Bo Chen, Ph.D. Director of Clinical Research CAS Medical Systems, Systems Inc Inc.

Branford, Connecticut, USA

Introduction
FORE-SIGHT development history How does it work? Animal and human validation studies p Comparison:
Difference between cerebral oximetry and pulse oximetry Difference between FORE-SIGHT and INVOS (Somanetics)

Clinical Studies
Adult cardiac surgery, elderly bypass, DHCA Adult non-cardiac major j surgery g y Orthopedic surgery (Beach Chair) Neonate: NICU and cardiac surgery (OR, CICU)

FORE-SIGHT Sight Development History

The Beginning: g g Paul Benni and Bo Chen Rutgers University, Department of Biomedical Engineering Ph.D. Research Projects, Early Generations Prototypes. Aim at building a better mouse trap than the Somanetic trend only device. The Key Milestone: Dr. Paul Benni Developed p Algorithms g for Absolute Measurement at CAS Medical Systems, Inc. (CASMED) 5 million dollar NIH grants award to CASMED for adult and neonatal cerebral oximeters research and development.
PI Name Benni, P Benni, P Benni, P Chen, B Chen, B Chen, B Chen, B Chen, B Project Title Neonatal Optical Noninvasive Brain Oxygenation Monitor Neonatal Optical Noninvasive Brain Oxygenation Monitor Neonatal Optical Noninvasive Brain Oxygenation Monitor Adult Optical Non-Invasive Brain Oxygenation Monitor Optical Cerebral Hemodynamics Monitor Adult Optical Non-Invasive Brain Oxygenation Monitor Adult Optical Non Non-Invasive Invasive Brain Oxygenation Monitor Adult Optical Non-Invasive Brain Oxygenation Monitor Adult Optical Non-Invasive Brain Oxygenation Monitor

Grant Number 1R43NS039723-01 2R44NS039723-02 5R44NS039723-03 1R43NS045488-01 1R43NS046147-01 2R44NS045488-02 3R44NS045488-02S1 3R44NS045488 02S1 5R44NS045488-03

2R44NS045488-04A1 Chen, B

FORE-SIGHT: The Technology

How does it work?

Cerebral Oximetry vs Pulse Oximetry

Pulse Oximetry SpO2 or SaO2: Arterial Oxygen Saturation Normal range: 90-100% Cerebral Oximetry SctO2: Regional Tissue Oxygen Saturation Normal Range: 60-80% SjvO2: Jugular Venous Oxygen Saturation Normal Range: 50-70%

Arteries Tissue
(Arterioles, capillaries, venules)

Veins

Elimination/Reduction of Extracerebral Tissue Interference

Elimination of Extracerebral Tissue Interference

Animal Model: Internal and External Carotid Arteries Occlusion Study y

Elimination of Extracerebral Tissue Interference

Results of scalp cuff occlusion study (venous or arterial) demonstrated that the FORESIGHT algorithm is effective at eliminating extracerebral tissue interference

NIRS probe Scalp occluder cuff

Scalp detector only

NIRS SnO2% and hemog globin (uM)

Brain oxygenation from Single brain detector algorithm l ith

Brain oxygenation from Dual-detector algorithm SnO2 %

TotalHb HbO2 Hb
VEN OCC ART OCC VEN OCC ART OCC VEN OCC ART OCC (min)

From Pulse Oximetry to Cerebral Oximetry

Oxygen Saturation SO2 = Oxy-Hemoglobin / (Total Hemoglobin) X 100% B h are based Both b d on Beer-Lamberts B b Law that h describes d ib light li h absorption b i Pulse Oximetry: Two wavelengths. Using light loss (Systole Diastole) to calculate only signals due to pulsation of arterial blood to derive arterial O2 saturation. Cerebral Oximetry: Looking into entire nonpulsating field to derive tissue O2 saturation. It requires precise light sources and more wavelengths to account for light lost from elements in addition to Oxy- and Deoxy-Hemoglobin.

Incident Light Inten nsity

Light lost due to pulsation of arterial blood Light lost due to non-pulsating arterial blood Light Los st Diastole Light Lo ost Systole Li ht l Light lost td due t to venous bl blood d

Pulse Oximetry

Light lost from the Background: Light lost due to other molecules Light scattering lost

Cerebral O i Oximetry t

Time

FORE-SIGHT: How does it work?

Near Infrared Measurement Window

Fundamental Principle of Oximetry: Beer Lambert Law

L

Iol1 Iol2

Il1 Il2
photodetector

Hb
Beer ee - Lambert a be t Law a A = -log (I1 / Io) = * c * L
A2 A = attenuation (OD) Io = incident light intensity I = detected light intensity = specific extinction coefficient (M-1 * cm-1) c = concentration of absorbing compound (M) L = distance light enters and leaves solution (cm) ( (pathlength) hl h)

HbO2

A1 = (Hb1 * [Hb] + HbO21 * [HbO2] )* L = (Hb2 * [Hb] + HbO22 * [HbO2] )* L [Hb] = Deoxy-Hemoglobin Concentration [HbO2] = Oxy-Hemoglobin Concentration O2 Saturation SO2 = [HbO2] / ([HbO2]+[Hb]) Pathlength is not needed for calculate SO2

FORE-SIGHT: H How does d it work? k?

Multi-Wavelength Modified Beer Lambert Equations

Iol1 Iol2 Iol3

Eq. (1)
Hb HbO2

Il1 Il2 Il3

photodetector

A = -log(I/Io) = * C * d * B + E

A is the optical attenuation in tissue at wavelength (units: optical density OD); Io is the incident light intensity (W/ 2); (W/cm ) I is i the th detected d t t d light li ht intensity i t it (W/cm (W/ 2); ) is i the th wavelength-dependent l th d d t absorption b ti coefficient ffi i t of f the th -1 -1 chromophore (OD * cm * M ); C is the concentration of chromophore (M); L is the light source to detector distance (cm); B is the light scattering differential pathlength factor (unit-less); E for non-hemoglobin optical losses (OD) which includes light scattering loss (OD), fixed background absorption (OD), and effect from patient dependent variables: such as skin tone, melanin (OD). For three independent wavelengths:

Background light lost

A1 = (Hb1 * Hb + HbO21 * HbO2 )* d * B + E1 A2 = (Hb2 * Hb + HbO22 * HbO2 )* d * B + E2 A3 = (Hb3 * Hb + HbO23 * HbO2 )* d * B + E3

Eq. (2) Eq (3) Eq. Eq. (4)

CASMED Patented P d algorithms: More wavelengths are needed to derive oxy and de-oxy hemoglobin concentrations in determining absolute SctO2, by accounting for background light lost.

A12 = (Hb12 * Hb + HbO212 * HbO2 )* d * B + E12 A13 = (Hb13 * Hb + HbO213 * HbO2 ) )* d * B + E13
A12 A13

[ ]

' 1

(d B )1

E12 E13

[ ]

' 1

(d B )1 =

Hb HbO2

AHb Hb (d B )1 Hb (d B )1 = AHbO2 HbO2 HbO2

SctO2% = (AHbO2 - HbO2)/(AHbO2 - HbO2 + AHb - Hb)*100%

Eq. (5) Eq. (6)

INVOS: Two LEDs (bandwidth about 30 nm), insufficient wavelength to resolve the background light lost, and also are not precise enough to do absolute quantification.

FORE-SIGHT: Four precise laser diodes (bandwidth < 1 nm). From the NIH funded research, it was determined that four precise wavelengths are needed to maximize the measurement accuracy of oxy and de-oxy hemoglobin in determining absolute SctO2, by compensating for wavelength dependent scattering losses, and by accounting for interference from other background light absorbers.

Key Differentiator Absolute vs. Trend Monitoring

FDA 510 (k) Indications for Use similarity and differences
FOREFORE SIGHT

The N Th Non-invasive i i Ad Adult lt C Cerebral b lO Oximeter i t M Model d l 2040 should h ld b be used as an adjunct monitor of regional hemoglobin oxygen saturation of blood in the brain of an adult. The Cerebral y should not be used as the sole basis Oximeter Monitor System for decisions as the diagnosis of therapy. The value of data from the Cerebral Oximeter Monitoring System has not been demonstrated in disease states. The noninvasive INVOS 5100 Cerebral Oximeter should be used as an adjunct monitor of trends in regional hemoglobin oxygen saturation of blood in the brain of an individual. Because INVOS values are relative within an individual, the INVOS should not be used as the sole basis for decisions as to diagnosis or therapy. The value of data from the INVOS has not been demonstrated in disease states. states

INVOS

Jugular Venous Oxygen Saturation Threshold

Cerebral Monitoring: Jugular Venous Oximetry Randall M. Schell, MD, and Daniel J. Cole, MD Department of Anesthesiology, Loma Linda University, Loma Linda, California Anesth Analg 2000;90:559-566

Reading of FORE-SIGHT on the same subject in previous photo.

FORE-SIGHT:
Animal Validation Study

correlation of SctO2 and SmvO2

FORE-SIGHT Human Validation Study

Duke Volunteer Study, funded by NIH

FORESIGHT

JB Catheter

Pulse Oximeter

Cerebral oximetry measures cerebral tissue oxygen saturation (SctO2) at the microvasculature level (about 70% venous and 30% arterial blood), therefore SctO2 value is roughly 10% above jugular venous saturation under most clinical condition.

FORE-SIGHT Human Validation Study

Comparision of Normal Cerebral Tissure Oxygen Saturation Values (Healthy ( y volunteers, awake, room air breathing) g)
70%
INVOS (rSO2) FORE-SIGHT (SctO2)

60%

Percenta age of Pop pulation

50% 40% 30% 20% 10% 0% < 40 < 45 < 50 < 55 < 60 < 65 < 70 < 75 < 80 < 85 < 90

SctO2 Value (%), awake, room air breathing

Case Report
A 78-year old female underwent aortic valve replacement procedure. In addition to standard monitors for cardiac anesthesia h i the h FORE-SIGHT FORE SIGHT Ab Absolute l Cerebral C b lO Oximeter i was utilized for monitoring cerebral tissue oxygen Saturation SctO2 with sensors placed bilaterally on the patients forehead. The pre induction SctO2 value was 55% and was drifting down to 50% post induction, and pre CPB. Since the FORE-SIGHT SctO2 value was low compared to what is normally seen for patients undergoing cardiac surgery, attempts were made to increase cerebral b l perfusion f and d oxygen d delivery l to maintain h her SctO2 level. It was soon determined that the low SctO2 reading was due to a low cardiac output (2 L/min) caused by server aortic valve stenosis, and this is confirmed by central venous saturation readings around 40s percent. Upon initiating CPB with full flow her status dramatically improved and her SctO2 level increased into the 70s and remained at this level until the end of the case.

Neonate Validation Methods

Procedure: VV-ECMO: (Veno-Venous Extracorporeal
Membrane Oxygenation) yg ) with Cephalad p Catheterization. Two clinical sites in the U.S.: Emory and CNMC. Protocol Cerebral venous oxygen saturation (SjvO2) obtained from cephalad catheter placed in internal jugular vein. Emory: y SctO2 data sampled p every y few seconds, Statsat SjvO2 monitor, and pulse oximeter (SpO2) to obtain high n for statistical analysis.

CNMC: C C Blood ood sa samples p es d drawn a e every e y few e hours ou s a and da analyzed a y ed by laboratory co-oximeter. Variations of SpO2, SjvO2, and SctO2 obtained from ECMO weaning period and from long term data recording over 2 to 10 days for each patient.

Figure 2: Scatterplot of cerebral oximetry SctO2 vs. the reference SctO2 derived f from high hi h t temporal l resolution l ti monitoring it i of f Sj SjvO O2 from f in-line i li St Statsat t t monitor it and d pulse oximetry SpO2.

FORE-SIGHT Neonate Study

Summary
The significance of cerebral oximetry monitoring FORE-SIGHT SIGHT is better technology FORE

Disclaimer: I am one of the inventers of the FORE-SIGHT Absolute Cerebral Oximeter. Therefore, I can be biased.

Figure 9: Case study with CPR given to Subject.

Duke Cardiac Study

Typical Pattern: DHCA Study, Mount Sinai Medical Center

Typical Pattern: DHCA Study, Mount Sinai Medical Center

St ar tp os t in du ct

Absolute Cereb bral Oxime etry SctO2 % of L&R sensors) (Average o

100 20 30 40 50 60 70 80 90
io n (n =1 5)

Pr e by pa ss (n =1 5) Pl at ea u 20 de g C (n =1 0) H yp ot he rm a M ax (n =1 5)

D ee p

D HC A +5 m in (n =1 4)

D HC A +1 0 m in (n =1 4) (n =1 4)

D HC A +1 5 m in

D HC A +2 0 m in (n =1 (n A +3 D HC SC P En d st ud y/ ch es A 0 m +3 + 5 in m 15 tc 0) in =7 (n in m lo s in ur e

D HC A +2 5 m

D HC

SctO2% Average

) =4 (n

) =2 (n =1 (n

DHCA Study, Mount Sinai Medical Center

Cerebral Oximetry Monitoring of Patients Undergoing Elective Thoracic Aortic Surgery with DHCA and SCP (15 Subjects)

4) =1

4)

DHCA Study, Mount Sinai Medical Center

Antegrade Selective Cerebral Perfusion

Orihashi K, et.al., Malposition of selective cerebral p perfusion catheter is not a rare event. Eur J Cardiothorac Surg. 2005 Apr;27(4):644-8.
Results: Catheter malposition was detected in 4 of 35 cases (11.4%). Conclusions: Catheter malposition on the right side is not a rare event during selective cerebral perfusion. The catheter can migrate into the right subclavian artery or common carotid artery. Pressure monitoring cannot reliably detect an occurrence of catheter migration into the right subclavian artery. Combined use of near-infrared spectroscopy, orbital ultrasound, and transesophageal echocardiography can be useful for detecting this event and making an appropriate decision without delay to prevent irreversible brain damage.

(A) Atherosclerotic ascending and arch aneurysm. (B) Fabrication of the trifurcated graft. (C) Selective cerebral perfusion and construction of the elephant trunk. (D) Completed repair.

Cerebral Desaturation due to Air Emboli

Below: Normal Pattern of SctO2 during Aortic Surgery SctO2 increases with cooling due to reduction of cerebral O2 consumption.

Outcome of this patient: Extubated on the fifth day post surgery. Patient was severely confused - not oriented to person, place l or ti time. P Patient ti t h has a prolonged recovery. Absolute cerebral oximetry is useful in clinical settings to identify catastrophic events that may occur during the course of surgeries that would otherwise have been missed.

Cerebral Desaturation due to Hypoperfusion

Normal SctO2 pattern - maintaining MAP 50-60mmHg 0 60 on CPB C provides id adequate d cerebral perfusion for most patients

Cerebral desaturation due to low blood pressure (MAP) during CPB

SctO2 failed to rise with cooling g on CPB in one patient p (out ( of 26 subjects). j ) The SctO2 variation corresponded to dynamic fluctuations of MAP, indicating an impaired cerebral auto-regulation for this patient. (Impaired cerebral autoregulation occurs often in people with advanced age, diabetes, hypertension, and existing cerebral vascular disease) Maintaining MAP at 50-60mmHg seems to be inadequate for certain patients. Cerebral oximetry is needed for tailored patient management during cardiac surgery

Effect of PaCO2 on Cerebral Tissue Oxygen Saturation SctO2

Cerebral Oximetry: Other Clinical Evidences

Murkin JM, et.al., Anesth Analg. Analg 2007 Jan;104(1):51-8 Jan;104(1):51 8.

Results from the overall randomized, blinded study of 200 CABG patients demonstrated prospectively that rSO2 monitoring is associated with a significant decrease in cumulative major morbidities, including stroke, death, y infarction, ,p prolonged g ventilatory y support pp and renal failure. myocardial

delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg F Forum . 2004;7(5):E376-81. 2004 7(5) E376 81
A large non-randomized series of 1698 cardiac surgical patients, comparison to an untreated comparator group of 2077 similar patients operated on in the immediately preceding 18-month interval. Cerebral oximetry was used to optimize and maintain intraoperative cerebral oxygenation oxygenation, a significant reduction in perioperative stroke rate, from 2.01 to 0.97%, was observed.

Goldman S, et.al., Optimizing intraoperative cerebral oxygen

Orihashi K, et.al., Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion. Eur J Cardiothorac S Surg . 2004 N Nov; 26(5):907-11. 26(5) 907 11
A sustained decrease in rSO2 was observed in patients with infarcts suggestive to hypoperfusion. Transient neurological events occurred more frequently in patients with sustained i dd drop b below l 55% f for over 5 min. i Recommend that recovery of drop in rSO2 below 55% should be addressed without delay.

Intervention Protocol

Goldman S, et al, Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg Forum. 2004;7(5):E376 2004;7(5):E376-81 81. Murkin JM, et al, Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. A Anesth h Analg. A l 2007 Jan;104(1):51-8.

Lessons Learned:

Challenges of a for Patient Monitoring Technology Different Era compare to the time when Pulse Oximetry was adopted by clinicians: Evidence-Based Medicine: Can it improve p patient p outcomes Benefit/Cost: reimbursement issue; Hospital administration demands More outcomes data support the use of NIRS in children than exist for pulse oximetry Clinical Research Driven Marketing: Success of Masimo, Aspect Medical.

Figure Top Left: Recorded SctO2 values from FORE-SIGHT cerebral oximetry monitoring with bilateral forehead sensors obtained from three patients, with methylene blue administration timing shown. Conclusion: Our results suggest that the FORE-SIGHT cerebral oximeter can be used to reliability detect brain oxygen desaturation events in cases where Methylene Blue is administered to treat vasoplegic syndrome. From: FORE-SIGHT Cerebral Oximeter: A Possible Solution to Methylene Blue Interference Gregory W. Fischer, M.D. and David L. Reich, M.D. Department of Anesthesiology, Mount Sinai Medical Center, New York (publication pending)

Figure Bottom Left: Concomitant with the initiation of the methylene blue loading dose, we noted that cerebral oximetry values (INVOS, Somanetics, Troy, MI) declined markedly in all patients despite significant improvement in systemic perfusion pressure. The image on the bottom left illustrates this phenomenon in two patients by replicating the INVOS monitor display. From: Mittnacht AJ, Fischer GW, Reich DL. Methylene
blue administration is associated with decreased cerebral oximetry values. Anesth Analg. 2007 Aug;105(2):549-50.

There is a question why the word absolute doesn't appear in the FORE-SIGHT indication for use. The answer: For a patient monitor, absolute is assumed unless marked as trends. For example, below is the "Indications For Use" of a Nellcor Pulse Oximeter. It is "for the continuous non-invasive monitoring of functional oxygen saturation of arterial hemoglobin (SpO2) and pulse rate." Notice that there is no word "absolute" in this indications for use . But nobody will doubt that the SpO2 and pulse rate that this Nellcor pulse oximeter provides are ABSOLUTE values.

Comparison of NIRS SctO2 vs. Blood Co-oximetry in Neonatal Pig Models with Intact Scalp and Removed Scalp (NIRS Probe optode separation = 25 mm)

Duke Cardiac Study

Figure: Mean, 25th-75th Percentile boxes for Median LRAvg Cerebral tissue saturation at standardized event times (shows data from Table 1 )

Duke Cardiac Study

Cerebral Tissue Oxygen Saturation Values for Cardiac Surgery Patients

Data are from the INVOS flip chart FORE-SIGHT: Median SctO2 value of awake cardiac surgery patients was 70%. Awake SctO2 variability was small (SD:3.9%, 2SD:62.2 to 77.8%, actual range 60.6 to 83%) independent of age, skin color and gender. (Macleod et al: ANESTH ANALG 2007; 104; S129) INVOS: Baseline rSO2 were 669%, range (defined as 2SD) was 48 to 84%. Actual range on figure were from <40 to <90%, Six percent of patients has baseline rSO2 value less than 50% - the suggested intervention threshold by Somanetics.

Table 1: Bilateral Difference of Absolute SctO2 Room Air Breathing O2 100% O2 100% +10 min Induction Induction +15 15 min Incision Incision +15 min Pre-CPB -5 min CPB on +10 10 min i CPB on +30 min Start Rewarming Pump Off End CPB +20 min Chest Closed

Average 1.8 2.1 1.8 2.5 2.4 2.3 2.5 2.5 26 2.6 2.7 2.4 2.6 3.0 2.8

Standard Deviation 1.2 1.3 1.4 1.6 2.0 2.2 2.4 1.9 20 2.0 2.4 2.3 1.8 1.9 2.2 Frequency 206 135 50 21 4

Max 4.0 4.1 5.1 5.6 8.5 7.9 10.3 8.3 71 7.1 7.5 9.6 6.5 7.6 7.1

Table 2: Histogram of Bilateral Difference of Absolute SctO2 (%) 2 4 6 8 10

Cumulative % 51.6% 82.7% 94.2% 99 1% 99.1% 100.0%

FORE-SIGHT vs INVOS Validation Study

FORE-SIGHT Validation Study (Duke adult volunteer study), result is the comparison of ABSOLUTE values (noninvasive SctO2 vs invasive blood samples jugular bulb and arterial).

INVOS validation lid i data d ( (chart h shows h on the h Somanetics webpage). Result is the comparison of TREND values changes of rSO2. (1) The Y axis value is rSO2, here indicates it is change of rSO2 (2) Value is marked from (-) to (+) indicates the chart shows only change of rSO2

Conclusion of INVOS validation study

Henson LC, Calalang C, Temp JA, Ward DS. Accuracy of a cerebral oximeter in healthy volunteers under conditions of isocapnic hypoxia. Anesthesiology. 1998 Jan;88(1):58 Jan;88(1):58-65. 65. Our major finding is that Sjv with bar O2 can be estimated by the INVOS 3100A using the uncorrected direct measurement rSO2 or by correcting the measurement using the measured SaO2 (Equation 2) under conditions of hypoxic exposure with controlled normocapnia and hypercapnia. This implies that the device detects changes g in cerebral oxygen yg saturation, , due to changes in cerebral blood flow induced by changes in PET CO2, which are not apparent from the arterial saturation. However, the wide variability among volunteers of the slope and intercept of the relation between the actual jugular venous saturation and the estimate from the device, as well as the occurrence of three clear outliers (Figure 2), limits the clinical use of the device to situations in which tracking trends in cerebral oxygenation would be acceptable.

FORE-SIGHT vs INVOS Validation Study

Some presentations cite the Kims (Ref 1) study for INVOS validation (see charts above). Fig. 3 compare jugular bulb O2 saturation SjvO2 with rSO2. SjvO2 and rSO2 are not the same parameter. The correct way is to compare rSO2 with fSO2 [fSO2 = a*SaO2 + (1(1 a)*SjvO2, )*SjvO2 see page197]. Here the data of this paper starts to fall apart. (See Fig 5. the distribution of a.) I dont believe that Kims paper included subjects that outliers (see next two photos, one is tested on the brand new INVOS.) But the same groups earlier study found that was a problem ( p (ref 2 Fig g 2). ) Next two photos show that the new INVOS has the same problem. The bottom line is the principle of physics says that you need one wavelength for one unknown absorber. A two wavelengths system like the INVOS can not resolve Hb, HbO2 and as the same time figures out what is the background light lost. So INVOS only can do TREND. ).
1. 2. Kim M, Ward D, Cartwright C, Kolano J, Chlebowski S, Henson L: Estimation of jugular venous O2 saturation from cerebral oximetry or arterial O2 saturation during isocapnic hypoxia. J Clin Monit 2001;16:191-99. Henson LC, Calalang C, Temp JA, Ward DS. Accuracy of a cerebral oximeter in healthy volunteers under conditions of isocapnic hypoxia. Anesthesiology. 1998 Jan;88(1):58-65.

Does SjvO2 Truly Reflects Brain Oxygenation during Hypothermia

Does SjvO2 Truly Reflects Brain Oxygenation during Hypothermia

Does SjvO2 Truly Reflects Brain Oxygenation during Hypothermia

Figure 1. Graphic depiction of temperature: time Figure 2. Graphic depiction of temperature: time relationship p during g cardiopulmonary p y bypass yp and deep p relationship p during g cardiopulmonary p y bypass yp and deep p hypothermic circulatory arrest for patient 14. hypothermic circulatory arrest for patient 18. Monitoring Temperatures from each monitoring site are plotted site temperatures are plotted every minute. Central sites every minute. Central sites are nasopharynx, tympanic are nasopharynx, tympanic membrane, esophagus, and membrane, esophagus, and pulmonary artery. pulmonary artery. Peripheral sites are bladder, rectum, Peripheral sites are bladder, rectum, axilla, and sole of axilla, and sole of the foot. The two slowest cooling central th f the foot. t Th The t two f fastest t t cooling li sites it were pulmonary l t l sites it were t tympanic i membrane b and d esophagus. h artery and esophagus. Stone, J. Do Standard Monitoring Sites Reflect True Brain Temperature When Profound Hypothermia Is Rapidly Induced and Reversed? Anesthesiology: 82(2), 1995:344-351

Does SjvO2 Truly Reflects Brain Oxygenation during Hypothermia

Nussmeier NA, Temperature during cardiopulmonary bypass: the discrepancies between monitored sites. Anesth Analg. 2006 Dec;103(6):1373-9. temperatures measured in body sites overestimated JB temperature during cooling and under-estimated d i di it d during i rewarming, i whereas h arterial outlet blood temperature provided a good approximation. Is the conclusion correct?

Akata T, Changes in body temperature during profound hypothermic cardiopulmonary bypass in adult patients undergoing aortic arch reconstruction. J Anesth. 2004;18(2):73-81. the CPB venous line temperature (CPBT), a reasonable indicator of mixed venous blood temperature during CPB and believed to best reflect core temperature d i during stabilized t bili d h hypothermia th i on CPB (pulmonary arterial temperature) PAT began to change immediately after the start of cooling or rewarming, closely matching the CPBT ( r = 0.98). a PA catheter thermistor, thermistor presumably because of its a placement immediately behind the superior vena cava, would provide a reliable measure of the mixed venous blood temperature.

Is the conclusion correct?

Does SjvO2 Truly Reflects Brain Oxygenation during Hypothermia

INVOS vs. SjvO2 during DHCA

Leyvi G, Bello R, Wasnick JD, Plestis K. Assessment of cerebral oxygen balance during deep hypothermic circulatory arrest by continuous jugular bulb venous saturation and near-infrared spectroscopy. J Cardiothorac Vasc Anesth. 2006 Dec;20(6):826-33.

Cerebral oximetry Market

Pediatric CVOR and ICU

From: Wernovsky G,et. et al al., Hypoplastic left heart syndrome: consensus and controversies in 2007. Cardiol Young. 2007 Sep;17 Suppl 2:75-86. Survey of f 52 large l pediatric d h heart surgery center (US and International)

Application of Beer - Lambert Law in Pulse Oximetry

Pulse oximetry: Assume the pulsatile signal (alternating current - AC) comes only from artery. Background light lost is in the direct current (DC) components Normalization AC/DC to cancel out the effect DC. Therefore, pulse oximetry is not affected by b k background d light l h lost. l Two wavelengths l h are sufficient to resolve SaO2.