Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists

Abstract

Background: Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry.

Methods: A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018.

Results: Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place.

Conclusions: Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.

Figure 1.

Flow sheet describing establishment, testing, submission, and data recording of survey. SCA: Society of Cardiovascular Anesthesiologists.

Figure 2

a – Question 7. Percentage of respondents (485 responses) who perform transesophageal echocardiography (TEE) in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. b – Question 8. Percentage of respondents (484 responses) who perform epi-aortic scanning, in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. c – Question 9. Percentage of respondents (486 responses) who perform double-clamping of the aorta during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. d – Question 10. Percentage of respondents (487 responses) who perform off-pump technique during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. e – Question 11. Percentage of respondents (479 responses) who have standardized institutional guidelines/standard operating procedures in place for managing patients’ blood pressure either intraoperatively excluding cardiopulmonary bypass (CPB), during CPB, depending on the surgeon’s preference, only in high-risk patients, or have no guidelines/procedures in place. Error bars represent 95% confidence intervals. f – Question 12. Percentage of respondents (482 responses) who routinely target a mean arterial pressure (MAP) of either >45 mmHg, >55 mmHg, >65 mmHg, >75 mmHg, >85 mmHg, according to a goal-directed algorithm, or do not target a specific MAP during cardiopulmonary bypass for patients thought to be at risk for postoperative cerebral injury. Error bars represent 95% confidence intervals. g – Question 13. Percentage of respondents (478 responses) who use cerebral oxygen saturation monitoring in their practice in either all cardiac surgeries, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. h – Question 14. Percentage of respondents (477 responses) who have standardized management strategies/standard operating procedures in place for cerebral protection during cardiac surgery in their institution (choose all that apply) either for all cardiac surgical patients, for patients at increased risk for perioperative cerebral injury, depending on the surgeon, who do not have standardized management strategies, or do not know the answer. Error bars represent 95% confidence intervals.

Figure 2

a – Question 7. Percentage of respondents (485 responses) who perform transesophageal echocardiography (TEE) in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. b – Question 8. Percentage of respondents (484 responses) who perform epi-aortic scanning, in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. c – Question 9. Percentage of respondents (486 responses) who perform double-clamping of the aorta during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. d – Question 10. Percentage of respondents (487 responses) who perform off-pump technique during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. e – Question 11. Percentage of respondents (479 responses) who have standardized institutional guidelines/standard operating procedures in place for managing patients’ blood pressure either intraoperatively excluding cardiopulmonary bypass (CPB), during CPB, depending on the surgeon’s preference, only in high-risk patients, or have no guidelines/procedures in place. Error bars represent 95% confidence intervals. f – Question 12. Percentage of respondents (482 responses) who routinely target a mean arterial pressure (MAP) of either >45 mmHg, >55 mmHg, >65 mmHg, >75 mmHg, >85 mmHg, according to a goal-directed algorithm, or do not target a specific MAP during cardiopulmonary bypass for patients thought to be at risk for postoperative cerebral injury. Error bars represent 95% confidence intervals. g – Question 13. Percentage of respondents (478 responses) who use cerebral oxygen saturation monitoring in their practice in either all cardiac surgeries, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. h – Question 14. Percentage of respondents (477 responses) who have standardized management strategies/standard operating procedures in place for cerebral protection during cardiac surgery in their institution (choose all that apply) either for all cardiac surgical patients, for patients at increased risk for perioperative cerebral injury, depending on the surgeon, who do not have standardized management strategies, or do not know the answer. Error bars represent 95% confidence intervals.

Figure 2

a – Question 7. Percentage of respondents (485 responses) who perform transesophageal echocardiography (TEE) in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. b – Question 8. Percentage of respondents (484 responses) who perform epi-aortic scanning, in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. c – Question 9. Percentage of respondents (486 responses) who perform double-clamping of the aorta during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. d – Question 10. Percentage of respondents (487 responses) who perform off-pump technique during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. e – Question 11. Percentage of respondents (479 responses) who have standardized institutional guidelines/standard operating procedures in place for managing patients’ blood pressure either intraoperatively excluding cardiopulmonary bypass (CPB), during CPB, depending on the surgeon’s preference, only in high-risk patients, or have no guidelines/procedures in place. Error bars represent 95% confidence intervals. f – Question 12. Percentage of respondents (482 responses) who routinely target a mean arterial pressure (MAP) of either >45 mmHg, >55 mmHg, >65 mmHg, >75 mmHg, >85 mmHg, according to a goal-directed algorithm, or do not target a specific MAP during cardiopulmonary bypass for patients thought to be at risk for postoperative cerebral injury. Error bars represent 95% confidence intervals. g – Question 13. Percentage of respondents (478 responses) who use cerebral oxygen saturation monitoring in their practice in either all cardiac surgeries, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. h – Question 14. Percentage of respondents (477 responses) who have standardized management strategies/standard operating procedures in place for cerebral protection during cardiac surgery in their institution (choose all that apply) either for all cardiac surgical patients, for patients at increased risk for perioperative cerebral injury, depending on the surgeon, who do not have standardized management strategies, or do not know the answer. Error bars represent 95% confidence intervals.

Figure 2

a – Question 7. Percentage of respondents (485 responses) who perform transesophageal echocardiography (TEE) in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. b – Question 8. Percentage of respondents (484 responses) who perform epi-aortic scanning, in their practice in either all cardiac surgical patients requiring aortic cannulation, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. c – Question 9. Percentage of respondents (486 responses) who perform double-clamping of the aorta during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. d – Question 10. Percentage of respondents (487 responses) who perform off-pump technique during Coronary Artery Bypass Grafting (CABG) in their practice in either 0–20%, 21–40%, 61–80%, or 81–100% of CABG surgeries, or who do not know the answer. Error bars represent 95% confidence intervals. e – Question 11. Percentage of respondents (479 responses) who have standardized institutional guidelines/standard operating procedures in place for managing patients’ blood pressure either intraoperatively excluding cardiopulmonary bypass (CPB), during CPB, depending on the surgeon’s preference, only in high-risk patients, or have no guidelines/procedures in place. Error bars represent 95% confidence intervals. f – Question 12. Percentage of respondents (482 responses) who routinely target a mean arterial pressure (MAP) of either >45 mmHg, >55 mmHg, >65 mmHg, >75 mmHg, >85 mmHg, according to a goal-directed algorithm, or do not target a specific MAP during cardiopulmonary bypass for patients thought to be at risk for postoperative cerebral injury. Error bars represent 95% confidence intervals. g – Question 13. Percentage of respondents (478 responses) who use cerebral oxygen saturation monitoring in their practice in either all cardiac surgeries, in patients at increased risk for perioperative cerebral injury, at the surgeon’s request, at the anesthesiologist’s request, as part of standardized institutional guidelines/standard operating procedures, never, or who do not know the answer (choose all that apply). Error bars represent 95% confidence intervals. h – Question 14. Percentage of respondents (477 responses) who have standardized management strategies/standard operating procedures in place for cerebral protection during cardiac surgery in their institution (choose all that apply) either for all cardiac surgical patients, for patients at increased risk for perioperative cerebral injury, depending on the surgeon, who do not have standardized management strategies, or do not know the answer. Error bars represent 95% confidence intervals.