Year : 2014 | Volume
| Issue : 2 | Page : 178-182
Effect of slow versus rapid rewarming on jugular bulb oxygen saturation in adult patients undergoing open heart surgery
Mohmaed Shaaban Ali1, Sameh Abd Al Rhman Sayed2, Maged Salah Mohamoud3, Sayed Kaoud Abd-Elshafy4, Mohamed Gomaa Almaz4
1 Departments of Anesthesia, Assiut University Hospital, Assiut, Egypt
2 Department of Cardiothoracic Surgery Department, Assiut University Hospital, Assiut, Egypt
3 Department of Clinical Pathology Department, Assiut University Hospital, Assiut, Egypt
4 Departments of Anesthesia Assiut University Hospital, Assiut, Egypt
Mohmaed Shaaban Ali
Department of Anesthesia, Assiut University Hospital, Assiut, PO Box 71111
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||16-Apr-2014|
Background: A debate has appeared in the recent literature about the optimum rewarming strategy (slow vs. rapid) for the best brain function. This study was designed to compare the effect of slow versus rapid rewarming on jugular bulb oxygen saturation (SjO 2 ) in adult patients undergoing open heart surgery. Materials and Methods: A total of 80 patients undergoing valve and adult congenital heart surgery were randomly allocated equally to rapid rewarming group 0.5 (0.136)°C/min and slow rewarming group 0.219 (0.055)°C/min in jugular bulb sampling was taken before, during and after surgery. Surgery was done at cardiopulmonary bypass (CPB) temperature of 28-30°C and rewarming was performed at the end of the surgical procedure. Results: CPB time, rewarming period were significantly longer in the slow rewarming group. Significant difference was observed in the number of the desaturated patients (SjO 2 ≤ 50%) between the two groups; 14 (35%) in rapid rewarming versus 6 (15%) in the slow rewarming group; P = 0.035 by Fisher's exact test. Conclusions: Slow rewarming could reduce the incidence of SjO 2 desaturation during rewarming in adult patients undergoing open heart surgery.
Keywords: Cardiopulmonary bypass, jugular bulb oxygen saturation, rapid rewarming, slow rewarming
|How to cite this article:|
Ali MS, Sayed SA, Mohamoud MS, Abd-Elshafy SK, Almaz MG. Effect of slow versus rapid rewarming on jugular bulb oxygen saturation in adult patients undergoing open heart surgery. Saudi J Anaesth 2014;8:178-82
|How to cite this URL:|
Ali MS, Sayed SA, Mohamoud MS, Abd-Elshafy SK, Almaz MG. Effect of slow versus rapid rewarming on jugular bulb oxygen saturation in adult patients undergoing open heart surgery. Saudi J Anaesth [serial online] 2014 [cited 2020 Aug 8];8:178-82. Available from: http://www.saudija.org/text.asp?2014/8/2/178/130698
| Introduction|| |
Despites advances in cardiopulmonary bypass (CPB) practice, brain injury after cardiac surgery with CPB remains a major concern. Although the etiology of brain injury is complex, it may be due to cerebral hypoperfusion, cerebral emboli, impaired cerebral oxygenation, systemic inflammatory response and brain hyperthermia during rewarming. ,,
Several studies have examined the impact of bypass temperature on post-operative cerebral outcome with a resultant increased awareness of the importance of CPB temperature management strategies. ,,, This increased awareness has likely led to evolution of temperature management.
However, a debate has appeared in the recent literature about the optimum rewarming strategy (slow vs. rapid) for the best brain function. During the rewarming from cold CPB, the brain can be exposed to periods of hyperthermia, impaired cerebral oxygenation that may lead to impaired brain function after CPB. ,,,,
Jugular bulb oxygen saturation (SjO 2 ) reflects the global balance between cerebral oxygen supply and demand. This balance has been shown to be impaired during rewarming from cold CPB 28°C. ,,,, Croughwell et al. found that SjO 2 ≤ 50% occurred in 23% of patients during the rewarming and in 16 patients out of 19 (84%) in Sapire's et al. study.  Such periods of jugular bulb desaturation during the rewarming were associated of impaired neurocognitive function. ,
Slow rewarming has been associated with better neurocognitive function  and improvement in SjO2  than rapid rewarming in patients' undergoing coronary artery bypass graft (CABG) surgery.
The aim of this study was to compare the effect of two rewarming strategies (slow vs. rapid) on SjO 2 , in adult patients undergoing open heart surgery using CPB.
| Materials and Methods|| |
After obtaining the local research ethical committee approval and written informed consent, 80 patients were randomly allocated by block randomization into two groups according to the rewarming technique used; rapid rewarming or conventional (n = 40) and slow rewarming (n = 40).
Adult patients undergoing open heart surgery (either rheumatic valve surgery or correction of adult congenital heart disease ventricular septal defect and atrial septal defect) were involved in this study. Patients with previous cardiac surgery, uncontrolled hypertension, pre-operative history of neurological impairment (symptomatic cerebrovascular disease with residual deficits) or psychiatric illness requiring treatment or insulin-dependent diabetes mellitus were excluded from the study.
All patients were pre-medicated with oral diazepam 10 mg 60-90 min before surgery. Anesthesia was induced by propofol (2-3 mg/kg), fentanyl (5-10 μg/kg) and pancuronium (0.1 mg/kg) was given to facilitate endotracheal intubation. Anesthesia was maintained with supplemental isoflurane (0.5-1.0%) in O 2 /air, propofol (2-5 mg/kg/h), fentanyl (1-2 μg/kg/h) and incremental doses of pancuronium were given as required.
Continuous monitoring of mean arterial pressure (MAP), right atrial pressure, electrocardiogram, oxygen saturation and intermittent monitoring of blood gases, electrolytes and clotting analysis were done.
A non-pulsatile heart-lung machine was used (COBE) (Cardiovascular, Inc. ARVADA and Co., 80004-3599, USA) with a flow rate of 2.2-2.4 l/min/m 2 body surface area and a membrane oxygenator. The pump was primed with crystalloid, non-glucose containing solution (Ringers' solution). Hematocrit was maintained above 20%. Alpha-stat blood gas strategy was used; PaCO 2 was maintained between 35 and 45 mmHg and moderate hypothermia (28-30°C) was used. Cold crystalloid cardioplegia was used and the solution was administered in the aortic root. The cardioplegia solution was given at a dose of 10-20 ml/kg. Further half-doses were given every 20-30 min as required. Continuous infusion of fentanyl (1-2 μg/kg/h) and propofol (2-5 mg/kg/h) was given to maintain anesthesia during CPB. Furthermore, the MAP was kept between 50 and 70 mmHg by using either glyceryl trinitrate or incremental doses of phenylephrine, as appropriate.
All patients were cooled to a temperature of 28-30°C. Rewarming was performed at the end of the surgical procedure to a nasopharyngeal (NP) temperature of 37°C. Patients in the rapid rewarming group were conventionally warmed by keeping NP-CPB perfusate temperature gradients between 4°C and 6°C and in slow rewarming group, NP-CPB perfusate temperature gradients were maintained between 1°C and 2°C. 
The jugular bulb catheter (Hydrocath 16 G, 15-20 cm) was placed by retrograde cannulation of the right internal jugular vein and its position was checked radiologically.  Intermittent samples were taken before CPB, at stable hypothermia, start of rewarming, at 32°C, at 34°C and at 36°C during rewarming, at 20 min after CPB. Jugular bulb samples (1 ml) were taken at a rate of 0.5 ml/min to avoid extracranial contamination. 
All data were analyzed with SPSS version 13 for Windows (SPSS Inc., Chicago, IL). Data was presented as mean (standard deviation or range) unless otherwise stated. Comparison between both groups was done using the independent samples t-test. While within groups' analysis was done using Wilcoxon signed ranks test compared with baseline values. Fisher's exact test was used for analyzing the number of patients with jugular bulb desaturation between rapid and slow rewarming groups.
Furthermore, multivariate analysis was done using lowest SjO 2 during rewarming as dependent variable and age, rewarming time, CPB time and ischemic time as independent variables. P < 0.05 was considered significant.
| Results|| |
Both groups were comparable in terms of age, sex, type of surgery, ejection fraction and number of patients with atrial fibrillation and those with the left atrial thrombus [Table 1].
|Table 1: Comparison of patient characteristics between rapid rewarming and slow rewarming groups|
Click here to view
CPB time and rewarming period were significantly longer in the slow rewarming group. The mean rate of rewarming was 0.5 (0.136)°C/min in rapid rewarming group, versus 0.219 (0.055)°C/min in slow rewarming group, P = 0.001 [Table 2].
|Table 2: Comparison of intraoperative and post-operative variables between rapid and slow rewarming groups|
Click here to view
The lowest NP temperature was 29.11 (0.75)°C and 29.24 (0.68)°C in rapid and slow rewarming groups respectively. Furthermore, no significant differences were observed in the mean temperatures values between both groups [Table 3].
|Table 3: Comparison of MAP, PaCO2, hematocrit and NP before, during and after CPB between slow rewarming and in rapid rewarming groups|
Click here to view
No significant differences were observed in mean arterial blood pressure, hematocrit and arterial carbon dioxide tension between both groups at any of the studied periods [Table 3].
High SjO 2 levels occurred during cooling and desaturation appeared during rewarming in both groups [Figure 1] and [Figure 2]. Although, there was no significant difference in mean SjO 2 at any time of the studied periods [Figure 1]. Significant difference was observed in the number of the desaturated patients (SjO 2 ≤ 50%) between the two groups; 14 (35%) in rapid rewarming versus 6 (15%) in the slow rewarming; P = 0.035 by Fisher's exact test.
|Figure 1: Comparison of jugular bulb oxygen saturation between rapid and slow rewarming before, during and after cardiopulmonary bypass|
Click here to view
|Figure 2: Box plot of lowest jugular bulb saturation (%) during rewarming (median and interquartile range)|
Click here to view
All patients had uneventful post-operative course except one patient in the rapid rewarming group was comatosed and died 5 days after surgery. He had multiple cerebral infarctions and his lowest SjO 2 value during rewarming was 37%. This patient underwent mitral valve replacement for mitral stenosis and had atrial fibrillation.
There was no significant relationship between lowest SjO 2 during rewarming as dependent variable and age, rewarming time, CPB time and ischemic time as independent variables [Table 4].
|Table 4: Multivariate analysis using lowest jugular bulb oxygen saturation as dependent variable and age, rewarming time, CPB time and ischemic time as independent variables|
Click here to view
| Discussion|| |
Reduction of SjO 2 occurred during rewarming from cold CPB in patients' undergoing CABG. ,,, In addition, it has been reported that such patients who experience SjO 2 desaturation during rewarming have an increased risk of post-operative cognitive deficits. , Therefore, new rewarming strategies should be thought, examined and used.
In this study, we have examined the effect of slow versus rapid rewarming on SjO 2 in adult patients undergoing open heart surgery. Although there were no significant differences in mean SjO 2 between groups, but 14 patients were desaturated (SjO 2 ≤ 50%) in rapid rewarming group versus six in slow rewarming group (P = 0.035).
These periods of desaturation during rapid rewarming could be explained by an imbalance between cerebral oxygen supply and demand. , Animal  and human  studies revealed that SjO 2 desaturation during rapid rewarming occurred due to an increase in cerebral metabolic rate that is temporarily unmatched by an increase in cerebral blood flow.
There have been controversial reports regarding the effect of rewarming rate on SjO 2 in patients who had CABG. ,,,,,,
Kadoi et al. in a small randomized study found no significant differences between slow or rapid rewarming in terms of the SjO 2 value or neurocognitive outcome either between diabetic or non-diabetic patients (15 patients in each group). Other authors have found that SjO 2 desaturation during rewarming was not a function of rewarming rate, but was related to increase in jugular bulb temperature. ,
Furthermore, Newman et al. in a prospective study reported that rewarming rate had no independent effect on post-operative cognitive decline in non-diabetic patients.
This discrepancy between the previous reports ,, and our study can be attributed to different age groups, different types of surgery, different anesthetic techniques or to the non-randomized nature of most of the studies that examined the effect of rewarming rate.
On the other hand, retrospective examination of the effect of rewarming rate on SjO 2 revealed that patients who warmed rapidly had a greater reduction in SjO 2 than who warmed slowly. ,, Also, rapid rewarming, low hematocrit and mean arterial blood pressure less than 60 mmHg appeared as contributing factors to SjO 2 desaturation during rewarming.  In our study, hematocrit and mean arterial blood pressure were comparable during the studied periods between the two groups.
Furthermore, two randomized studies addressed the effects of slow rewarming on improving jugular bulb saturation  and on getting better neurocognitive outcome than rapid rewarming.  The previous reports ,,, are in agreement with our study.
One patient in the rapid rewarming group had multiple cerebral infarctions and his lowest SjO 2 during rewarming was 37%. This gives us an idea about the importance of monitoring cerebral oxygenation in detecting patients at risk of brain injury during cardiac surgery. This issue has been addressed by using non-invasive regional cerebral oxygenation monitor (near infrared spectroscopy) in Slater's et al. and Mohands' et al.  studies.
Examining SjO 2 during slow and rapid rewarming without any neurological outcome and using patients' with different cardiac lesions (valve lesions and congenital heart defects) are considered limitations of this study.
| Conclusion|| |
SjO 2 appeared to be more preserved with slow rewarming in adult patients undergoing open heart surgery.
| References|| |
|1.||Grocott HP, Homi HM, Puskas F. Cognitive dysfunction after cardiac surgery: Revisiting etiology. Semin Cardiothorac Vasc Anesth 2005;9:123-9. |
|2.||Shaaban Ali M, Harmer M, Kirkham F. Cardiopulmonary bypass temperature and brain function. Anesthesia 2005;60:365-72. |
|3.||Arrowsmith JE, Grocott HP, Reves JG, Newman MF. Central nervous system complications of cardiac surgery. Br J Anaesth 2000;84:378-93. |
|4.||McLean RF, Wong BI, Naylor CD, Snow WG, Harrington EM, Gawel M, et al. Cardiopulmonary bypass, temperature, and central nervous system dysfunction. Circulation 1994;90:II250-5. |
|5.||Nathan HJ, Wells GA, Munson JL, Wozny D. Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery with cardiopulmonary bypass: A randomized trial. Circulation 2001;104 12 Suppl 1:I85-91. |
|6.||Croughwell ND, Newman MF, Blumenthal JA, White WD, Lewis JB, Frasco PE, et al. Jugular bulb saturation and cognitive dysfunction after cardiopulmonary bypass. Ann Thorac Surg 1994;58:1702-8. |
|7.||Kadoi Y, Saito S, Goto F, Fujita N. Decrease in jugular venous oxygen saturation during normothermic cardiopulmonary bypass predicts short-term postoperative neurologic dysfunction in elderly patients. J Am Coll Cardiol 2001;38:1450-5. |
|8.||Sapire KJ, Gopinath SP, Farhat G, Thakar DR, Gabrielli A, Jones JW, et al. Cerebral oxygenation during warming after cardiopulmonary bypass. Crit Care Med 1997;25:1655-62. |
|9.||Croughwell ND, White WD, Smith LR, Davis RD, Glower DD Jr, Reves JG, et al. Jugular bulb saturation and mixed venous saturation during cardiopulmonary bypass. J Card Surg 1995;10:503-8. |
|10.||Grigore AM, Grocott HP, Mathew JP, Phillips-Bute B, Stanley TO, Butler A, et al. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002;94:4-10. |
|11.||Kawahara F, Kadoi Y, Saito S, Goto F, Fujita N. Slow rewarming improves jugular venous oxygen saturation during rewarming. Acta Anaesthesiol Scand 2003;47:419-24. |
|12.||Hayman LA, Fahr LM, Taber KH, Hughes CL, Ritter AM, Robertson C. Radiographic assessment of jugular bulb catheters. Emerg Radiol 1995;2:331-8. |
|13.||Matta BF, Lam AM. The rate of blood withdrawal affects the accuracy of jugular venous bulb. Oxygen saturation measurements. Anesthesiology 1997;86:806-8. |
|14.||Enomoto S, Hindman BJ, Dexter F, Smith T, Cutkomp J. Rapid rewarming causes an increase in the cerebral metabolic rate for oxygen that is temporarily unmatched by cerebral blood flow. A study during cardiopulmonary bypass in rabbits. Anesthesiology 1996;84:1392-400. |
|15.||Croughwell ND, Frasco P, Blumenthal JA, Leone BJ, White WD, Reves JG. Warming during cardiopulmonary bypass is associated with jugular bulb desaturation. Ann Thorac Surg 1992;53:827-32. |
|16.||Kadoi Y, Saito S, Goto F, Fujita N. Slow rewarming has no effects on the decrease in jugular venous oxygen hemoglobin saturation and long-term cognitive outcome in diabetic patients. Anesth Analg 2002;94:1395-401. |
|17.||von Knobelsdorff G, Tonner PH, Hänel F, Bischoff P, Scholz J, Schulte am Esch J. Prolonged rewarming after hypothermic cardiopulmonary bypass does not attenuate reduction of jugular bulb oxygen saturation. J Cardiothorac Vasc Anesth 1997;11:689-93. |
|18.||Cook DJ, Orszulak TA, Daly RC, Buda DA. Cerebral hyperthermia during cardiopulmonary bypass in adults. J Thorac Cardiovasc Surg 1996;111:268-9. |
|19.||Newman MF, Kramer D, Croughwell ND, Sanderson I, Blumenthal JA, White WD, et al. Differential age effects of mean arterial pressure and rewarming on cognitive dysfunction after cardiac surgery. Anesth Analg 1995;81:236-42. |
|20.||Nakajima T, Kuro M, Hayashi Y, Kitaguchi K, Uchida O, Takaki O. Clinical evaluation of cerebral oxygen balance during cardiopulmonary bypass: On-line continuous monitoring of jugular venous oxyhemoglobin saturation. Anesth Analg 1992;74:630-5. |
|21.||von Knobelsdorff G, Hänel F, Werner C, Schulte am Esch J. Jugular bulb oxygen saturation and middle cerebral blood flow velocity during cardiopulmonary bypass. J Neurosurg Anesthesiol 1997;9:128-33. |
|22.||Slater JP, Guarino T, Stack J, Vinod K, Bustami RT, Brown JM 3 rd , et al. Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery. Ann Thorac Surg 2009;87:36-44. |
|23.||Mohandas BS, Jagadeesh AM, Vikram SB. Impact of monitoring cerebral oxygen saturation on the outcome of patients undergoing open heart surgery. Ann Card Anaesth 2013;16:102-6. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
|This article has been cited by|
||Effects of Hypothermic Cardiopulmonary Bypass on Internal Jugular Bulb Venous Oxygen Saturation, Cerebral Oxygen Saturation, and Bispectral Index in Pediatric Patients Undergoing Cardiac Surgery
| ||Zhiyong Hu,Lili Xu,Zhirui Zhu,Robert Seal,Patrick M. McQuillan |
| ||Medicine. 2016; 95(2): e2483 |
|[Pubmed] | [DOI]|