Effect of Different Positive End Expiratory Pressures on Regional Cerebral Oxygen Saturation

Evaluation of the Effect of Different PEEP Levels on Regional Cerebral Oxygen Saturation in Patients Undergoing Elective Craniotomy for Excision of Brain Tumors ; Randomized Controlled Clinical Trial

The goal of this prospective single-blind randomized clinical trial is to compare the effect of two different positive end expiratory pressure (PEEP) levels on regional cerebral oxygen saturation in patients scheduled for craniotomy due to supratentorial masses.

The main question it aims to answer is that how high PEEP level effects the regional cerebral oxygen saturation in patients with high intracranial pressure due to mass effect. Patients will be divided into two groups as Group low PEEP (5 cmH2O) and Group high PEEP (10 cmH2O). Researchers will compare the changes of regional cerebral oxygen saturations between two groups by near infra-red spectroscopy.

Study Overview

• Status: Recruiting
• Conditions: Regional Cerebral Oxygen Saturation
• Intervention / Treatment: Other: 5 cmH2O Positive end-expiratory pressure (PEEP); Other: 10 cmH2O Positive end-expiratory pressure (PEEP)

Detailed Description

In this prospective single-blind study, American Society of Anesthesiologists physical status classification system (ASA) I and II patients aged older than 18 years undergoing craniotomy will be enrolled for the study. Patients will be divided into two groups with computer-based randomization technique. Written and verbal approval will be taken from all patients. Premedication will not be used. Patients will be monitorized by standard non-invasive monitorization (electrocardiography, non-invasive blood pressure measurement, peripheral oxygen saturation) in the operating room. Cerebral/somatic oximeter, near infra-red spectroscopy (NIRS) sensor will be placed on the frontotemporal area and regional cerebral oxygen saturation will be monitorized continuously. Remifentanil infusion with a dose of 0.25 mcg/kg/min will be started two minutes before the induction. After preoxygenation with 6 L/min oxygen for 5 minutes, general anesthesia induction for patients in both groups will be held with intravenous 2 mg/kg propofol. Rocuronium bromide (0.6 mg/kg) will be used for muscle relaxation. Endotracheal intubation will be performed. Controlled mechanical ventilation will be used during the surgery. Invasive arterial blood pressure monitorization will be done and a central venous catheter will be placed in both groups.

In group low PEEP, the patients' settings of mechanical ventilation will be as tidal volume 6-8 mL/kg, inspired oxygen fraction (FiO2) 0.4, PEEP 5 cmH2O. Frequency will be set according to the end tidal carbon dioxide pressure (ETCO2) where it will be 30-32 mmHg.

In group high PEEP, the patients' settings of mechanical ventilation will be as tidal volume 6-8 mL/kg, inspired oxygen fraction (FiO2) 0.4, PEEP 10 cmH2O. Frequency will be set according to the end tidal carbon dioxide pressure (ETCO2) where it will be 30-32 mmHg.

Remifentanil with a dose of 0.05-2 mcg kg/min and propofol with a dose of 50-200 mcg/kg/min will be infused for general anesthesia maintenance in both groups. Dose of remifentanil infusion will be changed according to the blood pressure. If the mean arterial blood pressure and/or heart rate will decrease to 20% of the baseline mean arterial blood pressure and heart rate, the infusion dose will be lowered. If this decrease in heart rate will be over 25%, intravenous 0.5 mg atropin will be administered. If the mean arterial blood pressure will be under 55 mmHg, intravenous 5 mg ephedrine will be administered. If the mean arterial blood pressure will continue to decrease, PEEP will be lowered. If the peripheral oxygen saturation will be under 92%, the inspired oxygen fraction or PEEP will be increased. In these conditions, the patient will be out of study.

1 gr paracetamol will be given intravenously for pain relief. Sugammadex will be used with a dose of 4 mg/kg for extubation.

Regional cerebral oxygen saturation measures will be recorded nine (9) times during the study; pre-induction (period 1), post-induction (period 2), skull pinning (period 3), before dura opening (period 4), after dura opening (period 5), surgical resection of the mass (period 6), dura closure (period 7), end of the surgery (period 8) and end of anesthesia (period 9).

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Halide H Şahinkaya, MD; Phone Number: +905058892157; Email: drhhande@yahoo.com

Study Locations

• Turkey
  • Bozyaka
    • İzmir, Bozyaka, Turkey
      • Recruiting
      • University of Health Sciences İzmir Bozyaka Education and Research Hospital
      • Contact: Halide H Şahinkaya, MD; Phone Number: +905058892157; Email: drhhande@yahoo.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Older than 18 years
• American Society of Anesthesiologists physical status classification system (ASA) I and II
• Patients scheduled for elective craniotomy
• Patients with supratentorial mass

Exclusion Criteria:

• Hemoglobin concentration lower than 9 mg/dL
• Uncontrolled hypertension
• Congestive heart failure
• Severe chronic obstructive lung disease
• Cerebrovascular disease
• Pulmonary edema
• History of carotis surgery or stenosis of carotid artery
• Unstable hemodynamics
• Pregnancy
• Skin reaction to the NIRS sensor
• Patient's refusal

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Screening
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Group low PEEP; Positive end-expiratory pressure will be set at 5 cmH2O during controlled mechanical ventilation.	Other: 5 cmH2O Positive end-expiratory pressure (PEEP); PEEP will be set at 5 cmH2O
Active Comparator: Group high PEEP; Positive end-expiratory pressure will be set at 10 cmH2O during controlled mechanical ventilation.	Other: 10 cmH2O Positive end-expiratory pressure (PEEP); PEEP will be set at 10 cmH2O

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
regional cerebral oxygen saturation (SrO2) period 1	The measurement of regional cerebral oxygen saturation before anesthesia induction	Pre-induction
regional cerebral oxygen saturation (SrO2) period 2	The measurement of regional cerebral oxygen saturation after anesthesia induction	Up to 5 minutes after anethesia induction
regional cerebral oxygen saturation (SrO2) period 3	The measurement of regional cerebral oxygen saturation during skull pinning	From skull-pinning to final head position
regional cerebral oxygen saturation (SrO2) period 4	The measurement of regional cerebral oxygen saturation before dura opening	Just before dura opening
regional cerebral oxygen saturation (SrO2) period 5	The measurement of regional cerebral oxygen saturation after dura opening	Up to 5 minutes of dura opening
regional cerebral oxygen saturation (SrO2) period 6	The measurement of regional cerebral oxygen saturation during surgical resection of the mass	During surgical resection
regional cerebral oxygen saturation (SrO2) period 7	The measurement of regional cerebral oxygen saturation after dura closure	Up to 5 minutes of dura closure
regional cerebral oxygen saturation (SrO2) period 8	The measurement of regional cerebral oxygen saturation at the end of surgery	Within 5 minutes after the surgery
regional cerebral oxygen saturation (SrO2) period 9	The measurement of regional cerebral oxygen saturation at the end of anesthesia	Within 5 minutes after end of anesthesia

Collaborators and Investigators

• Sponsor: Bozyaka Training and Research Hospital
• Investigators: Study Chair: Halide H Şahinkaya, MD, University of Health Sciences İzmir Bozyaka Education and Research Hospital; Study Chair: Çağlar Ayar, MD, University of Health Sciences İzmir Bozyaka Education and Research Hospital; Study Chair: Alper Tabanlı, MD, University of Health Sciences İzmir Bozyaka Education and Research Hospital; Study Chair: Zeki T Tekgül, MD, University of Health Sciences İzmir Bozyaka Education and Research Hospital

Publications and helpful links

General Publications

• Calderon-Arnulphi M, Alaraj A, Slavin KV. Near infrared technology in neuroscience: past, present and future. Neurol Res. 2009 Jul;31(6):605-14. doi: 10.1179/174313209X383286.
• Kemerci PU, Demir A, Aydinli B, Guclu CY, Karadeniz U, Cicek OF, Tasoglu I, Ozgok A. 10 cm H2O PEEP application in laparoscopic surgery and cerebral oxygenation: a comparative study with INVOS and FORESIGHT. Surg Endosc. 2016 Mar;30(3):971-8. doi: 10.1007/s00464-015-4277-8. Epub 2015 Jun 23.
• Chen H, Zhou XF, Zhou DW, Zhou JX, Yu RG. Effect of increased positive end-expiratory pressure on intracranial pressure and cerebral oxygenation: impact of respiratory mechanics and hypovolemia. BMC Neurosci. 2021 Nov 25;22(1):72. doi: 10.1186/s12868-021-00674-9.

Study record dates

Study Major Dates

• Study Start (Actual): February 15, 2023
• Primary Completion (Estimated): October 15, 2023
• Study Completion (Estimated): November 15, 2023

Study Registration Dates

• First Submitted: June 30, 2023
• First Submitted That Met QC Criteria: July 18, 2023
• First Posted (Actual): July 27, 2023

Study Record Updates

• Last Update Posted (Actual): July 27, 2023
• Last Update Submitted That Met QC Criteria: July 18, 2023
• Last Verified: July 1, 2023

More Information

Terms related to this study

• Keywords: near-infrared spectroscopy; craniotomy; PEEP; regional cerebral oxygen saturation
• Other Study ID Numbers: NIRS

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No