consultant for Edwards Lifesciences, FAST BioMedical, and Astellas. Name: Karsten Bartels, MD, PhD. Contribution: This author helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: K. Bartels has received funding from NIH/NIDA (K23DA040923). Name: Charles H. Brown IV, MD, MHS. Contribution: This author helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: C. H. Brown IV has received funding from NIH/NIA (K76AG057020) and has consulted for and has a data share agreement with Medtronic. Name: Hilary Grocott, MD, FRCPC, FASE. Contribution: This author helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: H. Grocott is editor in chief of the Canadian Journal of Anesthesia and has funding from Canadian Institutes of Health Research (CIHR) investigating transfusion triggers in cardiac surgery (TRICS-III). Name: Matthias Heringlake, MD. Contribution: This author helped with conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: M. Heringlake reports honoraria for lectures and scientific advice by Covidien/Medtronic and scientific support by CAS Medical systems. Name: Tong Joo Gan, MD.
Funding Information:
Contribution: This author helped with organization of the conference, conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: T. J. Gan is a consultant for Acacia, Edwards Lifesciences, Mallinckrodt, Medtronic, and Merck. Name: Timothy E. Miller, MB, ChB, FRCA. Contribution: This author helped with organization of the conference, conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: T. E. Miller receives research grant and is a consultant for Edwards Lifesciences. Name: Matthew D. McEvoy, MD. Contribution: This author helped with organization of the conference, conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Conflicts of Interest: M. D. McEvoy receives research grants from Edwards Lifescience, Cheetah Medical, Tennessee Department of Health, and GE Foundation—all unrelated to this study. This manuscript was handled by: Gregory J. Crosby, MD.
Funding Information:
Funding: The Perioperative Quality Initiative-6 consensus conference was supported by unrestricted educational grants from the American Society for Enhanced Recovery and the Perioperative Quality Initiative, which have received grants from Baxter, Bev MD, Cadence, Cheetah Medical, Edwards, Heron Pharmaceutical, Mallinckrodt, Masimo, Medtronic, Merck, Trevena, and Pacira. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). A full list of contributors can be found at the end of the article. Reprints will not be available from the authors. Address correspondence to Matthew D. McEvoy, MD, Departments of Anesthesiology and Surgery, Vanderbilt University Medical Center, 1301 Medical Center Dr, TVC 4648, Nashville, TN 37232. Address e-mail to matthew.d.mcevoy@vumc.org.
Publisher Copyright:
© 2020 International Anesthesia Research Society.
PY - 2020
Y1 - 2020
N2 - Some neurological complications following surgery have been related to a mismatch in cerebral oxygen supply and demand that may either lead to more subtle changes of brain function or overt complications like stroke or coma. Discovery of a perioperative neurological complication may be outside the treatment window, thereby making prevention an important focus. Early commercial devices used differential spectroscopy to measure relative changes from baseline of 2 chromophores: oxy- and deoxyhemoglobin. It was the introduction of spatially resolved spectroscopy techniques that allowed near-infrared spectroscopy (NIRS)-based cerebral oximetry as we know it today. Modern cerebral oximeters measure the hemoglobin saturation of blood in a specific “optical field” containing arterial, capillary, and venous blood, not tissue oxygenation itself. Multiple cerebral oximeters are commercially available, all of which have technical differences that make them noninterchangeable. The mechanism and meaning of these measurements are likely not widely understood by many practicing physicians. Additionally, as with many clinically used monitors, there is a lack of high-quality evidence on which clinicians can base decisions in their effort to use cerebral oximetry to reduce neurocognitive complications after surgery. Therefore, the Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together an international team of multidisciplinary experts including anesthesiologists, surgeons, and critical care physicians to objectively survey the literature on cerebral oximetry and provide consensus, evidence-based recommendations for its use in accordance with the GRading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature. The group produced the following consensus recommendations: (1) interpreting perioperative cerebral oximetry measurements in the context of a preinduction baseline value; (2) interpreting perioperative cerebral oximetry measurements in the context of the physiologic variables that affect them; (3) using caution in comparing cerebral oximetry values between different manufacturers; (4) using preoperative cerebral oximetry to identify patients at increased risk of adverse outcomes after cardiac surgery; (5) using intraoperative cerebral oximetry indexed to preinduction baseline to identify patients at increased risk of adverse outcomes after cardiac surgery; (6) using cerebral oximetry to identify and guide management of acute cerebral malperfusion during cardiac surgery; (7) using an intraoperative cerebral oximetry-guided interventional algorithm to reduce intensive care unit (ICU) length of stay after cardiac surgery. Additionally, there was agreement that (8) there is insufficient evidence to recommend using intraoperative cerebral oximetry to reduce mortality or organ-specific morbidity after cardiac surgery; (9) there is insufficient evidence to recommend using intraoperative cerebral oximetry to improve outcomes after noncardiac surgery.
AB - Some neurological complications following surgery have been related to a mismatch in cerebral oxygen supply and demand that may either lead to more subtle changes of brain function or overt complications like stroke or coma. Discovery of a perioperative neurological complication may be outside the treatment window, thereby making prevention an important focus. Early commercial devices used differential spectroscopy to measure relative changes from baseline of 2 chromophores: oxy- and deoxyhemoglobin. It was the introduction of spatially resolved spectroscopy techniques that allowed near-infrared spectroscopy (NIRS)-based cerebral oximetry as we know it today. Modern cerebral oximeters measure the hemoglobin saturation of blood in a specific “optical field” containing arterial, capillary, and venous blood, not tissue oxygenation itself. Multiple cerebral oximeters are commercially available, all of which have technical differences that make them noninterchangeable. The mechanism and meaning of these measurements are likely not widely understood by many practicing physicians. Additionally, as with many clinically used monitors, there is a lack of high-quality evidence on which clinicians can base decisions in their effort to use cerebral oximetry to reduce neurocognitive complications after surgery. Therefore, the Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together an international team of multidisciplinary experts including anesthesiologists, surgeons, and critical care physicians to objectively survey the literature on cerebral oximetry and provide consensus, evidence-based recommendations for its use in accordance with the GRading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature. The group produced the following consensus recommendations: (1) interpreting perioperative cerebral oximetry measurements in the context of a preinduction baseline value; (2) interpreting perioperative cerebral oximetry measurements in the context of the physiologic variables that affect them; (3) using caution in comparing cerebral oximetry values between different manufacturers; (4) using preoperative cerebral oximetry to identify patients at increased risk of adverse outcomes after cardiac surgery; (5) using intraoperative cerebral oximetry indexed to preinduction baseline to identify patients at increased risk of adverse outcomes after cardiac surgery; (6) using cerebral oximetry to identify and guide management of acute cerebral malperfusion during cardiac surgery; (7) using an intraoperative cerebral oximetry-guided interventional algorithm to reduce intensive care unit (ICU) length of stay after cardiac surgery. Additionally, there was agreement that (8) there is insufficient evidence to recommend using intraoperative cerebral oximetry to reduce mortality or organ-specific morbidity after cardiac surgery; (9) there is insufficient evidence to recommend using intraoperative cerebral oximetry to improve outcomes after noncardiac surgery.
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U2 - 10.1213/ANE.0000000000005081
DO - 10.1213/ANE.0000000000005081
M3 - Review article
C2 - 33079868
AN - SCOPUS:85094222451
SN - 0003-2999
VL - 131
SP - 1444
EP - 1455
JO - Anesthesia and analgesia
JF - Anesthesia and analgesia
IS - 5
ER -