Changes in cerebral oxygenation and cognitive functions during controlled hypotension

Year 2021, , 1614 - 1623, 30.12.2021

Bengü Gülhan Aydın , Gamze Küçükosman , Özcan Pişkin , Necla Gülçek Rahşan Dilek Okyay , Hilal Ayoğlu

https://doi.org/10.17826/cumj.986099

Abstract

Purpose: This study aimed to evaluate the effect of controlled hypotension on cerebral oxygen saturation and postoperative cognitive dysfunction (POCD) in patients undergoing nasal surgery.
Materials and Methods: Forty patients were randomized by a sealed envelope method into two drug groups: esmolol (Group E, n=20) or nitroglycerin (Group N, n=20) administration prior to surgical incision. The cognitive functions of the patients were evaluated by the Mini-Mental State Examination Test 1 day before and 1 day after the operation. Regional oxygen saturation was monitored with near-infrared spectroscopy to detect cerebral desaturation.
Results: The desired mean arterial blood pressure (50-65 mmHg) could be achieved in all groups. A decline in cognitive function occured in 16 patients (40%) at the 24th postoperative hour. There was no statistically significant difference between the groups in terms of POCD. There was a significant relationship between POCD and cerebral desaturation status.
Conclusion: Cerebral desaturation seen during hypotensive anesthesia may cause early POCD development, therefore we think that close cerebral and hemodynamic monitoring during hypotensive anesthesia may preserve cognitive functions.

Keywords

Hypotensive anesthesia, cerebral oxygenation, cognitive function, esmolol, nitroglycerin

Kontrollü hipotansiyon sırasında serebral oksijenasyon ve kognitif fonksiyonlarda meydana gelen değişiklikler

Abstract

Amaç: Bu çalışmada, nazal cerrahi geçiren hastalarda uygulanan kontrollü hipotansiyonun serebral oksijen satürasyonu ve postoperatif kognitif disfonksiyon (POKD) üzerindeki etkisinin değerlendirmesi amaçlandı.
Gereç ve Yöntem: Kırk hasta kapalı zarf yöntemi ile esmolol (Grup E, n=20) ve nitrogliserin (Grup N, n=20) olmak üzere iki gruba ayrıldı. Hastaların kognitif fonksiyonları operasyondan 1 gün önce ve 1 gün sonra Mini Mental Durum Testi ile değerlendirildi. Serebral desatürasyonu saptamak için rejyonel serebral oksijen satürasyonu yakın kızılötesi spektroskopi ile izlendi.
Bulgular: Tüm gruplarda istenilen ortalama arteriyel kan basıncına (50-65 mmHg) ulaşıldı. Postoperatif 24. saatte 16 hastada (%40) kognitif fonksiyonlarda azalma meydana geldi. Postoperatif kognitif disfonksiyon açısından gruplar arasında istatistiksel olarak anlamlı fark yoktu. Postoperatif kognitif disfonksiyon ile serebral desatürasyon arasında anlamlı bir ilişki olduğu görüldü.
Sonuç: Hipotansif anestezi sırasında görülen serebral desatürasyon erken POKD gelişimine neden olabilmektedir, bu nedenle hipotansif anestezi sırasında yakın serebral ve hemodinamik monitorizasyon ile kognitif fonksiyonların korunabileceğini düşünmekteyiz.

Keywords

Hipotansif anestezi, serebral oksijenasyon, kognitif fonksiyon, esmolol, nitrogliserin

References

• 1. Degoute CS, Ray MJ, Manchon M, Dubreuil C, Banssillon V. Remifentanil and controlled hypotension; comparison with nitroprusside or esmolol during tympanoplasty. Can J Anaesth. 2001;48(1):20-27.
• 2. Van Aken H, Miller D. Delibrate hypotension. In: Miller RD, editor. Anesthesia. New York, USA: Churchill Livingstone Inc.; 2000. p.1470-90.
• 3. L. Strunin. “Organ perfusion during controlled hypotension”. Br J Anaesth 1975;47(7):793-8.
• 4. M. J. Lindop. “Complications and morbidity of controlled hypotension,” Br J Anaesth 1975;47(7):799-803.
• 5. Choi SH, Lee SJ, Jung YS, Shin YS, Jun DB, Hwang KH, Liu J, Kim KJ. Nitroglycerin- and nicardipine-induced hypotension does not affect cerebral oxygen saturation and postoperative cognitive function in patients undergoing orthognathic surgery. J Oral Maxillofac Surg. 2008 Oct;66(10):2104-9
• 6. Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005;17:463– 469.
• 7. Lei L, Katznelson R, Fedorko L, Carroll J, Poonawala H, Machina M, Styra R, Rao V, Djaiani G. Cerebral oximetry and postoperative delirium after cardiac surgery: a randomised, controlled trial. Anaesthesia. 2017;72(12):1456–66.
• 8. Yu Y, Zhang K, Zhang L, Zong H, Meng L, Han R. Cerebral near-infrared spectroscopy (NIRS) for perioperative monitoring of brain oxygenation in children and adults. Cochrane Database Syst Rev. 2018;1:CD010947.
• 9. Kotekar N, Shenkar A, Nagaraj R. Postoperative cognitive dysfunction -current preventive strategies. Clin Interv Aging. 2018;13: 2267–73.
• 10. Sergio Fantini, Angelo Sassaroli, Kristen T. Tgavalekos, Joshua Kornbluth. Cerebral blood flow and autoregulation: current measurement techniques and prospects for noninvasive optical methods. Neurophotonics. 2016 ; 3(3): 031411.
• 11. Textbook of Neuroanesthesia and Neurocritical Care Volume I - Neuroanesthesia Editors Hemanshu Prabhakar, Zulfiqar Ali Bölüm: Intraoperative Monitoring of the Brain, Hironobu Hayashi and Masahiko Kawaguchi page:47-48.
• 12. Degoute CS. Controlled hypotension: a guide to drug choice. Drugs. 2007;67(7):1053-76.
• 13. Folstein MF. ‘‘Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.
• 14. Güngen C, Ertan T, Eker E, Yaşar R, Engin F. Standardize Mini Mental Test’in Türk Toplumunda Hafif Demans Tanısında Geçerlik ve Güvenilirliği Türk Psikiyatri Dergisi 2002; 13(4):273-281.
• 15. Nair S, Collins M, Hung P, Rees G, Close D, Wormald PJ. The effect of beta-blocker premedication on the surgical field during endoscopic sinus surgery. Laryngoscope 2004;114:1042-6.
• 16. Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside And esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth 1995;42:373-6.
• 17. Choi WS, Samman N. Risks and benefits of deliberate hypotension in anaesthesia: a systematic review. International Journal of Oral and Maxillofacial Surgery 2008;37(8):687-703.
• 18. Cincikas D, Ivaskevicius J. Application of controlled arterial hypotension in endoscopic rhinosurgery. Medicina (Kaunas) 2003;39(9):852-9.
• 19. Van Beek AH, Claassen JA, Rikkert MG, Jansen RW. Cerebral autoregulation: an overview of current concepts and methodology with special focus on the elderly. J Cereb Blood Flow Metab. 2008;28(6):1071-1085.
• 20. Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology. 2007;107:213–220.
• 21. Ha TN, van Renen RG, Ludbrook GL, Wormald PJ. The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery. Int Forum Allergy Rhinol. 2016 Jul;6(7):701-9. doi: 10.1002/alr.21728.
• 22. Cottrell JE, Gupta B, Rappaport H, Turndorf H, Ransohoff J, Flamm ES. Intracranial pressure during nitroglycerin-induced hypotension. J Neurosurg. 1980 Sep;53(3):309-11.
• 23. Schulz JM, Al-Khazraji BK, Shoemaker JK. Sodium nitroglycerin induces middle cerebral artery vasodilatation in young, healthy adults. Exp Physiol. 2018;103(8):1047-1055.
• 24. Zayed M, Nassar H, Hasanin A, Saleh AH, Hassan P, Saad D, Mahmoud S, Abo Bakr G, Fouad E, Saleh N, Ismail M, El-Hadi H. Effects of nitroglycerin versus labetalol on peripheral perfusion during deliberate hypotension for sinus endoscopic surgery: a randomized, controlled, double-blinded trial. BMC Anesthesiol. 2020 Apr 17;20(1):85.
• 25. Saito S, Nishihara F, Akihiro T, et al. Landiolol and esmolol prevent tachycardia without altering cerebral blood flow. Can J Anaesth. 2005;52(10):1027-1034.
• 26. Heinke W, Zysset S, Hund-Georgiadis M, Olthoff D, von Cramon DY. The effect of esmolol on cerebral blood flow, cerebral vasoreactivity, and cognitive performance: a functional magnetic resonance imaging study. Anesthesiology. 2005;102(1):41-50.
• 27. Caverni V, Rosa G, Pinto G. Hipotensive anaesthesia and recovery of cognitive function in long term craniofacial surgery. J Craniofac Surg 2005; 16: 531-6.
• 28. Li D, Liu H. Cognitive function assessment should be included in preoperative evaluation. J Biomed Res. 2017 Nov 1;32(3):161–3.
• 29. Ghoneim MM, Block RI: Clinical, methodological and theoretical issues in the assessment of cognition after anaesthesia and surgery: a review. Eur J Anaesthesiol 2012; 29: 409–22.
• 30. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008; 108: 18–30.
• 31. Erdem AF, Kayabasoglu G, Tas Tuna A, Palabiyik O, Tomak Y, Beyaz SG. Effect of controlled hypotension on regional cerebral oxygen saturation during rhinoplasty: a prospective study. J Clin Monit Comput. 2016;30(5):655-660.
• 32. Niazi AA. Postoperative cognitive function and controlled hypotensive anesthesia in patients undergoing septoplasty. Egyptian Journal of Anesthesia 2016;32:61-66.
• 33. Celebi N, Artukoglu F, Dal D, Saricaoglu F, Celiker V, Aypar U. Effect of hypotensive anesthesia on cognitive functions. A comparison of esmolol and remifentanil during tympanoplasty. Saudi Med J. 2007;28(9):1357-1361.
• 34. Tobias JD. Cerebral oxygenation monitoring: near-infrared spectroscopy. Expert Rev Med Devices. 2006;3:235–43.
• 35. Brady KM, Lee JK, Kibler KK, Smielewski P, Czosnyka M, Easley RB, Koehler RC, Shaffner DH. Continuous time-domain analysis of cerebrovascular autoregulation using near-infrared spectroscopy. Stroke. 2007 Oct; 38(10):2818-25.
• 36. Zheng Y, Villamayor AJ, Merritt W, Pustavoitau A, Latif A, Bhambhani R, Frank S, Gurakar A, Singer A, Cameron A, Stevens RD, Hogue CW. Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation. Neurocrit Care. 2012 Aug;17(1):77-84.
• 37. Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Seminars in cardiothoracic and vascular anesthesia. 2007;11(4):274-81.
• 38. Turan E, Kol İÖ , Avcı O , İsbir AC , Kaygusuz K, Gürsoy S. Effect of Laparoscopic Bariatric Surgery on Cerebral Oxygenation. Turkiye Klinikleri J Med Sci. 2019;39(2):135-43.
• 39. Sun S, Liu NH, Huang SQ. Role of cerebral oxygenation for prediction of hypotension after spinal anesthesia for caesarean section. J Clin Monit Comput 2016;30:417–21.
• 40. Aguirre JA, Etzensperger F, Brada M, et al. The beach chair position for shoulder surgery in intravenous general anesthesia and controlled hypotension: Impact on cerebral oxygenation, cerebral blood flow and neurobehavioral outcome. J Clin Anesth. 2019;53:40-48.
• 41. Yao FS, Tseng CC, Ho CY, Levin SK, Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2004;18(5):552-558.
• 42. Zheng F, Sheinberg R, Yee MS, Ono M, Zheng Y, Hogue CW. Cerebral near-infrared spectroscopy monitoring and neurologic outcomes in adult cardiac surgery patients: a systematic review. Anesth Analg. 2013;116(3):663-76.
• 43. Visti T. Foss, Robin Christensen, Kim Z. Rokamp, Peter Nissen, Niels H. Secher, Henning B. Nielsen . Effect of phenylephrine vs. ephedrine on frontal lobe oxygenation during caesarean section with spinal anesthesia: an open label randomized controlled trial Front Physiol. 2014; 5: 81.
• 44. Bajwa SJ, Kaur J, Kulshrestha A, Haldar R, Sethi R, Singh A. Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation. J Anaesthesiol Clin Pharmacol. 2016;32(2):192-197.
• 45. Blau WS, Kafer ER, Anderson JA. Esmolol is more effective than sodium nitroprusside in reducing blood loss during orthognathic surgery. Anesth Analg. 1992 Aug;75(2):172-8.
• 46. Ghodraty M, Khatibi A, Rokhtabnak F, Maleki M, Parsa F. Comparing Labetalol and Nitroglycerine on Inducing Controlled Hypotension and Intraoperative Blood Loss in Rhinoplasty: A Single-Blinded Clinical Trial. Anesth Pain Med. 2017 25;7(5):e13677.