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CARDIOVASCULAR ANESTHESIA

Cerebral Oxygen Desaturation After Cardiopulmonary Bypass in a Patient with Raynaud's Phenomenon Detected by Near-Infrared Cerebral Oximetry

Jesse H. Aron, MD^*, Gregory W. Fink, MD, Michael F. Swartz, PA, Brant Ford, PA, Michael C. Hauser, MD^*, Colleen E. O'Leary, MD^*, and Ferenc Puskas, MD, PhD^*

From the Departments of *Anesthesiology, Surgery, and Division of Cardiothoracic Surgery, SUNY Upstate Medical University, Syracuse, New York.

Address correspondence and reprint requests to Ferenc Puskas, MD, PhD, Department of Anesthesiology, University of Colorado at Denver, and Health Sciences Center, 4200 East 9th Ave., B113, CO. Address e-mail to ferenc.puskas{at}uchsc.edu.

	Abstract

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Raynaud's phenomenon is characterized by episodes of arterial vasospasm precipitated by cold stress, usually affecting the digits of the hands. There is controversy about the occurrence of vasospasm in internal organ systems. In this report, we present a case of Raynaud's peripheral vasospasm accompanied by cerebral oxygen desaturation as detected by near infrared cerebral oximetry after separation from cardiopulmonary bypass.

	Introduction

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Raynaud's phenomenon is a vascular disease occurring in 3%–5% of the general population characterized by episodes of vasospasm primarily affecting the digits. These attacks are usually triggered by cold ambient temperatures or a stressful situation (1,2). Although controversial, vasospasm affecting the central nervous system or other vital organs has been suggested based on case series (3,4). We present a case of a patient with Raynaud's phenomenon who developed cerebral oximetric desaturation, possibly due to cerebral vasospasm after separation from cardiopulmonary bypass following cardiac surgery.

	CASE REPORT

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A 67-yr-old woman with a 40-yr history of Raynaud's phenomenon suffered an acute myocardial infarction complicated by mitral valve regurgitation, congestive heart failure, and atrial fibrillation 3 mo prior to admission. Her medical history was significant for hypertension treated with a diuretic and a 100 pack-year history of tobacco use. She stated her Raynaud's episodes were more frequent in cold weather or in an air-conditioned room. Cardiac catheterization showed significant stenosis of two coronary arteries and an estimated left ventricular ejection fraction of 45%. The patient was scheduled for coronary artery bypass grafting, mitral valve repair, and a modified MAZE procedure.

On the day of surgery, the patient complained of mild pain and numbness in both hands and toes when she was placed on the operating room table. General anesthesia was induced with intravenous midazolam and maintained with fentanyl, and isoflurane with vecuronium. A left femoral arterial catheter was placed without complications. Cerebral oxygen saturation (rSO₂) was measured with a near-infrared cerebral oximeter (INVOS 5100B Cerebral Oximeter, Somanetics Corporation, Troy, MI) using bilateral forehead probes. Initial cerebral oximetry readings (Fig. 1) before induction of anesthesia while breathing room air were 65% on the left and 55% on the right, with Spo₂ of 100%. After the commencement of cardiopulmonary bypass the patient's temperature was reduced to 34°C. A steady decline in cerebral saturation was observed reaching a nadir of 54% on the left and 44% on the right despite a Svo₂ of approximately 80%. The decline was attributed to hemodilution, and thus she was given two units of packed red blood cells. Subsequently, bilateral cerebral saturations returned to baseline levels. In anticipation of separation from bypass, infusions of milrinone at a rate of 0.5 µg · kg^–1 · min^–1, without an initial loading dose, and epinephrine 0.08 µg · kg^–1 · min^–1 were begun. During weaning from cardiopulmonary bypass a precipitous decrease in the bilateral rSo₂ was noted (Fig. 1). At the same time, the pulse oximetry waveform was unattainable, despite moving the probe to different monitoring sites. Arterial blood gas analysis revealed 100% arterial oxygen saturation and a Pao₂ of 497 mm Hg. Her mean arterial blood pressure was 76 mm Hg, CI 1.9 L · min^–1 · m^–2 and Svo₂ was 77%. A single dose of 40-µg nitroglycerin was given intravenously for suspected Raynaud's related vasospasm. Immediately the cerebral oximetric readings increased bilaterally to the mid the 60% range and the Spo₂ to 100%. A nitroglycerin infusion was subsequently started at 0.6 µg · kg^–1 · min^–1. The patient's cerebral oximetry remained at baseline until the end of the procedure. The patient emerged from anesthesia without clinical evidence of neurological impairment or perioperative myocardial infarction. She had an otherwise uneventful recovery from surgery without further Raynaud's episodes and was discharged from the hospital on the seventh postoperative day.

View larger version (12K): [in this window] [in a new window]   Figure 1. Time course of near-infrared cerebral oxygen saturation monitoring data. CPB, cardiopulmonary bypass; NTG, nitroglycerin.

	DISCUSSION

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Raynaud's phenomenon is a vascular disorder triggered by cold or emotional stress and resulting in exaggerated vasoconstriction and vasospasm of the digital arteries and arterioles. The fingers and less often the toes are affected, but the ear lobes, lips, nose, and nipples may also be involved (1). The vascular supply to the internal organs is usually protected from hypothermia by homeostatic mechanisms for maintaining core temperature. During cardiac surgery, though, manipulations in core temperature are often instituted. There is a controversy regarding the occurrence of vasospasm in the pulmonary, myocardial, or cerebral vasculature (3,4). In this report, we present a patient who developed evidence of peripheral Raynaud's vasospasm accompanied by cerebral oxygen desaturation suggestive of cerebral vascular involvement during rewarming on cardiopulmonary bypass. The use of the phosphodiesterase inhibitor, milrinone, a suggested therapeutic treatment option for Raynaud's phenomenon, did not prevent or improve the vasospasm, which was subsequently promptly relieved by nitroglycerine. It is possible that a higher dose of milrinone or use of an initial loading dose to increase the blood levels of the drug might have resulted in relief of vasospasm.

Raynaud's phenomenon can be grouped into two categories: primary (idiopathic) or secondary, related to other underlying conditions such as systemic sclerosis (2). The pathophysiology of Raynaud's phenomenon is believed to be due to a functional imbalance between vasodilatation and vasoconstriction in the microvasculature. Ferraccioli et al. (3) reported reduced cerebral blood flow suggesting central nervous system vasospasm using single photon emission computed tomography after a cold stress in nine patients with secondary Raynaud's. An epidemiologic study by Gelber et al. (2) found that individuals with Raynaud's syndrome have a more than twofold increased frequency of heart disease and an almost threefold increase in physician-diagnosed stroke. In contrast, a prospective pilot study found no significant increase in mean pulmonary artery pressures after peripheral vasospasm triggered by cold stress in patients with scleroderma (4).

Near-infrared spectroscopy (NIRS) provides a measurement of rSo₂ in the frontal cerebral cortex via two skin-mounted detectors placed on the forehead. A deep detector penetrates to the cerebral tissue while a shallow detector picks up signals from more superficial tissue and the skull. The cerebral oximetry system subtracts the surface reflections from the deeper readings to enhance fidelity (5). Indeed a 90% correlation between white matter tissue Po₂ and NIRS was previously demonstrated (6). It seems likely that the cerebral desaturation we detected in our case was, in fact, due to low tissue oxygen saturation, probably secondary to cerebral vasoconstriction. Possible interference due to extracranial vasoconstriction cannot, however, be excluded.

In summary, cardiac surgery with cardiopulmonary bypass results in temperature variations that have the potential to precipitate Raynaud's attacks in affected individuals. Our case suggests that vasoconstriction of the CNS vessels might accompany peripheral vasoconstriction during cardiac surgery related to core temperature perturbations or vasopressor use. Monitoring with NIRS is advocated for patients with Raynaud's phenomenon undergoing cardiac surgery.

	Footnotes

 
Accepted for publication January 3, 2007.

None of the authors received any financial support from Somanetics Corporation the manufacturer of the INVOS 5100B used in this report.

	REFERENCES

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1. Herrick AL. Pathogenesis of Raynaud's phenomenon. Rheumatology (Oxford) 2005;44:587–96.[Medline]
2. Gelber AC, Wigley FM, Stallings RY, et al. Symptoms of Raynaud's phenomenon in an inner-city African-American community: prevalence and self-reported cardiovascular comorbidity. J Clin Epidemiol 1999;52:441–6.[Web of Science][Medline]
3. Ferraccioli G, Di Poi E, Di Gregorio F, et al. Changes in regional cerebral blood flow after a cold hand test in systemic lupus erythematosus patients with Raynaud's syndrome. Lancet 1999;354:2135–6.[Web of Science][Medline]
4. Mukerjee D, Yap LB, Ong V, et al. The myth of pulmonary Raynaud's phenomenon: the contribution of pulmonary arterial vasospasm in patients with systemic sclerosis related pulmonary arterial hypertension. Ann Rheum Dis 2004;63:1627–31.[Abstract/Free Full Text]
5. Edmonds HL Jr, Ganzel BL, Austin EH III. Cerebral oximetry for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth 2004;8:147–66.[Medline]
6. Rothoerl RD, Faltermeier R, Burger R, et al. Dynamic correlation between tissue PO₂ and near infrared spectroscopy. Acta Neurochir Suppl 2002;81:311–3.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Aron, J. H. Articles by Puskas, F. Search for Related Content PubMed PubMed Citation Articles by Aron, J. H. Articles by Puskas, F.