The Influence of Carbon Dioxide on Cerebral Autoregulation During Sevoflurane-based Anesthesia in Patients With Type 2 Diabetes

Background: Cerebral autoregulation (CA) continuously adjusts cerebrovascular resistance to maintain cerebral blood flow (CBF) constant despite changes in blood pressure. Also, CBF is proportional to changes in arterial carbon dioxide (CO2) (cerebrovascular CO2 reactivity). Hypercapnia elicits cerebral vasodilation that attenuates CA efficacy, while hypocapnia produces cerebral vasoconstriction that enhances CA efficacy. In this study, we quantified the influence of sevoflurane anesthesia on CO2 reactivity and the CA-CO2 relationship. Methods: We studied patients with type 2 diabetes mellitus (DM), prone to cerebrovascular disease, and compared them to control subjects. In 33 patients (19 DM, 14 control), end-tidal CO2, blood pressure, and CBF velocity were monitored awake and during sevoflurane-based anesthesia. CA, calculated with transfer function analysis assessing phase lead (degrees) between low-frequency oscillations in CBF velocity and mean arterial blood pressure, was quantified during hypocapnia, normocapnia, and hypercapnia. Results: In both control and DM patients, awake CO2 reactivity was smaller (2.8%/mm Hg CO2) than during sevoflurane anesthesia (3.9%/mm Hg; P<0.005). Hyperventilation increased CA efficacy more (3 deg./mm Hg CO2) in controls than in DM patients (1.8 deg./mm Hg CO2; P<0.001) in both awake and sevoflurane-anesthetized states. Conclusions: The CA-CO2 relationship is impaired in awake patients with type 2 DM. Sevoflurane-based anesthesia does not further impair this relationship. In patients with DM, hypocapnia induces cerebral vasoconstriction, but CA efficacy does not improve as observed in healthy subjects.

[1]  W. Stok,et al.  Sevoflurane based anaesthesia does not affect already impaired cerebral autoregulation in patients with type 2 diabetes mellitus , 2018, British Journal of Anaesthesia.

[2]  W. Stok,et al.  Novel method for intraoperative assessment of cerebral autoregulation by paced breathing , 2017, British journal of anaesthesia.

[3]  A. Monsch,et al.  Associations Between Impaired Cerebral Blood Flow Autoregulation, Cerebral Oxygenation, and Biomarkers of Brain Injury and Postoperative Cognitive Dysfunction in Elderly Patients After Major Noncardiac Surgery , 2017, Anesthesia and analgesia.

[4]  J. Mehta,et al.  Cerebrovascular Reactivity to Carbon Dioxide Under Anesthesia: A Qualitative Systematic Review , 2015, Journal of neurosurgical anesthesiology.

[5]  Lingzhong Meng,et al.  Regulation of Cerebral Autoregulation by Carbon Dioxide , 2015, Anesthesiology.

[6]  Charles H. Brown,et al.  Shoulder Surgery in the Beach Chair Position Is Associated with Diminished Cerebral Autoregulation but No Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning: The Anesthesia Patient Safety Foundation Beach Chair Study , 2015, Anesthesia and analgesia.

[7]  W. Baumgartner,et al.  Risks for impaired cerebral autoregulation during cardiopulmonary bypass and postoperative stroke. , 2012, British journal of anaesthesia.

[8]  Bas A J M de Mol,et al.  Noninvasive Continuous Arterial Blood Pressure Monitoring with Nexfin® , 2012, Anesthesiology.

[9]  N. Juul,et al.  Regional cerebral blood flow responses to hyperventilation during sevoflurane anaesthesia studied with PET , 2010, Acta anaesthesiologica Scandinavica.

[10]  M. J. Turner,et al.  The Effects of Hypocapnia and the Cerebral Autoregulatory Response on Cerebrovascular Resistance and Apparent Zero Flow Pressure During Isoflurane Anesthesia , 2009, Anesthesia and analgesia.

[11]  N. Secher,et al.  Dynamic cerebral autoregulatory capacity is affected early in Type 2 diabetes. , 2008, Clinical science.

[12]  L. Zhaoping.  Attention capture by eye of origin singletons even without awareness--a hallmark of a bottom-up saliency map in the primary visual cortex. , 2008, Journal of vision.

[13]  C. Wallesch,et al.  Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with increased risk of stroke at cardiac surgery with cardiopulmonary bypass. , 2007, The Journal of thoracic and cardiovascular surgery.

[14]  F. Goto,et al.  Effects of nicardipine-induced hypotension on cerebrovascular carbon dioxide reactivity in patients with diabetes mellitus under sevoflurane anesthesia , 2007, Journal of Anesthesia.

[15]  A. Conti,et al.  Cerebral haemodynamic changes during propofol-remifentanil or sevoflurane anaesthesia: transcranial Doppler study under bispectral index monitoring. , 2006, British journal of anaesthesia.

[16]  S. Ogawa,et al.  Different effects on circulatory control during volatile induction and maintenance of anesthesia and total intravenous anesthesia: autonomic nervous activity and arterial cardiac baroreflex function evaluated by blood pressure and heart rate variability analysis. , 2006, Journal of clinical anesthesia.

[17]  S. Ogawa,et al.  The Effect of Sevoflurane on Dynamic Cerebral Blood Flow Autoregulation Assessed by Spectral and Transfer Function Analysis , 2006, Anesthesia and analgesia.

[18]  Jan Stam,et al.  Dynamic Cerebral Autoregulation in Acute Lacunar and Middle Cerebral Artery Territory Ischemic Stroke , 2005, Stroke.

[19]  A. Lam,et al.  The Effect of Hypocapnia on the Autoregulation of Cerebral Blood Flow During Administration of Isoflurane , 2005, Anesthesia and analgesia.

[20]  F. Kunimoto,et al.  Diabetic Patients Have an Impaired Cerebral Vasodilatory Response to Hypercapnia Under Propofol Anesthesia , 2003, Stroke.

[21]  M. Poulin,et al.  Cerebral blood flow sensitivity to CO2 measured with steady-state and Read's rebreathing methods , 2003, Respiratory Physiology & Neurobiology.

[22]  W W Mapleson,et al.  Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. , 2003, British journal of anaesthesia.

[23]  Kojiro Ide,et al.  Relationship between middle cerebral artery blood velocity and end-tidal PCO2 in the hypocapnic-hypercapnic range in humans. , 2003, Journal of applied physiology.

[24]  D. Ziegler,et al.  Impairment of cerebral autoregulation in diabetic patients with cardiovascular autonomic neuropathy and orthostatic hypotension , 2003, Diabetic medicine : a journal of the British Diabetic Association.

[25]  R. Kagan.  Invited editorial. , 2002, The Journal of burn care & rehabilitation.

[26]  K. Hanaoka,et al.  Cerebrovascular carbon dioxide reactivity during general anesthesia: a comparison between sevoflurane and isoflurane. , 1999, Anesthesia and analgesia.

[27]  A. Weyland,et al.  Effects of one minimum alveolar anesthetic concentration sevoflurane on cerebral metabolism, blood flow, and CO2 reactivity in cardiac patients. , 1999, Anesthesia and analgesia.

[28]  A. Kastrup,et al.  Sex dependency of cerebrovascular CO2 reactivity in normal subjects. , 1997, Stroke.

[29]  B. Matta,et al.  Effect of incremental doses of sevoflurane on cerebral pressure autoregulation in humans. , 1997, British journal of anaesthesia.

[30]  D. Newell,et al.  Dynamic and Static Cerebral Autoregulation during Isoflurane, Desflurane, and Propofol Anesthesia , 1995, Anesthesiology.

[31]  D. Newell,et al.  Comparison of static and dynamic cerebral autoregulation measurements. , 1995, Stroke.

[32]  W. White,et al.  Effect of aging on cerebral autoregulation during cardiopulmonary bypass. Association with postoperative cognitive dysfunction. , 1994, Circulation.

[33]  C. Giller.  The frequency-dependent behavior of cerebral autoregulation. , 1990, Neurosurgery.

[34]  L Kaiser,et al.  Adjusting for baseline: change or percentage change? , 1989, Statistics in medicine.

[35]  R. Aaslid,et al.  Cerebral autoregulation dynamics in humans. , 1989, Stroke.

[36]  P A Schneider,et al.  Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. , 1988, Stroke.

[37]  N. Lassen,et al.  Impaired autoregulation of cerebral blood flow in long-term type I (insulin-dependent) diabetic patients with nephropathy and retinopathy. , 2008, Clinical physiology.

[38]  R. Aaslid,et al.  Dependency of Blood Flow Velocity in the Middle Cerebral Artery on End-Tidal Carbon Dioxide Partial Pressure—A Transcranial Ultrasound Doppler Study , 1984, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[39]  P. Dandona,et al.  Cerebral blood flow in diabetes mellitus: evidence of abnormal cerebrovascular reactivity. , 1978, British medical journal.

[40]  J. Patterson,et al.  Analysis of Vasoactivity of Local pH, Pco2 and Bicarbonate on Pial Vessels , 1977, Stroke.

[41]  J. Patterson,et al.  Local Mechanism of CO2 Action on Cat Pial Arterioles , 1977, Stroke.

[42]  M. Reivich,et al.  ARTERIAL PCO2 AND CEREBRAL HEMODYNAMICS. , 1965, The American journal of physiology.

[43]  N. Lassen,et al.  Cerebral blood flow and oxygen consumption in man. , 1959, Physiological reviews.

[44]  S. Kety,et al.  THE EFFECTS OF ALTERED ARTERIAL TENSIONS OF CARBON DIOXIDE AND OXYGEN ON CEREBRAL BLOOD FLOW AND CEREBRAL OXYGEN CONSUMPTION OF NORMAL YOUNG MEN. , 1948, The Journal of clinical investigation.