Heart, Lung and Circulation
Review| Volume 24, ISSUE 6, P544-550, June 2015

Should Cerebral Near-infrared Spectroscopy be Standard of Care in Adult Cardiac Surgery?

Published:February 06, 2015DOI:
      Near-infrared spectroscopy (NIRS) is non-invasive, easy to use, and offers real-time monitoring of the oxygen content of cerebral tissue. An effective and user-friendly method of cerebral monitoring stands to offer a significant advance in patient care during adult cardiac surgery, particularly for surgery in which the continuity of cerebral vessels may be compromised. While the current evidence does not definitively show improvement in neurological outcomes, it can be argued that the overall risk to benefit ratio falls on the side of NIRS.
      NIRS also gives information about the oxygenation of systemic tissues. It may be that in surgery that does not involve the aortic arch, the value of NIRS will be in increased individualisation of patient management and improved systemic perfusion, impacting general outcomes as much as neurological outcomes.
      This review will summarise the need for neuromonitoring and the principles of NIRS. It will examine the thresholds used to define desaturation, the evidence for clinical benefit from NIRS, and the criticisms and limitations of NIRS. It will also discuss the uses of NIRS beyond improving neurological outcomes alone.


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        • Murkin J.M.
        NIRS: a standard of care for CPB vs. an evolving standard for selective cerebral perfusion?.
        J Extra Corpor Technol. 2009; 41: 11-14
        • Zheng F.
        • Sheinberg R.
        • Yee M.S.
        • Ono M.
        • Zheng Y.
        • Hogue C.
        Cerebral near-infrared spectroscopy monitoring and neurologic outcomes in adult cardiac surgery patients: a systematic review.
        Anesth Analg. 2013; 116: 663-676
        • Edmonds H.L.
        Pro: all cardiac surgical patients should have intraoperative cerebral oxygenation monitoring.
        J Cardiothorac Vasc Anesth. 2006; 20: 445-449
        • Hoffman G.M.
        Pro: near-infrared spectroscopy should be used for all cardiopulmonary bypass.
        J Cardiothorac Vasc Anesth. 2006; 20: 606-612
        • Murkin J.M.
        Is it better to shine a light, or rather to curse the darkness? Cerebral near-infrared spectroscopy and cardiac surgery.
        Eur J Cardiothorac Surg. 2013; 43: 1081-1083
        • Davies L.K.
        • Janelle G.M.
        Con: all cardiac surgical patients should not have intraoperative cerebral oxygenation monitoring.
        J Cardiothorac Vasc Anesth. 2006; 20: 450-455
        • Muehlschlegel S.
        • Lobato E.B.
        Con: all cardiac surgical patients should not have intraoperative cerebral oxygenation monitoring.
        J Cardiothorac Vasc Anesth. 2006; 20: 613-615
        • Satink T.
        • Cup E.H.
        • Ilott I.
        • Prins J.
        • de Swart B.J.
        • Nijhuis-van der Sanden M.W.
        Patients’ views on the impact of stroke on their roles and self: a thematic synthesis of qualitative studies.
        Arch Phys Med Rehabil. 2013; 94: 1171-1183
        • Likosky D.S.
        • Caplan L.R.
        • Weintraub R.M.
        • Hartman G.S.
        • Malenka D.J.
        • Ross C.S.
        • et al.
        • Northern New England Cardiovascular Disease Study Group
        Lebanon, New Hampshire. Intraoperative and postoperative variables associated with strokes following cardiac surgery.
        Heart Surg Forum. 2004; 7: E271-E276
        • Caplan L.R.
        • Hennerici M.
        Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism and ischemic stroke.
        Arch Neurol. 1998; 55: 1475-1482
        • Denault A.
        • Deschamps A.
        • Murkin J.M.
        Cerebral oximetry monitoring in anesthesiology.
        Anesth Rounds. 2008; 7
        • Uehara T.
        • Tabuchi M.
        • Kozawa S.
        • Mori E.
        MR angiographic evaluation of carotid and intracranial arteries in Japanese patients scheduled for coronary artery bypass grafting.
        Cerebrovasc Dis. 2001; 11: 341-345
        • Yoon B.W.
        • Bae H.J.
        • Kang D.W.
        • Lee S.H.
        • Hong K.S.
        • Kim K.B.
        • et al.
        Intracranial cerebral artery disease as a risk factor for central nervous system complications of coronary artery bypass graft surgery.
        Stroke. 2001; 32: 94-99
        • Edmonds H.L.
        Multi-modality neurophysiologic monitoring for cardiac surgery.
        Heart Surg Forum. 2002; 5: 225-228
        • Pugsley W.
        • Klinger L.
        • Paschalis C.
        • Treasure T.
        • Harrison M.
        • Newman S.
        The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning.
        Stroke. 1994; 25: 1393-1399
        • Lozano S.
        • Mossad E.
        Cerebral function monitors during pediatric cardiac surgery: can they make a difference?.
        J Cardiothorac Vasc Anesth. 2004; 18: 645-656
        • Edmonds H.L.
        • Thomas M.H.
        • Ganzel B.L.
        • Austin E.H.
        Monitoring the brain: transcranial Doppler.
        in: Subramaniam K. Park K.W. Subramaniam B. Anesthesia and Perioperative Care for Aortic Surgery. Springer Science + Business Media, LLC, New York, NY2011
        • Newman M.F.
        • Croughwell N.D.
        • Blumenthal J.A.
        • Lowry E.
        • White W.
        • Spillane W.
        • et al.
        Predictors of cognitive decline after cardiac operation.
        Ann Thorac Surg. 1995; 59: 1326-1330
        • Fischer G.W.
        • Silvay G.
        Cerebral oximetry in cardiac and major vascular surgery.
        HSR Proceedings in Intensive Care and Cardiovascular Anesthesia. 2010; 2: 249-256
        • Jobsis F.F.
        Noninvasive infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters.
        Science. 1977; 198: 1264-1267
        • Ghosh A.
        • Elwell C.
        • Smith M.
        Review article: cerebral near-infrared spectroscopy in adults: a work in progress.
        Anesth Analg. 2012; 115: 1373-1383
        • Schepens M.
        • Waanders F.
        Monitoring the brain: near-infrared spectroscopy.
        in: Coselli J.S. LeMaire S.A. Aortic arch surgery: principles, strategies and outcomes. Blackwell Publishing, Ltd, Oxford, UK2009
        • Matcher S.J.
        • Elwell C.E.
        • Cooper C.E.
        • Cope M.
        • Delpy D.T.
        Performance comparison of several published tissue near-infrared spectroscopy algorithms.
        Anal Biochem. 1995; 227: 54-68
        • Denault A.
        • Deschamps A.
        • Murkin J.M.
        A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy.
        Semin Cardiothorac Vasc Anesth. 2007; 11: 274-281
        • Slater J.P.
        • Guarino T.
        • Stack J.
        • Vinod K.
        • Bustami R.T.
        • Brown J.M.
        • et al.
        Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery.
        Ann Thorac Surg. 2009; 87: 36-44
        • Samra S.K.
        • Dy E.A.
        • Welch K.
        • Dorje P.
        • Zelenock G.B.
        • Stanley J.C.
        Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy.
        Anesthesiology. 2000; 93: 964-970
        • Hirofumi O.
        • Otone E.
        • Hiroshi I.
        • Satosi I.
        • Shigeo I.
        • Yasuhiro N.
        • et al.
        The effectiveness of regional cerebral oxygen saturation monitoring using near-infrared spectroscopy in carotid endarterectomy.
        J Clin Neurosci. 2003; 10: 79-83
        • Orihashi K.
        • Sueda T.
        • Okada K.
        • Imai K.
        Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion.
        Eur J Cardiothorac Surg. 2004; 26: 907-911
        • Higami T.
        • Kozawa S.
        • Asada T.
        • Obo H.
        • Gan K.
        • Iwahashi K.
        • et al.
        Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction.
        Ann Thorac Surg. 1999; 67: 1091-1096
        • Olsson C.
        • Thelin S.
        Regional cerebral saturation monitoring with near-infrared spectroscopy during selective antegrade cerebral perfusion: diagnostic performance and relationship to postoperative stroke.
        J Thorac Cardiovasc Surg. 2006; 131: 371-379
        • Yao F.S.
        • Tseng C.C.
        • Ho C.Y.
        • Levin S.K.
        • Illner P.
        Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery.
        J Cardiothorac Vasc Anesth. 2004; 18: 552-558
        • Fischer G.W.
        • Lin H.M.
        • Krol M.
        • Galati M.F.
        • Di Luozzo G.
        • Griepp R.B.
        • et al.
        Noninvasive cerebral oxygenation may predict outcome in patients undergoing aortic arch surgery.
        J Thorac Cardiovasc Surg. 2011; 141: 815-821
        • Murkin J.M.
        • Adams S.J.
        • Novick R.J.
        • Quantz M.
        • Bainbridge D.
        • Iglesias I.
        • et al.
        Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study.
        Anesth Analg. 2007; 104: 51-58
        • Urbanski P.P.
        • Babin-Ebell J.
        • Fröhner S.
        • Diegeler A.
        Insufficient unilateral cerebral perfusion during emergent aortic arch surgery.
        Interact Cardiovasc Thorac Surg. 2012; 14: 122-124
        • Faulkner J.T.
        • Hartley M.
        • Tang A.
        Using cerebral oximetry to prevent adverse outcomes during cardiac surgery.
        Perfusion. 2011; 26: 79-81
        • Vernick W.J.
        • Oware A.
        Early diagnosis of superior vena cava obstruction facilitated by the use of cerebral oximetry.
        J Cardiothorac Vasc Anesth. 2011; 25: 1101-1103
        • Prabhune A.
        • Sehic A.
        • Spence P.A.
        • Church T.
        • Edmonds H.L.
        Cerebral oximetry provides early warning of oxygen delivery failure during cardiopulmonary bypass.
        J Cardiothorac Vasc Anesth. 2002; 16: 204-206
        • Harrer M.
        • Waldenberger F.R.
        • Weiss G.
        • Folkmann S.
        • Gorlitzer M.
        • Moidl R.
        • Grabenwoeger M.
        Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy.
        Eur J Cardiothorac Surg. 2010; 38: 561-567
        • Schön J.
        • Serien V.
        • Heinze H.
        • Hanke T.
        • Bechtel M.
        • Eleftheriadis S.
        • et al.
        Association between cerebral desaturation and an increased risk of stroke in patients undergoing deep hypothermic circulatory arrest for cardiothoracic surgery.
        Appl Cardiopulm Pathophysiol. 2009; 13: 201-207
        • Goldman S.
        • Sutter F.
        • Ferdinand F.
        • Trace C.
        Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients.
        Heart Surg Forum. 2004; 7: E376-E381
        • Edmonds H.L.
        Protective effect of neuromonitoring during cardiac surgery.
        Ann NY Acad Sci. 2005; 1053: 12-19
        • Roach G.W.
        • Kanchuger M.
        • Mangano
        • Newman M.
        • Nussmeier N.
        • Wolman R.
        • et al.
        Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators.
        N Engl J Med. 1996; 335: 1857-1863
        • Misra M.
        • Stark J.
        • Dujovny M.
        • Widman R.
        • Ausman J.I.
        Transcranial cerebral oximetry in random normal subjects.
        Neurol Res. 1998; 20: 137-141
        • Schwarz G.
        • Litscher G.
        • Kleinert R.
        • Jobstmann R.
        Cerebral oximetry in dead subjects.
        J Neurosurg Anesth. 1996; 8: 189-193
        • Nemoto E.M.
        • Yonas H.
        • Kassam A.
        Clinical experience with cerebral oximetry in stroke and cardiac arrest.
        Crit Care Med. 2000; 28: 1052-1054
        • Maeda H.
        • Fukita K.
        • Oritani S.
        • Ishida K.
        • Zhu B.L.
        Evaluation of postmortem oximetry with references to the causes of death.
        Forensic Sci Int. 1997; 87: 201-210
        • Murkin J.M.
        • Cerebral Oximetry:
        Monitoring the Brain as the index organ.
        Anesthesiology. 2011; 114: 12-13
        • Samra S.K.
        • Chandlere W.F.
        Cerebral oximetry during circulatory arrest for aneurysm surgery.
        J Neurosurg Anesth. 1997; 9: 154-158
        • Hongo K.
        • Kobayashi S.
        • Okudera H.
        • Hokama M.
        • Nakagawa F.
        Noninvasive cerebral optical spectroscopy: depth-resolved measurements of cerebral hemodynamics using indocyanine green.
        Neurol Res. 1995; 17: 89-93
        • Al-Rawi P.G.
        • Smielewski P.
        • Kirkpatrick P.J.
        Evaluation of a near-infrared spectrometer (NIRO 300) for the detection of intracranial oxygenation changes in the adult head.
        Stroke. 2001; 32: 2492-2500
        • Germon T.J.
        • Young A.E.
        • Manara A.R.
        • Nelson R.J.
        Extracerebral absorption of near infrared light influences the detection of increased cerebral oxygenation monitored by near infrared spectroscopy.
        J Neurol Neurosurg Psychiatr. 1995; 58: 477-479
        • Selnes O.A.
        • Grega M.A.
        • Bailey M.M.
        • Pham L.D.
        • Zeger S.L.
        • Baumgartner W.A.
        • et al.
        Do management strategies for coronary artery disease influence 6-Year cognitive outcomes?.
        Ann Thorac Surg. 2009; 88: 445-454
        • Selnes O.A.
        • Gottesman R.F.
        • Grega M.A.
        • Baumgartner W.A.
        • Zeger S.L.
        • McKhann G.M.
        Cognitive and neurologic outcomes after coronary artery bypass surgery.
        N Engl J Med. 2012; 366: 250-257
        • Heringlake M.
        • Garbers C.
        • Käbler J.H.
        • Anderson I.
        • Heinze H.
        • Schön J.
        • et al.
        Preoperative cerebral oxygen saturation and clinical outcomes in cardiac surgery.
        Anesthesiology. 2011; 114: 58-69
        • Ono M.
        • Arnaoutakis G.J.
        • Fine D.M.
        • Brady K.
        • Easley R.B.
        • Zheng Y.
        • et al.
        Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with risk for acute kidney injury.
        Crit Care Med. 2013; 41: 464-471
        • Casati A.
        • Fanelli G.
        • Pietropaoli P.
        • Proietti R.
        • Tufano R.
        • Danelli G.
        • et al.
        Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia.
        Anesth Analg. 2005; 101: 740-747
        • Grocott H.P.
        Monitoring the brain in cardiac surgery – an evolving area for research.
        Anesthesia. 2012; 67: 213-225
        • Grocott H.P.
        • Davie S.N.
        Future uncertainties in the development of clinical cerebral oximetry.
        Front Physiol. 2013; 18: 360
        • Boston U.S.
        • Slater J.M.
        • Orszulak T.A.
        • Cook D.J.
        Hierarchy of regional oxygen delivery during cardiopulmonary bypass.
        Ann Thorac Surg. 2001; 71: 260-264