Original Article
The Association of Cerebral Desaturation During One-Lung Ventilation and Postoperative Recovery: A Prospective Observational Cohort Study

https://doi.org/10.1053/j.jvca.2020.07.065Get rights and content

Objectives

This study was designed to investigate whether cerebral oxygen desaturations during thoracic surgery are predictive of patients’ quality of recovery. As a secondary aim, the authors investigated the relationship among cerebral desaturations and postoperative delirium and hospital length of stay.

Design

This study was a prospective observational cohort study.

Setting

A single tertiary-care medical center from September 2012 through March 2014.

Patients

Adult patients scheduled for elective pulmonary surgery requiring one-lung ventilation.

Interventions

All patients were monitored with the ForeSight cerebral oximeter.

Measurements and Main Results

The primary assessment tool was the Postoperative Quality of Recovery Scale. Delirium was assessed using the Confusion Assessment Method. Of the 117 patients analyzed in the study, 60 of the patients desaturated below a cerebral oximetry level of 65% for a minimum of 3 minutes (51.3%). Patients who desaturated were significantly less likely to have cognitive recovery in the immediate postoperative period (p = 0.012), which did not persist in the postoperative period beyond day 0. Patients who desaturated also were more likely to have delirium (p = 0.048, odds ratio 2.81 [95% CI 1.01-7.79]) and longer length of stay (relative duration 1.35, 95% CI 1.05-1.73; p = 0.020).

Conclusions

Intraoperative cerebral oxygen desaturations, frequent during one-lung ventilation, are associated significantly with worse early cognitive recovery, high risk of postoperative delirium, and prolonged length of stay. Large interventional studies on cerebral oximetry in the thoracic operating room are warranted.

Introduction

Cerebral oximetry using near-infrared spectroscopy allows the noninvasive continuous monitoring of cerebral tissue oxygenation. The technology has been shown to correlate with jugular venous sampling, the standard of cerebral ischemia monitoring, in both pediatric1 and adult populations,2 and to correlate with mixed vascular cerebral blood oxygen saturations as well.3,4 Importantly, cerebral oxygen desaturations do not always correlate with other typical intraoperative measures such as cardiac output and peripheral pulse oximetry.5,6 Thus, near-infrared spectroscopy provides additional important information about patients’ intraoperative status. Initially, perioperative cerebral oximetry research focused on cardiac surgery patients, as this cohort had known significant incidences of delayed neurocognitive recovery, postoperative neurocognitive disorder, and cerebral vascular incidents.7, 8, 9 With increasing recognition of the incidence of cerebral oxygen desaturations, the use of this technology has expanded to include other procedures recognized as having increased risk of cerebral ischemia, including beach-chair-position orthopedic surgery, vascular surgery, thoracic surgery, and major abdominal procedures.10, 11, 12, 13, 14 Cerebral oxygen desaturations have been shown to be associated with a large variety of perioperative outcomes, including neurologic outcomes, such as delayed neurocognitive recovery and postoperative delirium; as well as non-neurologic outcomes, including acute kidney injury, overall morbidity, mortality, and length of stay,8,15, 16, 17 although the overall body of literature remains mixed and necessitates further research. Additionally, there is literature to support that tailoring anesthetic practice toward optimizing cerebral oxygenation during cardiac surgery leads to improved postoperative outcomes.18

There is a growing recognition of the importance of including patient-centered outcomes in research. Patient-centered outcomes research refers to a broad assembly of research goals that largely focus on ensuring patient and stakeholder partners in 3 research sections: planning, conduct, and dissemination.19 One segment of this larger assembly includes patient-important outcomes that reference an appreciation of patient expectations and priorities. Toward the goal of patient-centered outcomes research, one growing field of investigation in perioperative research is that of recovery.20,21 The Postoperative Quality of Recovery Scale (PQRS) is a tool developed to assess perioperative recovery of patients across multiple domains.22 It is a particularly useful tool, as it assesses both patient-important outcomes such as nausea, pain, and activities of daily living (ADL), as well as more traditional endpoints such as physiologic vitals and cognitive function.

Therefore, this study was designed to further investigate whether cerebral oxygen desaturations during thoracic surgery are predictive of patients’ recovery after surgery as measured by the PQRS. As a secondary aim, the authors investigated the relationship among cerebral oxygen desaturations and postoperative delirium and hospital length of stay. The authors hypothesized that patients with cerebral oxygen desaturation were less likely to recover and had a higher risk of developing delirium and longer lengths of stay.

Section snippets

Methods

This study was a prospective observational cohort study conducted at The Mount Sinai Hospital, with enrollment over the period of September 2012 through March 2014. Institutional review board approval was obtained at Mount Sinai Hospital, and all participants provided written informed consent. The trial was registered at clinicaltrials.gov (#NCT01835327).

The authors included adult patients scheduled for elective pulmonary thoracic surgery requiring one-lung ventilation who were willing and had

Results

Of the 130 patients assessed for inclusion in this study, 9 were excluded and 4 patients’ data were unusable; therefore, a total of 117 patients were analyzed. Patients were excluded due to lack of complete baseline data (2), final surgery included esophagectomy (1), failure to be extubated within 24 hours (4), withdrew prior to any postoperative assessment (1), or failure to have surgery (metastases found and surgery aborted) (1). Of the 117 patients, 60 of the patients desaturated below a

Discussion

This study found that cerebral oximetry desaturation events, defined as below 65% saturation for at least 3 minutes, were a frequent event (51.3%) during surgeries requiring one-lung ventilation. Furthermore, cerebral oxygen desaturations were associated with delayed neurocognitive recovery in the post-anesthesia care unit, an increased risk of delirium during hospitalization, and an increased length of stay.

Although there is increasing interest in the use of cerebral oximetry as a monitoring

Conclusion

This study found that cerebral oxygen desaturations were frequent during single-lung ventilation cases. The authors assessed postoperative recovery in this patient population using the PQRS tool, which supports a growing acknowledgement of the significance of patient-important outcomes. The authors found that intraoperative cerebral oxygen desaturations were associated significantly with delayed neurocognitive recovery, high risk of postoperative delirium, and prolonged length of stay. The

Acknowledgments

The authors acknowledge Jeffrey H. Silverstein, MD (Icahn School of Medicine at Mount Sinai), for his significant contributions to the conception, design, and execution of the study prior to his death in July 2015.

Conflicts of Interest

G. W. Fischer is a member of the speaker's bureau for Edwards Lifesciences. The other authors declare no competing interests.

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    Support for this study was provided partially by the Doris Duke Clinical Research fellowship (2012-2013). Remaining funding came from institutional and/or departmental sources.

    This was presented at a Poster Presentation at the American Society of Anesthesiologists Annual Meeting; October 2013; San Francisco, CA.

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    Published by Elsevier Inc.