Effect of hyperextension of the neck (rose position) on cerebral blood oxygenation in patients who underwent cleft palate reconstructive surgery: prospective cohort study using near-infrared spectroscopy

Abstract

Objectives To facilitate the best approach during cleft palate surgery, children are positioned with hyperextension of the neck. Extensive head extension may induce intraoperative cerebral ischemia if collateral flow is insufficient. To evaluate and monitor the effect of cerebral blood flow on cerebral tissue oxygenation, near-infrared spectroscopy has proved to be a valuable method. The aim of this study was to evaluate and quantify whether hyperextension affects the cerebral tissue oxygenation in children during cleft palate surgery. Materials and methods This prospective study included children (ASA 1 and 2) under the age of 3 years old who underwent cleft palate repair at the Wilhelmina Children's Hospital, in The Netherlands. Data were collected for date of birth, cleft type, date of cleft repair, and physiological parameters (MAP, saturation, heart rate, expiratory CO 2 and O 2 , temperature, and cerebral blood oxygenation) during surgery. The cerebral blood oxygenation was measured with NIRS. Results Thirty-four children were included in this study. The majority of the population was male (61.8%, n = 21). The mixed model analyses showed a significant drop at time of Rose position of − 4.25 (69-74 95% CI; p < 0.001) and − 4.39 (69-74 95% CI; p < 0.001). Postoperatively, none of the children displayed any neurological disturbance. Conclusion This study suggests that hyperextension of the head during cleft palate surgery leads to a significant decrease in cerebral oxygenation. Severe cerebral desaturation events during surgery were uncommon and do not seem to be of clinical relevance in ASA 1 and 2 children. Clinical relevance There was a significant drop in cerebral oxygenation after positioning however it is not clear whether this drop is truly significant physiologically in ASA 1 and 2 patients.

Use of combined cerebral and somatic renal near infrared spectroscopy during noncardiac surgery in children: a proposed algorithm

“…In our experience, significant CrSO2 desaturation was observed during a rigid laryngoscopy (due to overextension of the neck) (see Annex, Figure S1A) and during placement of a central venous catheter (due to turning the patient's head, Annex, Figure S2). Indeed, Smarius et al 15 have shown that hyperextension of the neck in children during surgery for cleft palate causes a significant drop of CrSO2. Optimize oxygenation. If the observed decline in CrSO2 coincides with an almost contemporary decrease in SpO2 (usually delayed by 10–15 seconds 16 ) consider an adjustment of FiO2, check of ETT patency 17 or dislocation, consider recruitment maneuvers, and adjustment of ventilator parameters. Optimize EtCO2.…”

“…In our experience, significant CrSO2 desaturation was observed during a rigid laryngoscopy (due to overextension of the neck) (see Annex, Figure S1A) and during placement of a central venous catheter (due to turning the patient's head, Annex, Figure S2). Indeed, Smarius et al 15 have shown that hyperextension of the neck in children during surgery for cleft palate causes a significant drop of CrSO2.…”

Cerebral Near-Infrared Spectroscopy: A Viable Tool in an Anesthesiologist’s Armamentarium for Pediatric Head and Neck Surgeries

“…The monitoring was applied before induction of anesthesia to obtain a baseline value as it is recommended to act upon changes from baseline (<20%) and trends in NIRS readings rather than an absolute number [ 1 ]. NIRS has been found to detect intraoperative cerebral desaturation in surgeries requiring extensive head rotation or extension [ 5 ]. In situations where the collateral carotid flow may be depleted due to external compression or surgical manipulation similar to our setting, NIRS may serve as a guide for the safe positioning of the patients as well.…”

Tiroidektomi Sırasında Semi-Fowler Pozisyonunun Serebral Oksijenizasyona Etkileri

“…They found a significant drop in cerebral oxygenation after positioning. However it is not clear whether this drop is truly significant physiologically in the American Society of Anaesthesiologists' (ASA) class 1 and 2 patients and none of the children had a neurological disturbance (12).…”