Cerebral near infrared spectroscopy oximetry in extremely preterm infants: phase II randomised clinical trial A phase II randomized clinical trial on cerebral near-infrared spectroscopy plus a treatment guideline versus treatment as usual for extremely preterm infants during the first three days of life (SafeBoosC): study protocol for a randomized controlled trial Cerebral Oxygen Saturation to Guide Oxygen Delivery in Preterm Neonates for the Immediate Transition after Birth: A 2-Center Randomized Controlled Pilot Feasibility Trial. Clinical use of cerebral oximetry in extremely preterm infants is feasible. The SafeBoosC II randomized trial: treatment guided by near-infrared spectroscopy reduces cerebral hypoxia without changing early biomarkers of brain injury Cerebral oxygenation, extraction, and autoregulation in very preterm infants who develop peri-intraventricular hemorrhage. Cerebral near infrared spectroscopy: emitter-detector separation must be increased. A Comparison of Pulse Oximetry and Near Infrared Spectroscopy (NIRS) in the Detection of Hypoxaemia Occurring With Pauses in Nasal Airflow in Neonates Randomized trial of near-infrared spectroscopy for personalized optimization of cerebral tissue oxygenation during cardiac surgery Effect of severe hypoxia on prefrontal cortex and muscle oxygenation responses at rest and during exhaustive exercise. Effect of Posture on Brain Hemodynamics in Preterm Newborns Not Mechanically Ventilated Intraoperative monitoring of cerebral NIRS oximetry leads to better postoperative cognitive performance: a pilot study. The SafeBoosC Phase II Randomised Clinical Trial: A Treatment Guideline for Targeted Near-Infrared-Derived Cerebral Tissue Oxygenation versus Standard Treatment in Extremely Preterm Infants The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study. Do Sustained Lung Inflations during Neonatal Resuscitation Affect Cerebral Blood Volume in Preterm Infants? A Randomized Controlled Pilot Study Cerebral oxygenation in the frontal lobe cortex during incremental exercise tests: the regional changes influenced by volitional exhaustion. Cerebral tissue oxygenation index and lactate at 24 hours postoperative predict survival and neurodevelopmental outcome after neonatal cardiac surgery Effects of endotracheal suctioning in high-frequency oscillatory and conventionally ventilated low birth weight neonates on cerebral hemodynamics observed by near infrared spectroscopy (NIRS). Flow-related techniques for preoperative goal-directed fluid optimization. Spatial and temporal analysis of human motor activity using noninvasive NIR topography. Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: a correlational study. Near-Infrared Spectroscopy can Monitor Dynamic Cerebral Autoregulation in Adults Phase 1 study of two inodilators in neonates undergoing cardiovascular surgery
Objective To determine if it is possible to stabilise the cerebral oxygenation of extremely preterm infants monitored by cerebral near infrared spectroscopy ( NIRS ) oximetry . Design Phase II r and omised , single blinded , parallel clinical trial . Setting Eight tertiary neonatal intensive care units in eight European countries . Participants 166 extremely preterm infants born before 28 weeks of gestation : 86 were r and omised to cerebral NIRS monitoring and 80 to blinded NIRS monitoring .  The only exclusion criterion was a decision not to provide life support . Interventions Monitoring of cerebral oxygenation using NIRS in combination with a dedicated treatment guideline during the first 72 hours of life ( experimental ) compared with blinded NIRS oxygenation monitoring with st and ard care ( control ) . Main outcome measures The primary outcome measure was the time spent outside the target range of 55 - 85 % for cerebral oxygenation multiplied by the mean absolute deviation , expressed in % hours ( burden of hypoxia and hyperoxia ) . One hour with an oxygenation of 50 % gives 5%hours of hypoxia . Secondary outcomes were all cause mortality at term equivalent age and a brain injury score assessed by cerebral ultrasonography . R and omisation Allocation sequence 1:1 with block sizes 4 and 6 in r and om order concealed for the investigators . The allocation was stratified for gestational age ( < 26 weeks or ≥26 weeks ) . Blinding Cerebral oxygenation measurements were blinded in the control group . All outcome assessors were blinded to group allocation . Results The 86 infants r and omised to the NIRS group had a median burden of hypoxia and hyperoxia of 36.1%hours ( interquartile range 9.2 - 79.5%hours ) compared with 81.3 ( 38.5 - 181.3 ) % hours in the control group , a reduction of 58 % ( 95 % confidence interval 35 % to 73 % , P<0.001 ) . In the experimental group the median burden of hypoxia was 16.6 ( interquartile range 5.4 - 68.1 ) % hours , compared with 53.6 ( 17.4 - 171.3 ) % hours in the control group ( P=0.0012 ) . The median burden of hyperoxia was similar between the groups : 1.2 ( interquartile range 0.3 - 9.6 ) % hours in the experimental group compared with 1.1 ( 0.1 - 23.4 ) % hours in the control group ( P=0.98 ) . We found no statistically significant differences between the two groups at term corrected age . No severe adverse reactions were associated with the device . Conclusions Cerebral oxygenation was stabilised in extremely preterm infants using a dedicated treatment guideline in combination with cerebral NIRS monitoring . Trial registration Clinical Trial.gov NCT01590316 Background Every year in Europe about 25,000 infants are born extremely preterm . These infants have a 20 % mortality rate , and 25 % of survivors have severe long-term cerebral impairment . Preventative measures are key to reduce mortality and morbidity in an extremely preterm population . The primary objective of the SafeBoosC phase II trial is to examine if it is possible to stabilize the cerebral oxygenation of extremely preterm infants during the first 72 hours of life through the application of cerebral near-infrared spectroscopy ( NIRS ) oximetry and implementation of an clinical treatment guideline based on intervention thresholds of cerebral regional tissue saturation rStO2 . Methods / Design SafeBoosC is a r and omized , blinded , multinational , phase II clinical trial . The inclusion criteria are : neonates born more than 12 weeks preterm ; decision to conduct full life support ; parental informed consent ; and possibility to place the cerebral NIRS oximeter within 3 hours after birth . The infants will be r and omized into one of two groups . Both groups will have a cerebral oximeter monitoring device placed within three hours of birth . In the experimental group , the cerebral oxygenation reading will supplement the st and ard treatment using a predefined treatment guideline . In the control group , the cerebral oxygenation reading will not be visible and the infant will be treated according to the local st and ards . The primary outcome is the multiplication of the duration and magnitude of rStO2 values outside the target ranges of 55 % to 85 % , that is , the ‘ burden of hypoxia and hyperoxia ’ expressed in ‘ % hours ’ . To detect a 50 % difference between the experimental and control group in % hours , 166 infants in total must be r and omized . Secondary outcomes are mortality at term date , cerebral ultrasound score , and interburst intervals on an amplitude-integrated electroencephalogram at 64 hours of life and explorative outcomes include neurodevelopmental outcome at 2 years corrected age , magnetic resonance imaging at term , blood biomarkers at 6 and 64 hours after birth , and adverse events . Discussion Cerebral oximetry guided interventions have the potential to improve neurodevelopmental outcome in extremely preterm infants . It is a logical first step to test if it is possible to reduce the burden of hypoxia and hyperoxia . Trial registration Clinical Trial.gov , OBJECTIVE To assess if monitoring of cerebral regional tissue oxygen saturation ( crSO2 ) using near-infrared spectroscopy ( NIRS ) to guide respiratory and supplemental oxygen support reduces burden of cerebral hypoxia and hyperoxia in preterm neonates during resuscitation after birth . STUDY DESIGN Preterm neonates < 34(+0 ) weeks of gestation were included in a prospect i ve r and omized controlled pilot feasibility study at 2 tertiary level neonatal intensive care units . In a NIRS-visible group , crSO2 monitoring in addition to pulse oximetry was used to guide respiratory and supplemental oxygen support during the first 15 minutes after birth . In a NIRS-not-visible group , only pulse oximetry was used . The primary outcomes were burden of cerebral hypoxia ( < 10th percentile ) or hyperoxia ( > 90th percentile ) measured in % minutes crSO2 during the first 15 minutes after birth . Secondary outcomes were all cause of mortality and /or cerebral injury and neurologic outcome at term age . Allocation sequence was 1:1 with block-r and omization of 30 preterm neonates at each site . RESULTS In the NIRS-visible group burden of cerebral hypoxia in % minutes , crSO2 was halved , and the relative reduction was 55.4 % ( 95 % CI 37.6 - 73.2 % ; P = .028 ) . Cerebral hyperoxia was observed in NIRS-visible group in 3 neonates with supplemental oxygen and in NIRS-not-visible group in 2 . Cerebral injury rate and neurologic outcome at term age was similar in both groups . Two neonates died in the NIRS-not-visible group and none in the NIRS-visible group . No severe adverse reactions were observed . CONCLUSIONS Reduction of burden of cerebral hypoxia during immediate transition and resuscitation after birth is feasible by crSO2 monitoring to guide respiratory and supplemental oxygen support . TRIAL REGISTRATION Clinical Trials.gov : NCT02017691 INTRODUCTION The research programme Safeguarding the Brains of our smallest Children ( SafeBoosC ) aims to test the benefits and harms of cerebral near-infrared spectroscopy ( NIRS ) oximetry in infants born before 28 weeks of gestation . In a phase II trial , infants will be r and omised to visible cerebral NIRS oximetry with pre-specified treatment guidelines compared to st and ard care with blinded NIRS-monitoring . The primary outcome is duration multiplied with the extent outside the normal range of regional tissue oxygen saturation of haemoglobin ( rStO2 ) of 55 to 85 % in percentage hours ( burden ) . This study was a pilot of the Visible -Oximetry Group . MATERIAL AND METHODS This was an observational study including ten infants . RESULTS The median gestational age was 26 weeks+three days , and the median start-up time was 133 minutes after delivery .  The median recording time was 69.7 hours , mean rStO2 was 64.2±4.5 % , median burden of hyper- and hypoxia was 30.3 % hours ( range 2.8 - 112.3 ) . Clinical staff responded to an out of range value 29 times -- only once to values above 85 % . In comparison , there were 83 periods of more than ten minutes with an rStO2 below 55 % and four episodes with an rStO2 above 85 % . These periods accounted for 72 % of the total hypoxia burden . A total of 18 of the 29 interventions were adjustments of FiO2 which in 13 of the 18 times result ed in an out-of-range SpO2 . Two infants suffered second-degree burns from the sensor . Five infants died . In all cases , this was unrelated to NIRS monitoring and treatment . CONCLUSION The intervention of early cerebral NIRS monitoring proved feasible , but prolonged periods of hypoxia went untreated . Thus , a revision of the treatment guideline and an alarm system is required . FUNDING The Elsass Foundation funded the present study . TRIAL REGISTRATION Clinical trials.gov : NCT01530360 Background : The SafeBoosC phase II multicentre r and omized clinical trial investigated the benefits and harms of monitoring cerebral oxygenation by near-infrared spectroscopy ( NIRS ) combined with an evidence -based treatment guideline vs. no NIRS data and treatment as usual in the control group during the first 72 h of life . The trial demonstrated a significant reduction in the burden of cerebral hypoxia in the experimental group . We now report the blindly assessed and analyzed treatment effects on electroencephalographic ( EEG ) outcomes ( burst rate and spectral edge frequency 95 % ( SEF95 ) ) and blood biomarkers of brain injury ( S100β , brain fatty acid-binding protein , and neuroketal ) . Methods : One hundred and sixty-six extremely preterm infants were r and omized to either experimental or control group .  EEG was recorded at 64 h of age and blood sample s were collected at 6 and 64 h of age . Results : One hundred and thirty-three EEGs were evaluated . The two groups did not differ regarding burst rates ( experimental 7.2 vs. control 7.7 burst/min ) or SEF95 ( experimental 18.1 vs. control 18.0 Hz ) . The two groups did not differ regarding blood S100β , brain fatty acid-binding protein , and neuroketal concentrations at 6 and 64 h ( n = 123 participants ) . Conclusion : Treatment guided by NIRS  reduced the cerebral burden of hypoxia without affecting EEG or the selected blood biomarkers OBJECTIVE To test the hypothesis that near-infrared spectroscopy (NIRS)-determined patterns of regional cerebral oxygen saturation ( rScO2 ) , cerebral fractional tissue oxygen extraction ( cFTOE ) , and autoregulatory ability can identify neonates at risk for developing peri-intraventricular hemorrhage ( PIVH ) . STUDY DESIGN This case-control study is a sub analysis of 30 neonates who developed PIVH > 12 hours after admission as part of a lager prospect i ve observational cohort study comprising 650 preterm neonates born at ≤32 weeks ' gestational age . PIVH was diagnosed by cranial ultrasound , performed at least once daily . Mean arterial blood pressure ( MABP ) , NIRS-determined rScO2 , cFTOE , and MABP-rScO2 correlation were monitored from birth to 72 hours of age . RESULTS Infants with PIVH received more inotropic drugs before being diagnosed with PIVH . Significantly more infants with severe PIVH needed treatment for patent ductus arteriosus . The MABP-rScO2 correlation was > 0.5 significantly more often before mild/moderate PIVH and after severe PIVH compared with controls . rScO2 was higher and cFTOE lower in infants before severe PIVH . CONCLUSION NIRS-monitored rScO2 and cFTOE suggest cerebral hyperperfusion in infants with severe PIVH . Moreover , MABP-rScO2 correlation indicates more blood pressure-passive brain perfusion in infants with PIVH . Continuous assessment of patterns of cerebral oxygenation and arterial blood pressure may identify those preterm infants at risk for severe PIVH and prompt consideration of preventive measures We have compared the effect of increasing optode separation ( range 0.7 - 5.5 cm ) on the sensitivity of near infrared spectroscopy ( NIRS ) to discrete reductions in scalp and cerebral oxygenation in 10 healthy men ( mean age 32 , range 26 - 39 yr ) using multichannel NIRS . During cerebral oligaemia ( a mean reduction in middle cerebral artery flow velocity of 47 % ) induced by a mean reduction in end-tidal PCO2 of 2.4 kPa , the decrease in oxyhaemoglobin detected by NIRS became significantly greater with increasing optode separation ( P < 0.0001 ) . In response to scalp hyperaemia induced by inflation and release of a pneumatic scalp tourniquet , increases in oxyhaemoglobin became significantly smaller with increasing optode separation ( P < 0.0002 ) . These results are consistent with theoretical models of the behaviour of NIR light in the adult head and support the concept of using multi-detector NIRS to separate intra- and extracranial NIR signal changes . However , the emitter-detector separation used by currently available cerebral oximeters is not large enough to provide optimal spatial resolution Objective .The aim of this study was to compare the ability of NIRS and pulse oximetry to detect changes in cerebral oxygenation occurring inresponse to a pause in nasal airflow ( PNA ) . Methods .Twenty-onerecordings of cerebral oxygenation index by NIRS together with oxyhemoglobinsaturation by pulse oximetry were measured on 17 preterm infants with ahistory of apnoea .  Photoplethysmography was used to confirm the accuracy ofthe pulse oximetry data . PNA events were defined as pauses of greater than 4seconds in a thermistor trace measuring nasal air flow . Results .Baseline variability in oxygenation index ( Hbdiff ) was found to be from−0.12 to + 0.13 µmol 100 g brain−1 . A fall in Hbdiff orSpO2 was defined as a decrease of greater magnitude than 2 st and arddeviations from the baseline , i.e. , −0.12 µmol 100 gbrain−1 and 3 % respectively . In 68 % of 468 PNA events a fall inoxyhemoglobin saturation ( SpO2 ) was detected and in 56 % a fall inHbdiff was detected . In 20 % of events there was no fall in cerebraloxygenation despite a fall in SpO2 . In 8 % of PNA episodes werecorded a fall in cerebral oxygenation but no fall in SpO2 . Whena fall in cerebral oxygenation was recorded , the fall was greater when theevent was also associated with a fall in SpO2 ( median(interquartile range ( IQR ) ) 0.32 ( 0.21–0.69 ) vs. 0.25 (0.16–0.43)µmol 100 g brain−1 , p < 0.05 ) . When all the PNAepisodes were review ed no close correlation was shown between the magnitudeof change in cerebral oxygenation and the change in SpO2 for smallchanges in both indices . However , large falls ( > 1.5 µmol 100 gbrain−1 ) in cerebral oxygenation were closely associated with largechanges in SpO2 . Conclusions .We conclude that bothtechniques are sensitive to changes in oxygenation during PNA . Small changesin cerebral Hbdiff and arterial SpO2 do not always correlate forphysiological reasons . A change in Hbdiff of > 0.3 µmol 100 gbrain−1 is likely to be physiologically significant and isassociated with a change in SpO2 of 12 % Background We assessed whether a near-infrared spectroscopy (NIRS)-based algorithm for the personalized optimization of cerebral oxygenation during cardiopulmonary bypass combined with a restrictive red cell transfusion threshold would reduce perioperative injury to the brain , heart , and kidneys . Methods In a r and omized controlled trial , participants in three UK centres were r and omized with concealed allocation to a NIRS ( INVOS 5100 ; Medtronic Inc. , Minneapolis , MN , USA)-based ' patient-specific ' algorithm that included a restrictive red cell transfusion threshold ( haematocrit 18 % ) or to a ' generic ' non-NIRS-based algorithm ( st and ard care ) . The NIRS algorithm aim ed to maintain cerebral oxygenation at an absolute value of > 50 % or at > 70 % of baseline values . The primary outcome for the trial was cognitive function measured up to 3 months postsurgery . Results The analysis population comprised eligible r and omized patients who underwent valve or combined valve surgery and coronary artery bypass grafts using cardiopulmonary bypass between December 2009 and January 2014 ( n = 98 patient-specific algorithm ; n = 106 generic algorithm ) . There was no difference between the groups for the three core cognitive domains ( attention , verbal memory , and motor coordination ) or for the non-core domains psychomotor speed and visuo-spatial skills . The NIRS group had higher scores for verbal fluency ; mean difference 3.73 ( 95 % confidence interval 1.50 , 5.96 ) . Red cell transfusions , biomarkers of brain , kidney , and myocardial injury , adverse events , and health-care costs were similar between the groups . Conclusions These results do not support the use of NIRS-based algorithms for the personalized optimization of cerebral oxygenation in adult cardiac surgery . Clinical trial registration http://www.controlled-trials.com , IS RCT N 23557269 Near infrared spectroscopy ( NIRS ) may provide valuable insight into the determinants of exercise performance . We examined the effects of severe hypoxia on cerebral ( prefrontal lobe ) and muscle ( gastrocnemius ) oxygenation at rest and during a fatiguing task . After a 15-min rest , 15 healthy subjects ( age 25.3 + /- 0.9 yr ) performed a sustained contraction of the ankle extensors at 40 % of maximal voluntary force until exhaustion . The contraction was performed at two different fractions of inspired O2 fraction ( F(IO2 ) = 0.21/0.11 ) in r and omized and single-blind fashion . Cerebral and muscle oxy-(HbO2 ) deoxy-(HHb ) total-hemoglobin ( HbTot ) and tissue oxygenation index ( TOI ) were monitored continuously by NIRS .  Arterial O2 saturation ( SpO2 ) was estimated by pulse oximetry throughout the protocol . Muscle TOI did not differ between normoxia and hypoxia after the 15-min rest , whereas SpO2 and cerebral TOI significantly dropped ( -6.5 + /- 0.9 % and -3.9 + /- 1.0 % , respectively , P<0.05 ) in hypoxia . The muscle NIRS changes during exercise were similar in normoxia and hypoxia , whereas the increased cerebral HbTot and HbO2 near exhaustion were markedly reduced in hypoxia . In conclusion , although F(IO2 ) had no significant effect on endurance time , NIRS patterns near exhaustion in hypoxia differed from normoxia Background : Changes in head posture influence brain hemodynamics . Optimal positioning has been recommended as 1 of 10 potentially better practice s to reduce the incidence of brain injury in preterm newborns . Objectives : The aim of this study was to evaluate by near-infrared spectroscopy ( NIRS ) the effect of different head and body positions and the influence of gestational age ( GA ) and nasal continuous positive airway pressure on brain hemodynamics in very preterm newborns . Methods : 24 stable preterm newborns were studied by NIRS in 6 different postures including head rotation and head inclination in both supine and prone positions . Changes in normalized tissue hemoglobin index ( nTHI ) and tissue oxygenation index ( TOI ) were measured after posture variations . Results : No statistically significant changes in nTHI and in TOI were found in the 6 postures . nTHI variations , expression of cerebral blood volume variations , were influenced by GA . A reduction in nTHI , with a stable TOI , in the less mature infants ( with GA ≤26 weeks ) , occurred on head rotation ; nTHI increased again when the head was derotated . Conclusions : Hemodynamic changes after posture variations depend on GA . Head rotation in newborns with GA ≤26 weeks produced a reduction in nTHI with stable TOI . Possible physiopathological mechanisms are discussed OBJECTIVES The aim of this study is the assessment of the regional cerebral oximetry - NIRS ( near infrared spectroscopy ) as an intraoperative monitoring system to protect the patient against the incidents of brain desaturations . We hypothesize that patients monitored with NIRS present a smaller range of postoperative cognitive dysfunctions ( POCD ) in comparison with those without NIRS monitoring during lumbar spine surgery in a prone position . SETTING S This study was performed at the Clinical Department of Neurosurgery and Oncology of the Central Nervous System , Medical University of Lodz , Pol and . PARTICIPANTS The study completed 43 adult patients qualified for the surgical treatment of lumbar spondylosis . Before the procedures they were r and omized into two subgroups : one monitored intraoperatively by means of NIRS cerebral oximetry ( INVOS 5100 ) , which numbered 13 patients – 30.2 % ( 13 NIRS devices were made available to the authors ) and the other without NIRS intraoperative monitoring , totaling 30 people – 69.8 % . The patients who presented a history of psychiatric , neurological and cardiovascular disorders which impair cognitive processes were disqualified from the study . PRIMARY AND SECONDARY OUTCOME MEASURES A comprehensive battery of neuropsychological tests was preoperatively performed on all patients . The subjects were then divided into two groups : with and without NIRS monitoring . Both groups were statistically homogeneous . Computerized anesthesia records were used to obtain intraoperative data : mean arterial pressure , heart rate , pulsoximetry and cerebral regional oxygenation . The depth of anesthesia monitor was not used . Besides , all the patients passed the same battery of neurocognitive tests 7 days and 1 month postoperatively . The Mann-Whitney test was performed to compare POCD and therefore assess the usefulness of NIRS as a monitoring mechanism during anesthesia in the prone position . RESULTS There was a significant ( p < 0.05 ) difference in the presence of cognitive deficiencies between the subgroup monitored with NIRS and the subgroup without NIRS . It included : Digit Span Test overall score and forward repetition score 7 days after operation , N- back Test results after 30 days in version 0 " back " - time , N-back Test version 1 " back " results in the number of correct answers and the number of errors . CONCLUSIONS NIRS cerebral oximetry may be useful in reducing postoperative cognitive complications in patients operated on in the prone positioning . TRIAL REGISTRATION RNN/556/08/KB – approval of the ethics committee at Medical University of Lodz , Pol and Near-infrared spectroscopy-derived regional tissue oxygen saturation of haemoglobin ( rStO2 ) reflects venous oxygen saturation . If cerebral metabolism is stable , rStO2 can be used as an estimate of cerebral oxygen delivery . The SafeBoosC phase II r and omised clinical trial hypothesises that the burden of hypo- and hyperoxia can be reduced by the combined use of close monitoring of the cerebral rStO2 and a treatment guideline to correct deviations in rStO2 outside a predefined target range . Aims : To describe the rationale for and content of this treatment guideline . Methods : Review of the literature and assessment of the quality of evidence and the grade of recommendation for each of the interventions . Results and Conclusions : A clinical intervention algorithm based on the main determinants of cerebral perfusion-oxygenation changes during the first hours after birth was generated . The treatment guideline is presented to assist neonatologists in making decisions in relation to cerebral oximetry readings in preterm infants within the SafeBoosC phase II r and omised clinical trial . The evidence grade s were relatively low and the guideline can not be recommended outside a research setting BACKGROUND Beach chair positioning for shoulder surgery is associated with measurable cerebral desaturation events ( CDEs ) in up to 80 % of patients .  Near-infrared spectroscopy ( NIRS ) technology allows real-time measurement of cerebral oxygenation and may minimize the frequency of CDEs . The purpose of this study was to investigate the incidence of CDEs when anesthetists were aware of and blinded to NIRS monitoring and to determine the short-term cognitive effects of surgery in the beach chair position . METHODS NIRS was used to monitor cerebral oxygenation saturation in 41 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position . Patients were r and omized to 2 groups , anesthetists aware of or blinded to NIRS data . The Montreal Cognitive Assessment ( MoCA ) was used to assess cognitive function preoperatively , immediately postoperatively , and at 2 and 6 weeks postoperatively . RESULTS Overall , 7 ( 17.5 % ) patients experienced a CDE , 5 ( 25 % ) in the aware group and 2 ( 10 % ) in the blinded group . There was no significant difference in MoCA scores between the aware and blinded groups preoperatively ( 27.9.1 vs. 28.2 ; P = .436 ) , immediately postoperatively ( 26.1 vs. 26.2 ; P = .778 ) , 2 weeks postoperatively ( 28.0 vs. 28.1 ; P = .737 ) , or 6 weeks postoperatively ( 28.5 vs. 28.4 ; P = .779 ) . There was a correlation of NIRS with systolic blood pressure ( r = 0.448 ) , diastolic blood pressure ( r = 0.708 ) , and mean arterial pressure ( r = 0.608 ) . CONCLUSION In our series , the incidence of CDEs was much lower than previously reported and was not lowered by use of NIRS . Patients did not have significant cognitive deficits after arthroscopic surgery in the beach chair position , and there was a correlation between NIRS and intraoperative brachial blood pressure Background Sustained lung inflations ( SLI ) during neonatal resuscitation may promote alveolar recruitment in preterm infants . While most of the studies focus on respiratory outcome , the impact of SLI on the brain has n’t been investigated yet . Objective Do SLI affect cerebral blood volume ( CBV ) in preterm infants ? Methods Preterm infants of gestation 28 weeks 0 days to 33 weeks 6 days with requirement for respiratory support ( RS ) were included in this r and omized controlled pilot trial . Within the first 15 minutes after birth near-infrared spectroscopy ( NIRS ) measurements using ‘ NIRO-200-NX ’ ( Hamamatsu , Japan ) were performed to evaluate changes in CBV and cerebral tissue oxygenation . Two groups were compared based on RS : In SLI group RS was given by applying 1–3 SLI ( 30 cmH2O for 15 s ) continued by respiratory st and ard care . Control group received respiratory st and ard care only . Results 40 infants ( 20 in each group ) with mean gestational age of 32 weeks one day ( ±2 days ) and birth weight of 1707 ( ±470 ) g were included . In the control group ΔCBV was significantly decreasing , whereas in SLI group ΔCBV showed similar values during the whole period of 15 minutes . Comparing both groups within the first 15 minutes ΔCBV showed a tendency toward different overall courses ( p = 0.051 ) . Conclusion This is the first study demonstrating an impact of SLI on CBV . Further studies are warranted including reconfirmation of the present findings in infants with lower gestational age . Future investigations on SLI should not only focus on respiratory outcome but also on the consequences on the developing brain . Trial Registration German Clinical Trials Register DRKS00005161 The present study examined the regional differences of cortical oxygenation in the frontal lobe by near-infrared spectroscopy ( NIRS ) during incremental exercise tests and the precise location of NIRS was examined by brain magnetic resonance imaging ( MRI ) .  Pulmonary gas exchange and NIRS measurement during incremental cycling ergometry tests were investigated in 14 men . In 7 of these subjects , the right middle cerebral artery mean velocity ( MCA Vmean ) was simultaneously measured by transcranial Doppler ( TCD ) . In the right medial of the frontal lobe cortex , Tissue Oxygenation Index ( TOI ) increased by 8.8 % with its peak value at respiratory compensation threshold ( RCT ) and Normalized Tissue Hemoglobin Index ( nTHI ) increased until endpoint by 16.2 % . During incremental exercise tests , the changing pattern of TOI was different according to the distribution of the probes . Volitional exhaustion by exercise induced the deteriorated TOI and MCA Vmean , whereas nTHI increased IMPORTANCE There are no well-established noninvasive biomarkers for identifying patients at risk for poor outcome after surgery for congenital heart disease . Few studies have assessed prognostic accuracy of cerebral tissue oxygenation index ( cTOI ) measured by near infrared spectroscopy ( NIRS ) . OBJECTIVE To assess the utility of noninvasive NIRS monitoring as a predictor of outcomes after neonatal cardiac surgery through measurement of cTOI . To examine the utility of noninvasive NIRS monitoring in combination with lactate concentration and inotropic score in prediction of outcomes after neonatal cardiac surgery . DESIGN Prospect i ve longitudinal cohort study . SETTING Operating room and cardiac intensive care unit , Children 's National Heart Institute . PARTICIPANTS Seventy-five patients with complex congenital heart disease undergoing surgical repair within first month of life .  EXPOSURE Cerebral TOI , blood lactate , and inotropic scores were measured preoperative , intraoperative and up to 24 hours postoperative . MAIN OUTCOME MEASURES Postoperative mortality and neurodevelopmental outcome assessed by the Bayley Scales of Infant Development ( BSID II ) . Mental and motor scores were obtained at 6 , 15 , and 21 months . Good outcome was defined as survival and BSID mental and motor scores ≥70 points . Poor outcome was defined as death or BSID scores < 70 at most recent follow-up . RESULTS Cohort of 75 patients prospect ively followed including 40 patients with single ventricle and 35 with two ventricles . Four patients died before discharge and ten died within 21 months . Seven patients were lost to follow-up . Among survivors with follow-up ( n = 54 ) , BSID was abnormal in 25 ( 46 % ) . Patients with poor outcome ( n = 39 ) had lower mean cTOI 60 minutes off-CPB ( 48 % vs. 58 % , P = .003 ) and 24 hours postoperative ( 49 % vs. 59 % , P < .001 ) , higher lactate ( 8.2 vs. 5.0 mmol/L , P = .005 ) and higher inotropic scores ( 10 vs. 6 , P = .02 ) at 24 hours postoperative . ROC analysis indicated that cTOI had moderate predictive accuracy of outcome ( AUC = 0.751 , P < .001 ) . Multivariable regression analysis confirmed that predictive accuracy was improved using both cTOI and lactate at 24 hours postoperative ( AUC = 0.813 , 95 % CI : 0.705 - 0.921 , P < .001 ) with optimal cutoff values < 58 % and > 7.4 mmol/L , respectively ( sensitivity = 95 % ) . CONCLUSION Cerebral TOI combined with lactate at 24 hours postoperative are accurate non-invasive predictive biomarkers of patient survival and neurodevelopmental outcome in neonates with CHD undergoing cardiac surgery Adverse changes in cerebral hemodynamics during endotracheal suctioning have been reported in conventionally ventilated newborns , whereas observations on the effect of endotracheal suctioning during high-frequency ventilation have not been reported to date . The present study was design ed to investigate the effect of endotracheal suctioning on cerebral hemodynamics in high-frequency and conventionally ventilated infants . Changes in cerebral concentration of oxygenated ( cO(2)Hb ) and deoxygenated hemoglobin ( cHHb ) and oxidized cytochrome aa3 ( cCyt.aa3 ) were measured by noninvasive near-infrared spectroscopy . In an open prospect i ve study , 26 suctioning periods in 9 high-frequency and in 6 conventionally ventilated newborn infants were investigated . Heart rate , arterial oxygen saturation ( SaO(2 ) ) , mean blood pressure ( MABP ) , and transcutaneous carbon dioxide tension ( TcpCO(2 ) ) were monitored continuously . In both groups , a marked decrease in heart rate , SaO(2 ) and in cO(2)Hb , an increase in cHHb , and a variable pattern in the concentration of total hemoglobin were noted during endotracheal suctioning . During suctioning , no statistically significant differences between the two methods of mechanical ventilation could be observed . We conclude that the mode of ventilation had no significant effect on changes in cerebral hemodynamics during endotracheal suctioning BACKGROUND Improved postoperative outcome has been demonstrated by perioperative maximization of cardiac stroke volume ( SV ) with fluid challenges , so-called goal -directed therapy . Oesophageal Doppler ( OD ) has been the most common technique for goal -directed therapy , but other flow-related techniques and parameters are available and they are potentially easier to apply in clinical practice . The objective of this investigation was therefore to use OD for preoperative SV maximization and compare the findings with a Modelflow determined SV , with an OD estimated corrected flow time ( FTc ) , with central venous oxygenation ( Svo2 ) and with muscle and brain oxygenation assessed with near infrared spectroscopy ( NIRS ) . METHODS Twelve patients scheduled for radical prostatectomy were anaesthetized before optimization of SV estimated by OD . A fluid challenge of 200 ml colloid was provided and repeated if at least a 10 % increment in OD SV was obtained . Values were compared with simultaneously measured values of Modelflow SV , FTc , Svo2 and muscle and cerebral oxygenation estimated by NIRS . RESULTS Based upon OD assessment , optimization of SV was achieved after the administration of 400 - 800 ml ( mean 483 ml ) of colloid . The hypothetical volumes administered for optimization based upon Modelflow and Svo2 differed from OD in 10 and 11 patients , respectively . Changes in FTc and NIRS were inconsistent with OD guided optimization . CONCLUSION Preoperative SV optimization guided by OD for goal -directed therapy is preferable compared with Modelflow SV , FTc , NIRS and Svo2 until outcome studies for the latter are available The effect of motor activity on the left fronto- central region of the human brain was analyzed spatially and temporally by using noninvasive near-infrared light ( NIR ) topography . The changes in oxygenation states caused by motor activity were measured using intensity-modulated NIR spectroscopy at ten measurement positions on the head surface . The subject r and omly performed unilateral finger opposition for 30 s as motor stimulation . When the subject performed contralateral ( right ) finger movement , significant increases in both oxygenated hemoglobin ( oxy-Hb ) and total hemoglobin ( total-Hb ) and decreases in deoxygenated hemoglobin ( deoxy-Hb ) were observed in a particular area . By mapping the static topograms of the changes of each Hb and comparing them with an anatomical image of MRI , it was found that the particular area was located on the motor cortex along the central sulcus . By mapping the dynamic topograms of the changes of total-Hb , which reflect the cerebral blood volume , and analyzing the spatiotemporal hemodynamic changes associated with the brain activity , it was found that the regional change in cerebral blood volume in the primary motor area overlaps the global change around the motor cortex . These results demonstrate that NIR topography can be used to effectively observe the human brain activity OBJECTIVES To examine the relationship between  regional cerebral oxygen saturation ( rSO2 ) , delayed cerebral ischaemia ( DCI ) , and outcomes after aneurysmal subarachnoid haemorrhage ( aSAH ) . RESEARCH METHODOLOGY Subjects ( n = 163 ) with aSAH , age 21 - 75 years , and Fisher grade > 1 were included in the study .  Continuous rSO2 monitoring was performed for 5 - 10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex . rSO2<50 indicated desaturation . DCI was defined as neurological deterioration due to impaired cerebral blood flow . Three- and 12-month functional outcomes were assessed by the modified Rankin scale ( MRS ) as good ( 0 - 3 ) and poor ( 4 - 6 ) . RESULTS DCI occurred in 57 % of patients ; of these 66 % had rSO2<50 . Overall , 56 % had rSO2<50 on either side , 21 % and 16 % had poor MRS at 3 and 12 months . Subjects with rSO2 < 50 were 3.25 times more likely to have DCI compared to those with rSO2 > 50 ( OR 3.25 , 95%CI 1.58 - 6.69 ) , positive predictive value ( PPV ) = 70 % . Subjects with rSO2 < 50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 > 50 ( OR 2.7 , 95%CI 1.1 - 7.2 ) , PPV = 70 % . CONCLUSIONS These results suggest that NIRS has the potential for detecting DCI after aSAH . This potential needs to be further explored in a larger prospect i ve study Objective To study the correlation between a dynamic index of cerebral autoregulation assessed with blood flow velocity ( FV ) using transcranial Doppler , and a tissue oxygenation index ( TOI ) recorded with near-infrared spectroscopy ( NIRS ) . Methods Twenty-three patients with sepsis , severe sepsis , or septic shock were monitored daily on up to four consecutive days .  FV , TOI , and mean arterial blood pressure ( ABP )  were recorded for 60 min every day . An index of autoregulation ( Mx ) was calculated as the moving correlation coefficient between 10-s averaged values of FV and ABP over moving 5 min time-windows . The index Tox was evaluated as the correlation coefficient between TOI and ABP in the same way . The indices Mx and Tox , ABP and arterial partial pressure of CO2 were averaged for each patient . Results Synchronized slow waves , presenting with periods from 20 s to 2 min , were seen in the TOI and FV of most patients , with a reasonable coherence between the signals in this b and width ( coherence > 0.5 ) . The indices , Mx and Tox , demonstrated good correlation with each other ( R = 0.81 ; P < 0.0001 ) in the whole group of patients . Both indices showed a significant ( P < 0.05 ) tendency to indicate weaker autoregulation in the state of vasodilatation associated with greater values of arterial partial pressure of CO2 or lower values of ABP . Conclusion NIRS shows promise for the continuous assessment of cerebral autoregulation in adults Background : Inodilators are routinely used in cardiovascular surgery with cardiopulmonary bypass ( CPB ) . Information regarding safety and tolerability of the novel molecule , levosimendan ( LEVO ) , in newborns is anecdotal ; no pharmacokinetic data in this population are available . Methods : This was a phase I , r and omized , and blinded study . Neonates undergoing surgical repair for congenital heart defects received stepwise dose increases of milrinone ( MR ; 0.5–1 μg/kg/min , n = 9 ) or LEVO ( 0.1–0.2 μg/kg/min , n = 11 ) as an i.v . continuous infusion , starting before CPB . Infants had continuous , time-locked , physiological , and near-infrared spectroscopy ( NIRS ) ( cerebral and peripheral ) recordings during the first 24 h , and at 48 and 96 h postsurgery . Serial biochemistry and pharmacokinetic studies were performed . Results : During the first 24 h postsurgery , patients showed time-related , group-independent increased cerebral tissue oxygenation and decreased diastolic blood pressure ; in addition , group-dependent differences in heart rate and peripheral perfusion were found . Early postsurgery , MR-treated infants showed lower pH , higher glycemia , and higher inotrope score . The groups differed in cerebral NIRS-derived variables from 24 to 96 h. Study drug withdrawal at 96 h was more frequent with LEVO . LEVO intermediate metabolites were detected in plasma at day 14 after surgery . Conclusion : LEVO is well tolerated  in critically ill neonates . LEVO may have advantages over MR in terms of the dosing regimen
The only eligible r and omised clinical trial did not demonstrate any consistent effects of NIRS plus a guideline on the assessed clinical outcomes .
The trial was , however , only powered to detect difference in cerebral oxygenation , not morbidities or mortality .
BACKGROUND Cerebral injury and long-term neurodevelopmental impairment is common in extremely preterm infants .
Cerebral near-infrared spectroscopy ( NIRS ) enables continuous estimation of cerebral oxygenation .
This diagnostic method coupled with appropriate interventions if NIRS is out of normal range ( that is cerebral oxygenation within the 55 % to 85 % range ) may offer benefits without causing more harms .
Therefore , NIRS coupled with appropriate responses to abnormal findings on NIRS needs assessment in a systematic review of r and omised clinical trials and quasi-r and omised studies .
OBJECTIVES To evaluate the benefits and harms of interventions that attempt to alter cerebral oxygenation guided by cerebral NIRS monitoring in order to prevent cerebral injury , improve neurological outcome , and increase survival in preterm infants born more than 8 weeks preterm .