Cerebral Oxygenation and Activity During Surgical Repair of Neonates With Congenital Diaphragmatic Hernia: A Center Comparison Analysis

Sophie A. Costerus*, Dries Hendrikx, Joen IJsselmuiden, Katrin Zahn, Alba Perez-Ortiz, Sabine Van Huffel, Robert B. Flint, Alexander Caicedo, René Wijnen, Lucas Wessel, Jurgen C. de Graaff, Dick Tibboel, Gunnar Naulaers

*Corresponding author for this work

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Background and aim: Neonatal brain monitoring is increasingly used due to reports of brain injury perioperatively. Little is known about the effect of sedatives (midazolam) and anesthetics (sevoflurane) on cerebral oxygenation (rScO2) and cerebral activity. This study aims to determine these effects in the perioperative period.

Methods: This is an observational, prospective study in two tertiary pediatric surgical centers. All neonates with a congenital diaphragmatic hernia received perioperative cerebral oxygenation and activity measurements. Patients were stratified based on intraoperatively administrated medication: the sevoflurane group (continuous sevoflurane, bolus fentanyl, bolus rocuronium) and the midazolam group (continuous midazolam, continuous fentanyl, and continuous vecuronium).

Results: Intraoperatively, rScO2 was higher in the sevoflurane compared to the midazolam group (84%, IQR 77–95 vs. 65%, IQR 59–76, p = < 0.001), fractional tissue oxygen extraction was lower (14%, IQR 5–21 vs. 31%, IQR 29–40, p = < 0.001), the duration of hypoxia was shorter (2%, IQR 0.4–9.6 vs. 38.6%, IQR 4.9–70, p = 0.023), and cerebral activity decreased more: slow delta: 2.16 vs. 4.35 μV2 (p = 0.0049), fast delta: 0.73 vs. 1.37 μV2 (p = < 0.001). In the first 30 min of the surgical procedure, a 3-fold increase in fast delta (10.48–31.22 μV2) and a 5-fold increase in gamma (1.42–7.58 μV2) were observed in the midazolam group.

Conclusion: Sevoflurane-based anesthesia resulted in increased cerebral oxygenation and decreased cerebral activity, suggesting adequate anesthesia. Midazolam-based anesthesia in neonates with a more severe CDH led to alarmingly low rScO2 values, below hypoxia threshold, and increased values of EEG power during the first 30 min of surgery. This might indicate conscious experience of pain. Integrating population-pharmacokinetic models and multimodal neuromonitoring are needed for personalized pharmacotherapy in these vulnerable patients.
Original languageEnglish
Article number798952
JournalFrontiers in Pediatrics
Publication statusPublished - 17 Dec 2021

Bibliographical note

Research supported by Bijzonder Onderzoeksfonds KU Leuven (BOF): C24/15/036.
The effect of perinatal stress on the later outcome in preterm babies, EU: H2020 MSCA-ITN2018: Integrating Functional Assessment measures for Neonatal
Safeguard (INFANS), funded by the European Commission under Grant Agreement #813483.
This research received funding from the Flemish Government (AI Research Program). SV and DH are affiliated to Leuven.
AI—KU Leuven Institute for AI, B3000, Leuven, Belgium.
DH was a SB Ph.D. fellow at Fonds voor Wetenschappelijk Onderzoek (FWO), Vlaanderen, supported by the Flemish government.


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