Method for personalized prevention of neurological complications in cardiac surgery patients

Abstract

FIELD: cardiology.SUBSTANCE: used for personalized prevention of neurological complications in cardiac surgery patients. The method involves conducting sessions of interval hypoxia-hyperoxia, which are performed for 3 days before surgery. In this case, the initial level of regional oxygen saturation of the brain (rSO2) is determined based on cerebral tissue oximetry (CTO) data in the para-infrared spectrum. Then, during the hypoxic phase, under the control of the central oxygen therapy center, the inspiratory fraction of oxygen is individually selected until rSO2 decreases by 20% from the initial level.EFFECT: method allows to reduce the number of neurological complications in patients operated under artificial circulation and improve the results of cardiac surgery.1 cl, 1 ex

Description

[0001] The invention relates to medicine, namely to technologies of prehabilitation and anesthetic support during cardiac surgery.

[0002] The global aging of the population has resulted in the emergence of a large number of elderly patients with a high degree of comorbidity in medical hospitals and an increase in the absolute and relative incidence of cardiovascular diseases requiring cardiac surgery. Cardiac surgery is associated with a significant load on the body's systems, especially in elderly vulnerable patients with reduced physiological reserve [1]. A number of clinical studies have shown that up to 50% of elderly people scheduled for cardiac surgery can be considered frail, which is defined as a cumulative decrease in the performance of many physiological systems, leading to vulnerability to stressful events [2].

[0003] One of the main causes of many complications developing during cardiac surgery is ischemia-reperfusion injury of the brain associated with aggressive factors of the intraoperative period and the use of artificial circulation, subsequently leading to clinically manifest neurological complications and the progression of cognitive dysfunction. Neurological complications occupy an important place in the structure of perioperative complications in cardiac surgery, which include: life-incompatible brain injury, acute cerebrovascular accident (ACVA), transient ischemic attack (TIA), severe disturbances of consciousness (coma), seizures without signs of focal damage, postoperative delirium, delayed neurocognitive recovery, postoperative neurocognitive disorder [3].

[0004] To prevent the development of neurological complications, preparatory measures are taken prior to cardiac surgery, including preventive rehabilitation [4]. Recent research emphasizes the importance of preoperative measures aimed at improving the patient's readiness for surgery and the effectiveness of postoperative recovery. This strategy is called prehabilitation. These measures include:

[0005] - physical prehabilitation (aerobic exercise, respiratory training);

[0006] - optimization of the patient’s nutritional status;

[0007] - socio-psychological training [5].

[0008] Despite the broad scope of prehabilitation in cardiac surgery, the results of its application remain unsatisfactory. The search for new methods capable of increasing the effectiveness of standard preventive measures remains relevant. The application of many prehabilitation concepts may be significantly limited by patient age, high comorbidity, low functional reserve, and the severity of the underlying pathology. The development of new approaches to the prevention of neurological complications and the formation of a neuroprotective phenotype is extremely important; hypoxic preconditioning methods may be considered as such [6].

[0009] Short-term episodes of hypoxia and subsequent reoxygenation activate the production of a number of transcription factors and reactive oxygen species (ROS), which together trigger mechanisms of cardio- and neuroprotection [7]. The effect of hypoxic preconditioning can be potentiated by replacing normoxic periods with administering a hyperoxic gas-air mixture to the patient [8]. In the context of use in the preoperative period of cardiac surgery, this technique can be characterized as hypoxic-hyperoxic preconditioning (HHP) and is used to prevent perioperative complications, particularly neurological ones [9].

[0010] A method for preventing neurological complications in cardiac surgery patients is known, which consists of conducting interval hypoxic-hyperoxic exposures

[10] .

[0011] This method is closest to the claimed method in terms of its technical essence and achievable result and has been selected as a prototype. A disadvantage of this method is its impossibility of its application in routine cardiac surgery, which is limited by regulated hospitalization periods. This method requires GGP sessions to be performed within 7 days before surgery, which is associated with a longer preoperative hospitalization period, the need for a reserve bed capacity, the risk of developing hospitalization-associated nosocomial infections, logistical difficulties in patient routing, and increased economic costs. Therefore, its widespread use in routine cardiac surgery is severely limited.This method also does not lead to the implementation of an organoprotective phenotype in all patients to whom it is used, since it is not personalized, but involves conducting a hypoxic phase until peripheral saturation decreases to 82%, while it does not take into account the developing adaptive changes in the brain and does not lead to post-transcriptional changes in the central nervous system.

[0012] The objective of the invention is to create an effective method that allows for personalized prevention of neurological complications in cardiac surgery patients, with the possibility of use in routine clinical practice.

[0013] The incidence of neurological complications in cardiac surgery remains high, which is associated, among other things, with an imbalance in systemic oxygen delivery and consumption by the brain

[11] . To monitor regional cerebral oxygen saturation, cerebral tissue oximetry in the para-infrared spectrum (rSO2) is used using disposable sensors with absorbent properties. This method is a non-invasive method for assessing local perfusion of cortical tissue in the areas supplied by the anterior and middle cerebral arteries. In some patients, one or more episodes of decreased rSO2 occur during cardiopulmonary bypass

[12] . Patients who have experienced episodes of decreased rSO2 levels during cardiac surgery are at increased risk of developing neurological complications; therefore, rSO2 monitoring is included in the standards of multimodal neurological monitoring in cardiac surgery [13,14].A number of randomized studies have shown that the incidence of postoperative neurological complications was significantly higher in patient groups where rSO2 levels decreased by > 15% from baseline

[15] . Intraoperative cerebral desaturation > 20% from baseline is also associated with delirium and decreased cognitive abilities after cardiac surgery

[16] . In this regard, achieving individual limits of cerebral autoregulation based on rSO2 determination during HGP is pathogenetically justified within the framework of a personalized prehabilitation strategy.A short-term decrease in rSO2 by 20% from baseline values ​​during three sessions of GGP is a sufficient trigger for the activation of endogenous processes of short-term neuroadaptation and can induce the implementation of an organoprotective phenotype in a short period of time before surgery, without increasing the duration of hospitalization required for the full course of preoperative GGP described in the prototype method.

[0014] The stated objective is achieved by conducting sessions of interval hypoxia-hyperoxia for 3 days prior to surgery. During the hypoxic phase, the inspiratory oxygen fraction is individually adjusted to reduce cerebral tissue oximetry in the para-infrared spectrum by 20% of the baseline.

[0015] What is new in the proposed invention is the implementation of interval hypoxia-hyperoxia sessions for 3 days before surgery with a targeted reduction in the value of cerebral tissue oximetry in the para-infrared spectrum by 20% of the initial value during the hypoxic phase.

[0016] The technical result of this invention is a reduction in the number of neurological complications in patients operated under artificial circulation and an improvement in the results of cardiac surgery.

[0017] The claimed combination of distinctive features exhibits new properties that are not clearly derived from the state of the art in this field and are not obvious to a specialist. No identical combination of features was found in the analyzed patent and scientific medical literature. The proposed method can be used in practical healthcare to improve the quality and effectiveness of treatment. Based on the above, this technical solution should be considered compliant with the patentability criteria: "novelty," "inventive step," and "industrial applicability." The method is implemented as follows: sessions of interval hypoxia-hyperoxia are conducted for 3 days prior to surgery. During the hypoxic phase, the inspiratory oxygen fraction is individually adjusted to reduce cerebral tissue oximetry in the para-infrared spectrum by 20% of the baseline.

[0018] Clinical example.

[0019] Patient L., 68 years old; weight 100 kg; height 172 cm

[0020] Main diagnosis: Ischemic heart disease, angina pectoris 3 FC, stenosis of the anterior descending artery of the middle third 75%, stenosis of the right coronary artery of the proximal third 75%, PICS (2020), mitral valve insufficiency stage 2.

[0021] Concomitant diseases: Stage 2 COPD, incomplete remission. Stage 2 obesity. The baseline level of regional cerebral oxygen saturation, according to cerebral tissue oximetry in the para-infrared spectrum, was 68%. Before the intervention, the patient underwent 3 days of interval hypoxia-hyperoxia sessions. During the hypoxic phase, the inspiratory oxygen fraction was individually adjusted and amounted to 10-12% to achieve a cerebral tissue oximetry value in the para-infrared spectrum of 54%. The patient underwent mammary coronary artery bypass grafting of the LAD, aortocoronary artery bypass grafting of the RCA, mitral valve replacement under cardiopulmonary bypass and pharmaco-cold cardioplegia with Custodiol under combined anesthesia and mechanical ventilation. The duration of cardiopulmonary bypass was 140 minutes, with a total myocardial ischemia time of 105 minutes. Cardiac support was established using the aorta-to-right atrium approach. Cardiac bypass was performed in a non-pulsatile mode.Perfusion index 2.8 l / min / m. 2 Postoperative mechanical ventilation lasted 5 hours. No neurological complications (including stroke, delirium, delayed neurocognitive recovery, or postoperative neurocognitive dysfunction) were reported. Hospitalization lasted 10 days, and the patient was discharged for outpatient observation in satisfactory condition.

[0022] The method proposed by the authors has been tested in 40 patients and allows for the prevention of the development of neurological complications in cardiac surgery patients with improved outcomes of interventions.

[0023] List of references:

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Claims

A method for personalized prevention of neurological complications in cardiac surgery patients, consisting of conducting sessions of interval hypoxia-hyperoxia, characterized in that the sessions of interval hypoxia-hyperoxia are performed for 3 days before surgery, while the initial level of regional saturation of the brain with oxygen (rSO2) is determined according to cerebral tissue oximetry (CTO) in the para-infrared spectrum, then during the hypoxic phase, under the control of CTO, the inspiratory fraction of oxygen is individually selected until rSO2 decreases by 20% from the initial level.