| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
Department of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Departments of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston Texas, Department of Pediatric Cardiac Anesthesiology, Lucile Packard Children’s Hospital at Stanford, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
Address correspondence to Dean B. Andropoulos, MD, 6621 Fannin WT19345H, Houston TX 77030. Address email to dra{at}bcm.tmc.edu
 |
Abstract |
|---|
 Top Abstract IntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
IMPLICATIONS: Brain monitoring for pediatric cardiac surgery (near infrared cerebral oximetry, transcranial Doppler ultrasound, and processed electroencephalogram) is now readily available and has the potential to improve neurological outcomes.
|
Introduction |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
-stat (not correcting ABG for temperature) versus pH stat (correcting ABG for temperature), hematocrit on bypass, and the rate and extent of cooling and rewarming. When assessing neurological outcome in children after open-heart surgery, clinicians and investigators often assume that these children are neurologically normal before surgery. However, central nervous system (CNS) malformations are more frequent in patients with congenital heart disease, specifically those with hypoplastic left heart syndrome (HLHS), where brain dysgenesis may approach 30% (6,11). In addition, children with chromosomal defects, particularly those with microdeletions of chromosome 22, have a more frequent incidence of CNS abnormalities, as do neonates with coarctation of aorta (12,13). Hence, these developmental brain disturbances contribute to the incidence of brain injury in the perioperative setting.
Although vital organs are routinely monitored during congenital heart surgery with CPB, the brain is not typically monitored. Any strategy for prevention or rescue from adverse neurological events during CPB must start with the routine use of neurological monitoring systems that allow easy, reliable, and reproducible detection of these events. Despite the availability of several modalities of monitoring for almost 20 years, in our opinion neurological monitoring during CPB remains in its infancy. In this article, we review the currently available modalities for neurological monitoring during congenital heart surgery in children and present preliminary evidence that such monitoring improves neurological outcome in this high-risk population.
|
Electroencephalographic Monitors |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
The Bispectral Index (BIS) monitor (Aspect Medical Systems, Newton, MA) is one device approved by the United States Food and Drug Administration (FDA) currently used to assess the depth of anesthesia. BIS sensor electrodes are applied to the forehead and temple, producing a frontal-temporal montage that connects to a processing unit. The device is easy to use; electrode placement is not difficult, and the monitor requires no calibration or warm up time. Via a proprietary algorithm of Aspect Corporation based on the normal adult EEG, BIS uses Fourier transformation and bispectral analysis of a one-channel processed EEG pattern to compute a single number, the BIS (16). This index ranges from 0 (isoelectric EEG) to 100 (awake) with mean awake values in the 90–100 range in adults, infants, and children (17). The real-time unprocessed EEG wave form of the BIS can be used to recognize EEG burst suppression or electrical silence, which could be useful in alerting the anesthesiologist of the need to continue cooling before the initiation of DHCA. Even this use has limitations; rarely, for example, an isoelectric EEG in the newborn infant may not correlate with a lack of all cortical activity (18). The BIS is subject to motion artifact, electromyographic activity, and radiofrequency interference from electrical equipment in the operating room. BIS values are anesthetic-specific; for example, the BIS value in children at 1 MAC halothane is 56, versus 36 for 1 MAC isoflurane, although at awakening the values are identical (19).
During CPB, hemodilution and temperature changes alter pharmacokinetics and pharmacodynamics of opioid anesthetics, which can lead to awareness under anesthesia (20). The overall incidence of awareness in adults undergoing cardiac surgery varies from 1.1% (21) to 23%, which is more than that reported for general surgical procedures (22,23). Although there are no documented reports of awareness under anesthesia in children undergoing heart surgery, BIS or other EEG monitoring is potentially useful to detect a level of anesthetic depth associated with awareness. In a cohort of children undergoing open-heart surgery with an anesthetic tailored for "fast-tracking," BIS increased during rewarming, a period considered at risk for awareness under anesthesia (24). However, in this study, and in a similar study in infants <1 year of age, BIS did not correlate with stress hormone levels, a surrogate for light levels of anesthesia, nor with plasma fentanyl levels (25). Additional studies are needed to determine the utility of the BIS monitor in infants and children undergoing CPB with or without DHCA.
The Patient State Index (PSI) (Physiometrix, Inc, N. Billerica, MA) is a FDA-approved 4-channel processed EEG monitor also based on the adult EEG, which may have less dependence on the anesthetic used than the BIS (26). Comparison of the BIS and PSI in adults revealed a wide variation in individual values associated with loss of consciousness during induction of anesthesia, and there was a significant incidence of erroneous classification of the patient being unconscious when they could follow commands (27). The BIS and PSI demonstrated only about 70% accuracy in predicting loss or return of consciousness. Other drawbacks of the PSI include the larger area necessary for sensor placement on the front of the forehead compared with the BIS, which competes with other neurological monitors, such as near-infrared cerebral oximeter.
It is difficult to recommend EEG monitoring for routine use in infants and children undergoing pediatric CPB at this time. Reasons include the paucity of pediatric studies, particularly with the PSI, and the finding that EEG changes were responsible for only 5% of abnormal neurological monitor findings in a large pediatric study (4), and that these abnormal readings on the EEG did not appear to correlate with adverse postoperative outcomes.
|
Monitors of Cerebral Oxygenation |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
The proximal detector in the Somanetics INVOS system (Somanetics, Inc. Troy, MI) detects light absorbed by extracranial tissues and is subtracted from the total signal (detected by the distal electrode), leaving only the intracranial contribution. The pediatric model (INVOS 5100) is designed for patients weighing 4–40 kg and uses a different algorithm that takes into account the thinner skull and extracranial tissues of infants and children (32). This device is FDA-approved for use in children, is compact, simple to use, and requires no warm up. It uses two near-infrared wavelengths: 730 and 810 nm. The INVOS processor displays a numerical value; the rSO2i, which is the ratio of oxyhemoglobin to total hemoglobin in the light path. The rSO2i is reported as a percentage on a scale from 15% to 95%. A cerebral blood volume index, representing the total hemoglobin in the light path, can also be calculated. This measurement may be used as an estimate of cerebral blood volume, although currently it can be used for research purposes only because it is not FDA approved owing to insufficient data correlating it with other measurements of cerebral blood volume.
The NIRO 300 (Hamamatsu Photonics, Hamamatsu, Japan) uses spatially resolved spectrophotometry to calculate absolute concentrations of oxygenated hemoglobin and total hemoglobin rather than hemoglobin saturations. Theoretically, this could lead to improved accuracy; however, this device is not FDA approved. Prototype cerebral oximeters using frequency-domain technology are under development and have the potential to measure absolute rather than calculated rSO2i (28).
Direct comparison of the INVOS 4100 and NIRO 300 in healthy anesthetized adults during normocapnia, hypocapnia, and hypercapnia revealed a positive correlation for data points in both absolute values, and change from baseline values (r = 0.58 and 0.85, respectively) (25). Bland-Altman comparison of the 2 devices demonstrated that although the correlation was good when all 60 values were combined, there may be large differences by individual comparison (33). The INVOS 5100 pediatric sensor tends to read significantly higher (by 14% ± 8%) than the NIRO 300 4 cm interoptode sensor (pediatric equivalent) (31). Regardless of the device used, it is important to note that all devices measure combined arterial and venous blood oxygen saturation and the values obtained will therefore not be identical to measured jugular venous bulb oxygen saturation (SjvO2). Therefore, maneuvers that increase arterial oxygen saturation, e.g., increasing FIO2, will increase cerebral oxygenation as measured by these devices, but may not change the SjvO2. These devices are best used as trend monitors, with each patient serving as his or her own control, and a 20% relative decrease from baseline may be a clinically important change in the Somanetics system (4). Newer software versions continuously calculate and display the relative change from baseline and allow labeling of significant events, such as the start of CPB or DHCA.
In an attempt to validate the noninvasive measurement of rSO2i in children with congenital heart disease SjvO2 and rSO2i have been compared. In one study of 40 infants and children undergoing congenital heart surgery or cardiac catheterization, the correlation for paired measurements was poor except for infants less than 1 year of age (34). In another study of 30 infants and children undergoing cardiac catheterization, an excellent correlation (r = 0.93) was found (35). Greeley et al. (36) derived cerebral metabolic rate for oxygen consumption (CMRO2) from cerebral blood flow measurements calculated using 133Xe washout technology and jugular venous and arterial oxygen saturation measurements in infants and children undergoing congenital heart surgery. They compared CMRO2 to changes in oxygenated hemoglobin (HbO2) signal measured by NIRS and demonstrated important parallels. After DHCA, cerebral blood flow and CMRO2 were depressed, whereas HbO2 was increased when compared with patients undergoing continuous bypass without DHCA. Recovery from DHCA produced low CMRO2 and a limited ability to use oxygen, resulting in an increased HbO2 signal.
Near-infrared light is also absorbed by Cu++ atoms of cytochrome a,a3, making NIRS a potentially useful monitor of cerebral intraneuronal oxygen delivery by assessing the redox state of cytochrome molecules in the electron chain of the mitochondria. The Hamamatsu NIRO 300 can measure cytochrome redox state. However, the light absorption by hemoglobin is an order of magnitude greater than that of cytochrome a,a3, and the cytochrome a,a3 absorption signal is highly dependent on hematocrit, bringing into question the validity of these readings (37).
Animal Models with Relevance to Pediatric Cardiac Surgery
Animal models have well known limitations; however, important data have been generated using such models that support the use of NIRS as a monitor that measures meaningful changes in brain oxygenation that reflect disturbances in neuronal functioning. Low rSO2i can lead to cell dysfunction, cell death, and by extension, poor neurological outcome in these models. These studies cannot be done in humans for obvious reasons. In a model of graded cerebral hypoxemia at normothermia in neonatal piglets with a baseline rSO2i of 68%, Kurth et al. (38) determined that the threshold for half of the animals to experience an increased cerebral lactate concentration was a rSO2i of 44%. Minor EEG changes occurred in half of the animals at an rSO2i of 42%, major EEG change at an rSO2i of 37%, and decreased brain adenosine triphosphate in half of the animals at an rSO2i of 33%. rSO2i also strongly correlated with sagittal sinus oxygen saturation, cerebral blood flow measured by laser Doppler flowmetry, and PaO2.
In piglet models of DHCA, Sakamoto et al. (39,40) used NIRS under varying conditions: differing hematocrits (20% versus 30%) and temperatures (15°C versus 25°C), pH-stat versus -stat blood gas management, and varying lengths of DHCA (60–100 minutes). They determined that the nadir of rSO2i occurred sooner at higher temperatures, lower hematocrits, and with -stat blood gas management. The time spent at the nadir of rSO2i correlated with neurological outcome determined both behaviorally and on neuropathologic examination: all animals with rSO2i nadir time <25 minutes were free of any evidence of neurological injury.
In another piglet model, NIRS detected cerebral desaturation when the superior vena cava (SVC) was partially or totally occluded during CPB. No other measurements were affected by this maneuver: arterial blood pressure, heart rate, SVC pressure measurements in the case of partial occlusion, or mixed venous oxygen saturation measured in the bypass circuit. Cerebral desaturation may develop in infants if they have SVC obstruction during SVC cannulation for bypass or in patients undergoing cavopulmonary anastomosis, where the SVC is often partially occluded (41).
Clinical Data in Pediatric Cardiac Surgery
Baseline preoperative rSO2i as measured by a frequency-domain oximeter varies with different cardiac lesions (29). The baseline rSO2i breathing room air is approximately 70% in acyanotic patients without large left to right intracardiac shunts; rSO2i for cyanotic patients is usually 40%–60%. Ramamoorthy et al. (42) exposed neonates with unrepaired HLHS to two different inspired gas mixtures to control pulmonary overcirculation. Those treated with 17% inspired oxygen had rSO2i averaging 53%, and those who received 21% oxygen and 3% inspired CO2 had rSO2i averaging 68%; however, there were no significant differences in the arterial saturation between groups. Significant decreases in rSO2i occur during periods of hemodynamic instability or arterial desaturation (43). Increases in rSO2i occur during cooling and vary with the rate of temperature change. Improvements in cardiac output and oxygen delivery result in an increase in rSO2i. Characteristic changes in cerebral oxygenation occur during CPB in children with or without DHCA (Fig. 1) (43).
|
Recent studies using -stat blood gas management for simpler surgeries (i.e., ventricular septal defect or tetralogy of Fallot repair) and mild or moderate hypothermia of 25°C–35°C have demonstrated a lower rSO2i in the patients undergoing bypass with colder temperatures (25°C–28°C) versus warmer bypass at 32°C–35°C (46,47). This suggests that the cerebral vasoconstriction from decreased PaCO2 at the lower temperature decreases oxygen delivery more than the effect of cooling to decrease CMRO2, resulting in lower rSO2i. These studies demonstrate that NIRS may play a role in more moderate hypothermia because approximately 30% of patients in these studies experienced significant cerebral oxygen desaturation (absolute rSO2i <50%, or more than 20% relative decrease from baseline). Finally, in a study of cyanotic patients with aortopulmonary collaterals undergoing hypothermic CPB and randomized to -stat versus pH stat blood gas management, rSO2i was significantly lower in the -stat group (48).
Relationship Between Low rSO2i and Adverse Neurological Outcome
Clinical evidence suggests a correlation between low rSO2i and adverse neurological outcome. A study of 26 infants and children undergoing surgery with bypass and DHCA found that the 3 patients with low rSO2i had acute postoperative neurological changes: seizures in 1 and prolonged coma in 2 (44). In these 3 patients the increase in rSO2i was much less after the onset of CPB (average 3% relative increase versus 33% increase in patients without neurological deficit) and the duration of cooling before DHCA was shorter. Austin et al. (4) studied 250 pediatric patients undergoing cardiac surgery with bypass and found that 41% of patients experienced prolonged periods of relative cerebral oxygen desaturation, defined as more than 20% decrease less than prebypass baseline. One-quarter of these patients with cerebral desaturation had postoperative adverse neurological events consisting of prolonged coma, seizures, or hemiparesis.
It would be intuitive to conclude that low rSO2i as measured by NIRS leads to adverse neurological outcomes and therefore should be monitored and treated. The studies cited above support this notion. However, additional prospective outcome data in infants and children using this modality are necessary. An additional limitation of the NIRS monitor is that it measures rSO2i in only a small tissue volume of the frontal cerebral cortex; other areas of the cortex and deeper structures in the brain are not assessed by this technique. It would be useful to attempt to correlate abnormal rSO2i with the frequency of changes detected by magnetic resonance imaging after CPB in newborns, specifically periventricular leukomalacia (49).
Other Uses of NIRS
Other important areas of investigation include correlating the rSO2i with mixed venous oxygen saturation (SvO2) to assess whether it can be used as a noninvasive measure of SvO2. Preliminary data suggest that measured SVC HbO2 saturation correlates well in infants with congenital heart disease after cardiac surgery (50). Other potential uses of this technology include measuring HbO2 saturation in subdiaprhagmatic viscera (e.g., kidney and intestines). There is evidence that these values decline significantly during aortic cross-clamping for coarctation repair (51) and are preserved during cerebral RLFP; this may have implications for end organ function (52,53).
|
Transcranial Doppler Ultrasound |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
The most consistent and reproducible technique for clinical use in patients of all ages is to monitor the middle cerebral artery (MCA) through the temporal window, which can usually be found just above the zygoma and just anterior to the tragus of the ear (54). Several transducer probes are available, ranging from very small disk probes suitable for infants and children, to larger, heavier probes for adolescents and adults. The depth of the sample volume and angle of insonation is adjusted until the bifurcation of the MCA and the anterior cerebral artery (ACA) is detected. This is heralded by a maximal antegrade signal (positive deflection, toward the transducer) from the MCA, accompanied by a retrograde signal from the ACA (negative deflection, away from the transducer) of the same or very similar velocity and wave form as the MCA flow.
In infants, an alternative site for monitoring is through the anterior fontanelle, using a hand-held pencil-type probe, placing the probe over the lateral edge of the fontanelle, and aiming caudally, at a greater depth than for the temporal window, at the internal carotid artery. The depth of measurement and normal flow velocities for the MCA through the temporal window are listed in Table 1 (55). These normal velocities were determined in awake children without cardiovascular disease, under perfect examination conditions. Lesions producing large diastolic runoff (e.g., large patent ductus arteriosus) will decrease diastolic blood flow to the brain. Hemodynamic instability, less than optimal probe positioning, and general anesthesia may reduce these velocities in clinical practice. Typically the clinician must accept a stable baseline for the individual patient and use it as the basis for comparison. Fixation of the probe in the optimal position is problematic. There are several commercial devices available for fixation in larger patients (Table 2), but in practice it is often simpler to affix a small disk Doppler probe with a clear adhesive dressing and clear tape over the temporal window of infants and children, assuring access and some mobility to the probe for the frequent adjustments that may be necessary. Currently available FDA approved TCD manufacturers are listed in Table 2.
|
|
-stat blood gas strategy was used, which can produce relative cerebral vasoconstriction during cooling in smaller arterioles downstream to the MCA and ACA (57). TCD of the MCA through the temporal window was used to describe the cerebral pressure-flow velocity relationship during hypothermic bypass in 25 neonates and infants <9 months old. CBFV was examined over a wide range of cerebral perfusion pressure varying from 6 to 90 mm Hg at 3 temperatures: normothermia (36°C–37°C), moderate hypothermia (23°C–25°C), and profound hypothermia (14°C–20°C). Cerebral pressure flow autoregulation was preserved with normothermia, partially affected with moderate hypothermia, and totally lost with profound hypothermia; these results agree with previous research performed using xenon washout to quantitate cerebral blood flow (58).
TCD has also been used to determine the threshold of detectable cerebral perfusion during low-flow CPB. Zimmerman et al. (59) studied 28 neonates during bypass undergoing the arterial switch operation with -stat blood gas management. At 14°C–15°C, bypass flow was sequentially reduced to 0 mL · kg–1 · min–1. All patients had detectable CBFV more than 20 mL · kg–1 · min–1, although one had no perfusion at 20 mL · kg–1 · min–1 and 8 had none at 10 mL · kg–1 · min–1, leading the authors to conclude that 30 mL · kg–1 · min–1 was the minimum acceptable flow in this population. Andropoulos et al. (60) used TCD of the MCA to determine the level of bypass flow necessary during RLFP for neonatal aortic arch reconstruction. They studied 34 neonates and established a baseline mean CBFV under full flow bypass (150 mL · kg–1 · min–1) using pH stat management at 17°C–22°C: a mean of 22 cm/s. These authors then used the TCD signal to determine the necessary bypass flow during RLFP, a mean of 63 mL · kg–1 · min–1. Interestingly, this level of bypass flow did not correlate with mean arterial blood pressure in the radial artery or rSO2i measured by NIRS. The necessary CPB flow as determined by TCD varied widely, leading the authors to conclude that TCD was a valuable monitor to ensure adequate but not excessive cerebral blood flow during this complicated perfusion technique. The TCD is a useful monitor to detect acute decreases in CBFV; this can allow for adjustment of bypass cannulae, which might avert a neurological disaster (61,62).
Isolated cerebral emboli are a frequent occurrence during open-heart surgery in children. Emboli are easily detected by TCD, although false positive artifacts from electrocautery and physical contact with the ultrasound transducer occur (63). True emboli have characteristic audio and visual signals and are designated as high intensity transient signals (HITS) that can be counted by the TCD software. The HITS counter can be an accurate gauge of the number of emboli detected in the artery being monitored; however, it does not distinguish false positive artifacts, and if a large number of emboli are detected in a short period of time, the number counted is meaningless. In actual practice, the anesthesiologist can observe the monitor intermittently and decide whether the number of emboli detected is clinically significant and initiate treatment. Despite the potential utility of this monitor to detect emboli, one study found that the number of emboli detected in the carotid artery during pediatric congenital heart surgery does not appear to correlate with acute postoperative neurological deficits (63). Another limitation of emboli detection is that it only occurs after the fact; however, limitation of further emboli may be possible with this monitor.
One caveat when usng TCD clinically is that this device measures CBFV rather than blood flow. CBFV is dependent on the diameter of the blood vessel, whereas cerebral blood flow depends on cerebral vascular resistance, which changes in response to changes in CO2, temperature, cerebral perfusion pressure, and bypass flow. Thus, changes in CBFV often correlate well with changes in cerebral blood flow in the individual patient, particularly at deep hypothermia when autoregulation is lost and the caliber of the blood vessels is unchanged. However, the clinician must always estimate the state of the patient’s cerebral vascular resistance to translate TCD into meaningful information for clinical decision-making.
|
Multimodality Neurological Monitoring |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
In this study EEG changes were responsible for only 5% of the monitoring abnormalities, with NIRS changes responsible for 58% and TCD 37%. The 26% incidence of acute neurological complications in the pretreatment phase of this study is more than most other reports of neurological outcomes after congenital heart surgery (3). Although this study was prospective, it was neither randomized nor controlled. However, it represents the best evidence that multimodality neurological monitoring, particularly NIRS and TCD, in conjunction with a treatment algorithm can reduce adverse neurological outcomes during congenital heart surgery. A modification of the treatment algorithm used in the Austin et al. study (4) is presented in Table 3. These modifications account for the anesthesiologist being the interpreter of the monitors (instead of a dedicated technician as used in the Austin et al. study) and the use of these monitors in the pre- and post-CPB periods. Eliminating the need for a separate technician obviates the problems of technician availability and third-party reimbursement for placement and interpretation of the neurological monitors. It should be noted that although low rSO2i values have been correlated with acute gross neurological outcomes, there are no data correlating low rSO2i with either more subtle neuropsychological dysfunction or long-term neurodevelopmental outcomes in congenital heart disease.
|
|
Adverse Effects of Neurological Monitoring |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
|
Conclusion |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
|
References |
|---|
|
TopAbstractIntroductionElectroencephalographic MonitorsMonitors of Cerebral OxygenationTranscranial Doppler UltrasoundMultimodality Neurological...Adverse Effects of Neurological...ConclusionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  V. Y. Chock and A. S. Davis Bedside Cerebral Monitoring to Predict Neurodevelopmental Outcomes NeoReviews, March 1, 2009; 10(3): e121 - e129. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. C. Hirsch, J. R. Charpie, R. G. Ohye, and J. G. Gurney Near-infrared spectroscopy: What we know and what we need to know--A systematic review of the congenital heart disease literature J. Thorac. Cardiovasc. Surg., January 1, 2009; 137(1): 154 - 159. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. D. Tobias Cerebral Oximetry Monitoring with Near Infrared Spectroscopy Detects Alterations in Oxygenation Before Pulse Oximetry J Intensive Care Med, November 1, 2008; 23(6): 384 - 388. [Abstract] [PDF]
|
|
|
|
|
|
M. Redlin, A. Koster, M. Huebler, W. Boettcher, N. Nagdyman, R. Hetzer, H. Kuppe, and W. M. Kuebler Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants: relevance of near-infrared spectroscopy. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 962 - 967. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. D. Tobias Cerebral Oximetry Using Near-Infrared Spectroscopy Aids in the Diagnosis of Interrupted Aortic Arch J Intensive Care Med, September 1, 2008; 23(5): 335 - 337. [Abstract] [PDF]
|
|
|
|
 |
|
 P. M. A. Lemmers, M. C. Toet, and F. van Bel Impact of Patent Ductus Arteriosus and Subsequent Therapy With Indomethacin on Cerebral Oxygenation in Preterm Infants Pediatrics, January 1, 2008; 121(1): 142 - 147. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. N. Fenton, K. Lessman, K. Glogowski, S. Fogg, and K. F. Duncan Cerebral Oxygen Saturation Does Not Normalize Until After Stage 2 Single Ventricle Palliation Ann. Thorac. Surg., April 1, 2007; 83(4): 1431 - 1436. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. D. Williams and C. Ramamoorthy Brain monitoring and protection during pediatric cardiac surgery. Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2007; 11(1): 23 - 33. [Abstract] [PDF]
|
|
|
|
|
|
J. D. Tobias Cerebral Oximetry Monitoring Provides Early Warning of Hypercyanotic Spells in an Infant with Tetralogy of Fallot J Intensive Care Med, March 1, 2007; 22(2): 118 - 120. [Abstract] [PDF]
|
|
|
|
 |
|
 W. M Medlin and J. J Sistino Cerebral oxygen saturation changes during modified ultrafiltration Perfusion, November 1, 2006; 21(6): 325 - 328. [Abstract] [PDF]
|
|
|
|
|
|
G. M. Hoffman Neurologic Monitoring on Cardiopulmonary Bypass: What Are We Obligated to Do? Ann. Thorac. Surg., June 1, 2006; 81(6): S2373 - S2380. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T.-Y. Hsia and P. J. Gruber Factors Influencing Neurologic Outcome After Neonatal Cardiopulmonary Bypass: What We Can and Cannot Control Ann. Thorac. Surg., June 1, 2006; 81(6): S2381 - S2388. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. D. Kussman, D. Wypij, J. A. DiNardo, J. Newburger, R. A. Jonas, J. Bartlett, E. McGrath, and P. C. Laussen An Evaluation of Bilateral Monitoring of Cerebral Oxygen Saturation During Pediatric Cardiac Surgery Anesth. Analg., November 1, 2005; 101(5): 1294 - 1300. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. R. Mariano, L. F. Chu, C. T. Albanese, and C. Ramamoorthy Successful Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula in a Newborn with Single Ventricle Physiology Anesth. Analg., October 1, 2005; 101(4): 1000 - 1002. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Azakie, J. Muse, M. Gardner, K. L. Skidmore, S. P. Miller, T. R. Karl, and P. S. McQuillen Cerebral oxygen balance is impaired during repair of aortic coarctation in infants and children J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 830 - 836. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
