Goal-directed therapy based on rScO2 monitoring in elderly patients with one-lung ventilation: a randomized trial on perioperative inflammation and postoperative delirium

Abstract

Background The incidence of postoperative delirium (POD) is high in elderly patients with one-lung ventilation, which is mostly related to the impairment of cerebral oxygen supply/demand balance during operation. (Surgical) stress can cause changes to normal physiological function and increase oxygen supply to the brain. When cerebral oxygen supply/demand is unbalanced, other organs may have already suffered from hypoperfusion or even hypoxic damages leading to increased release of inflammatory factors. Regional saturation of cerebral oxygenation (rScO2) monitoring can noninvasively monitor the variation of regional cerebral oxygen supply/demand balance in real time, and it has a good correlation with the occurrence of POD. S-100β is one of the markers commonly used to predict and diagnose POD, and lactate is one of the important indicators for the quality of tissue perfusion. The study explores whether the goal-directed therapy based on rScO2 monitoring can reduce perioperative inflammatory factor levels and POD incidence in elderly patients with one-lung ventilation and improve tissue perfusion. Methods The study is registered on Chinese Clinical Trial Registry (ChiCTR2100054888). A total of 159 patients scheduled for thoracoscopic lobectomy under general anesthesia were divided into the control group (n = 81) and the goal-directed therapy group (GDT group, n = 78). On the basis of the conventional management in the control group, the GDT group applied goal-directed rScO2 monitoring to maintain rScO2 at ±20% baseline level during one-lung ventilation. The levels of interleukin-1β, interleukin-6, tumor necrosis factor-α, and lactate; the intensity of postoperative pain; and the incidence of POD before anesthesia (T1), at the end of operation (T2), on day 1 after operation (T3), on day 3 after operation (T4), and on day 7 after operation or before discharge (T5) were compared respectively between the two groups. Results The incidence of POD at T3 and the awakening time in the GDT group were lower than those in the control group (P < 0.05). During T2 to T4, the levels of inflammatory factors and lactate concentration in the control group were higher than those in the GDT group (P < 0.05). During T3 to T4, the levels of C-reactive protein and lactate in the control group were higher than those in the GDT group (P < 0.05). During T2 to T3, the levels of S-100β in the control group were higher than those in the GDT group (P < 0.05). The levels of inflammatory factors and lactate concentration in both groups during T2 to T4 were higher than those at T1 and T5 (P < 0.05), and there was no statistical difference at T1 versus T5 (P > 0.05). There was no significant difference in postoperative pain intensity, the incidence of agitation during awakening, and postoperative hospital stays between the two groups. Conclusion Goal-directed therapy based on rScO2 monitoring can reduce perioperative inflammatory factor levels, postoperative delirium incidence, and postoperative awakening time and improve tissue perfusion in elderly patients with one-lung ventilation. Trial registration The Chinese Clinical Trial Registry ChiCTR2100054888. Registered on 28 December 2021

Effect of perioperative goal-directed fluid therapy on postoperative complications after thoracic surgery with one-lung ventilation: a systematic review and meta-analysis

“…The sample sizes of the studies ranged from 59 to 232 patients, and a total of 1318 patients were analyzed. Five of the included studies had a sample size of more than 100 patients (45%) [ 16 , 18 , 21 , 25 , 26 ], nine studies were RCTs [ 4 , 11 , 16 – 18 , 23 – 26 ], and two were observational studies [ 21 , 22 ]. Ten studies compared GDFT with CFT [ 4 , 11 , 16 – 18 , 21 – 25 ], and one study compared GDFT with RFT [ 26 ].…”

“…Five of the included studies had a sample size of more than 100 patients (45%) [ 16 , 18 , 21 , 25 , 26 ], nine studies were RCTs [ 4 , 11 , 16 – 18 , 23 – 26 ], and two were observational studies [ 21 , 22 ]. Ten studies compared GDFT with CFT [ 4 , 11 , 16 – 18 , 21 – 25 ], and one study compared GDFT with RFT [ 26 ]. For the RFT strategy, fluids and norepinephrine were administered to maintain the mean arterial pressure (MAP) > 65 mmHg [ 26 ].…”

“…For lung resections (7/11) [ 11 , 16 , 17 , 22 , 23 , 25 , 26 ], the incidence of postoperative complications was lower in the GDFT group (OR 0.37, 95% CI 0.18–0.76; P = 0.007; I 2 = 73%). However, for esophagectomies, no statistically significant difference in the incidence of postoperative complications between the two groups was found (4/11) [ 4 , 18 , 21 , 24 ] (Fig.…”

“… Tang et al 2021 [ 24 ] China RCT GDFT: n = 33 Control: n = 32 Minimally invasive esophagectomy GDFT SVV < 11% CFT Postoperative complications; Mortality; LOS; Fluid balance. Wang et al 2022 [ 25 ] China RCT GDFT: n = 78 Control: n = 81 Thoracoscopy lobectomy GDFT rScO 2 ± 20% (baseline level) CFT Postoperative complications; Inflammatory factors; Awakening time; VAS score. Li et al 2021 [ 26 ] China RCT GDFT: n = 59 Control: n = 59 Thoracoscopy lobectomy GDFT SVV 10%-13% CI > 2.5 ml min −1 m −2 RFT Postoperative complications; Mortality; Length of hospital stay; Fluid balance.…”

Implication of age-related changes on anesthesia management

“…Interestingly, in the elderly population, GDFT was useful in reducing POD incidence when guided by cerebral perfusion via regional cerebral oxygen saturation,[ 28 ] leading to a shorter recovery time and lower production of pro-inflammatory factors. [ 29 ]…”