Cerebral protection: latest evidences and trends. PRESENTATION скачать в хорошем качестве

Cerebral protection: latest evidences and trends. PRESENTATION

Good morning, everyone. Neurological complication rates can vary considerably depending on the cerebral protection techniques employed, patient-specific characteristics, clinical presentation, and the experience of the surgical center. A multidisciplinary approach is considered fundamental for comprehensive patient management. Neurological complications are primarily represented by: Postoperative stroke, Postoperative cognitive dysfunction, Paraplegia and spinal cord ischemia. The cause of these complications can be traced to: Cerebral Embolization, Hypotension and Hypoperfusion during Circulatory Arrest and Cerebral Perfusion, Hyperperfusion, Systemic Inflammation How can we implement strategies to minimize these possible complications, especially in complex aortic procedures? First, careful planning of elective procedures is essential to build a cohesive team between the surgeon, anesthetist, perfusionist, nurses, and surgical technicians. While it is not possible to prepare in the same way for emergencies, regularly discussing of elective cases helps strengthen the team, making responses to critical situations smoother and more automatic. Next, accurate preoperative diagnostics are essential for surgical planning. Thoracoabdominal Angio-CT, preferably ECG-gated, is the reference examination in both emergency and elective settings, offering a detailed assessment of the vascular anatomy of the entire aorta. Optimizing the operating room requires careful organization. Cerebral monitoring with NIRS, EEG, and when is possible transcranial Doppler (TCD). Tools such as ROTEM/TEG, and Doppler flowmetry are essential. Another crucial point is The choice of the surgical strategy. PREMISE Hypothermia plays a crucial role in complex surgery. However, the literature highlights three main challenges: Variability in measurement methods, Lack of a uniform definition of hypothermia, Variability in circulatory arrest times. As mentioned, we need to use a standardized classification to define and categorize hypothermia. Below is the classification we have adopted, based on the latest international guidelines on cardiopulmonary bypass in adult cardiac surgery, EACTS and STS It has been shown that DHCA provides adequate brain and end-organ protection up to arrest periods of 30 min. The use of high-moderate hypothermia with antegrade cerebral perfusion is emerging as the preferred strategy for aortic arch surgery. It allows for an extended circulatory arrest period of over 90 minutes, enabling even the most complex aortic arch reconstructions. The advantages include Reduced coagulation impact and Improved neurological recovery resulting in better outcomes without the adverse effects of deep hypothermia. A fundamental aspect to consider in antegrade cerebral perfusion (ACP) is the flow rate and perfusion pressure. This raises the question, “What is the ideal flow rate?” According to authors such as Kazui, Tian, and Olson, during unilateral antegrade cerebral perfusion, a maintained flow of 8-10 ml per kg per min is considered adequate, provided the Circle of Willis is intact. However, if the Circle of Willis is incomplete or carotid stenosis is present, bilateral perfusion is recommended, with a maintained flow of 10-15 ml per kg per min. Effective monitoring during Antegrade Cerebral Perfusion includes perfusion pressure, cerebral oximetry, and, in more advanced settings, transcranial Doppler. RCP It involves perfusing oxygenated venous blood through the sagittal sinus via the superior vena cava. An ideal Flow Rate of 200-500 ml per min is used to prevent endothelial damage and ensure effective perfusion. It is very important to monitor Central venous pressure (CVP) during RCP. At our center, we have chosen high-moderate hypothermic circulatory arrest with antegrade cerebral perfusion. Our CPB circuit is specifically designed to ensure safety and efficacy during circulatory arrest and selective perfusion of the supra-aortic vessels. The setup includes: a. A 3/8-inch tube directing blood flow to the right axillary artery. b. Another 3/8-inch tube for systemic reperfusion or femoral artery cannulation, if needed. c. A UAI connector 3/8-3/8-1/4integrated into the circuit. d. A ¼ (quarter-inch tube dedicated to selective cerebral perfusion. 𝐓𝐡𝐢𝐬 𝐢𝐬 𝐨𝐮𝐫 𝐬𝐞𝐭𝐮𝐩: a. 𝐈𝐬𝐨𝐥𝐚𝐭𝐢𝐨𝐧 𝐚𝐧𝐝 𝐜𝐚𝐧𝐧𝐮𝐥𝐚𝐭𝐢𝐨𝐧 𝐨𝐟 𝐭𝐡𝐞 𝐫𝐢𝐠𝐡𝐭 𝐚𝐱𝐢𝐥𝐥𝐚𝐫𝐲 𝐚𝐫𝐭𝐞𝐫𝐲. b. 𝐀𝐜𝐡𝐢𝐞𝐯𝐢𝐧𝐠 𝐚 𝐜𝐨𝐧𝐭𝐫𝐨𝐥𝐥𝐞𝐝 𝐛𝐨𝐝𝐲 𝐭𝐞𝐦𝐩𝐞𝐫𝐚𝐭𝐮𝐫𝐞 𝐨𝐟 𝟐5 / 27°𝐂: Clamping of the brachiocephalic trunk and perfusion through the right axillary artery at approximately 7 ml per Kg per min. If needed, a cannula is inserted into the left common carotid artery, adding a supplemental flow of 1 ml per kg per min c. During the procedure, it is essential to monitor cerebral oximetry. d. 𝐏𝐞𝐫𝐟𝐮𝐬𝐢𝐨𝐧 𝐨𝐟 𝐭𝐡𝐞 𝐬𝐮𝐩𝐫𝐚-𝐚𝐨𝐫𝐭𝐢𝐜 𝐭𝐫𝐮𝐧𝐤𝐬 𝐰𝐢𝐭𝐡 𝐭𝐡𝐢𝐬 𝐜𝐨𝐧𝐟𝐢𝐠𝐮𝐫𝐚𝐭𝐢𝐨𝐧 𝐢𝐬 𝐦𝐚𝐧𝐚𝐠𝐞𝐝 𝐰𝐢𝐭𝐡 𝐚 𝐬𝐢𝐧𝐠𝐥𝐞 𝐫𝐨𝐥𝐥𝐞𝐫, 𝐬𝐢𝐦𝐩𝐥𝐢𝐟𝐲𝐢𝐧𝐠 𝐟𝐥𝐨𝐰 𝐦𝐚𝐧𝐚𝐠𝐞𝐦𝐞𝐧𝐭 𝐚𝐧𝐝 𝐞𝐧𝐬𝐮𝐫𝐢𝐧𝐠 𝐞𝐟𝐟𝐞𝐜𝐭𝐢𝐯𝐞 𝐛𝐥𝐨𝐨𝐝 𝐝𝐢𝐬𝐭𝐫𝐢𝐛𝐮𝐭𝐢𝐨𝐧.