Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113

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Journal of Cardiothoracic and Vascular Anesthesia

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Review Article

Neuromonitoring and Neurocognitive Outcomes in

Cardiac Surgery: A Narrative Review
Benjamin Milne, MBBS FRCA*,
Thomas Gilbey, MBBS FRCA PhD*, Livia Gautel, ,1y,
Gudrun Kunst, MD PhD EDAIC FRCA FFICM* z
*
Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
y
School of Biological Sciences in Edinburgh, University of Edinburgh, Edinburgh, UK
z
School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of
Excellence, London, UK

Neurocognitive dysfunction after cardiac surgery can present with diverse clinical phenotypes, which include postoperative delirium,
postoperative cognitive dysfunction, and stroke, and it presents a significant healthcare burden for both patients and providers. Neuro-
logic monitoring during cardiac surgery includes several modalities assessing cerebral perfusion and oxygenation (near-infrared spectros-
copy, transcranial Doppler and jugular venous bulb saturation monitoring) and those that measure cerebral function (processed and
unprocessed electroencephalogram), reflecting an absence of a single, definitive neuromonitor. This narrative review briefly describes the
technologic basis of these neuromonitoring modalities, before exploring their use in clinical practice, both as tools to predict neurocogni-
tive dysfunction, and with a bundle of interventions designed to optimize cerebral oxygen supply, with the aim of reducing postoperative
delirium and cognitive dysfunction following cardiac surgery.
Ó 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

Key Words: neurocognitive dysfunction; cardiac surgery; postoperative cognitive dysfunction; neuromonitor; near-infrared spectroscopy; transcranial doppler;
jugular venous bulb saturation; electroencephalogram

NEUROCOGNITIVE DYSFUNCTION affects up to 50%
of patients following cardiac surgery, representing a common
pathway of individual, and interacting, perioperative patho-
physiologic processes.1 These include neuronal and vascular
damage, embolism, and inflammation, which result in abnor-
mal oxygen delivery and demand, as well as altered cerebral
autoregulation. These insults often are compounded by under-
lying neurodegenerative pathologies.2
Benjamin Milne and Thomas Gilbey are NIHR (National Institute of Health
Research) funded Clinical Academic Fellows.
1
Address correspondence to Gudrun Kunst MD PhD EDAIC FRCA FFICM,
Department of Anaesthetics and Pain Medicine, King’s College Hospital NHS
Foundation TRust, Denmark Hill, London SE5 9RS, United Kingdom
E-mail address: gudrun.kunst@kcl.ac.uk (G. Kunst).
The heterogeneity of the implicated pathologic processes
results in different clinical phenotypes of neurocognitive dys-
function, including postoperative delirium (POD), postopera-
tive cognitive dysfunction (POCD), and stroke.3 The
multifactorial etiology is reflected in the development of dif-
ferent modalities for neurologic monitoring during cardiac sur-
gery. These are broadly divided into devices monitoring
cerebral perfusion and oxygenation, such as near-infrared
spectroscopy (NIRS), transcranial Doppler (TCD), and jugular
venous bulb saturation monitors, and those that monitor cere-
bral function, such as the electroencephalogram (EEG) (Fig 1).
This review focuses on the use of cerebral monitoring and
clinical outcomes in cardiac surgery, incorporating the most
recent evidence, including the use of multimodality monitor-
ing, and placing this in the context of previous trials and

https://doi.org/10.1053/j.jvca.2021.07.029
1053-0770/Ó 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113 2099

Fig 1. Pathologic processes, clinical phenotypes, and different modalities for neurological monitoring. DOA, depth of anesthesia; EEG, unprocessed electroen-
cephalogram; JVBS, jugular venous bulb saturation monitoring; NIRS, near-infrared spectroscopy; pEEG, processed electroencephalogram; POCD, postoperative
cognitive dysfunction; POD, postoperative delirium; TCD, transcranial Doppler.

current guidance. Comparison not only is made among the
modalities in general, but also among currently available
NIRS devices specifically, to assist clinicians in the application
of the evidence base for the benefit of their patients.
Definitions
The following definitions will aid in contextualizing the dis-
cussion of the evidence base in this review. Numerous studies
have been beset by lack of, or failure to adopt, consensus defi-
nitions, and as such these should not be considered the defini-
tions used in individual studies.
POD
POD is a fluctuating disturbance in attention and awareness,
with disturbed cognition or perception, representing an acute
change from baseline (not due to a preexisting neurocognitive
disorder or occurring in the context of a severely reduced
arousal level) within one week of the procedure, or until
discharge.2,4,5 POD occurs in up to 50% of postcardiac surgery
patients.1
POCD
POCD is an objectively measurable decline in cognitive
function, demonstrated on testing of cognitive domains (partic-
ularly memory and executive function), and detectable from
the point of expected neurologic recovery (30 days postproce-
dure). This is primarily a research definition, requiring neuro-
psychiatric testing, but it corresponds to the clinically
observable decline in function in some patients postopera-
tively, for which the term "postoperative neurocognitive
2100 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
dysfunction (NCD)" has been coined.2,4 The prevalence varies
over time, but the incidence of POCD at five years can be as
high as 42%.6
Stroke
The etiology of postcardiac surgery stroke involves cerebral
embolism (50%-75% of patients) and also hypoperfusion.7 In
a meta-analysis, the pooled event rate was 2.%.8
In most included studies, and in this review, the clinical
term “delayed neurocognitive recovery” is not used, and most
early (<30 days postprocedure) dysfunction is described as
POD.4
Monitors of Cerebral Perfusion and Oxygenation
NIRS
NIRS devices emit different wavelength photons of electro-
magnetic radiation (EMR) in the near-infrared (700-1000 nm)
range, which either are absorbed by the cerebral parenchyma
or undertake a parabolic arc through the underlying tissues to
be detected by receptors.9,10 A proximal receptor measures
photons from the extracerebral tissue, and the distal receptor
detects photons from the deeper tissue, usually near the junc-
tion of the anterior (ACA) and middle cerebral (MCA)
arteries.9,10 The device uses the modified Beer-Lambert law to
provide a measurement of regional cerebral oxygen saturation
(rSO2) through expression, as a percentage, of the proportion
of measured oxyhemoglobin (at 920 nm) to total hemoglobin
(760 nm).9,10 The frontal cortex is often the region monitored,
the overlying skin being suitably accessible and exposed, as
well as having clinical importance as a watershed area. This
represents the most distal tissue supplied by both the ACA and
MCA, which is vulnerable to hypoperfusion and embolic
material.10-12 However, the NIRS-monitored region of the cor-
tex is small and may lie outside the watershed zone.
NIRS has a long history of use in research and clinical prac-
tice, and has been shown to measure cerebral desaturation
with changes in cerebral blood flow (CBF), and physiologic
studies have demonstrated validity for the measurement of
cerebral oxygenation.13-15 There are now several devices cur-
rently approved for clinical use by the US Food and Drug
Administration (FDA), with the most frequently used monitors
and their key features, as well as advantages and disadvan-
tages, listed in Table 1.3,16-39
As most hemoglobin within the cranium resides within the
venous system, a normal rSO2 is about 70%, with a range of
50% to 75%, based on the assumption of a fixed venous-to-
arterial ratio.3,10 Inter-individual variability has been demon-
strated in healthy volunteers, and a meta-analysis of preopera-
tive rSO2 values in cardiac surgery patients found a 95%
reference range of 51% to 82%, with a mean baseline of
approximately 66%.10,40 Furthermore, a reducing baseline
value is observed with advancing age, with a reduced value in
female patients, and when combined with a likely degree of
reading error related to differing proportions of arterial and
venous blood in the measured region, NIRS may best be con-
sidered as a “trend” monitor.10,41
Despite different approaches to a numeric definition for
desaturation, among studies demonstrating a value to the use
of NIRS, there is reasonable agreement that a decrement of
10% to 20% from baseline, or an absolute value <50%, war-
rants intervention.9,42-50 Two small single-center studies in
patients undergoing awake carotid endarterectomies assessed
sensitivity and specificity of NIRS-detected desaturations for
diagnosis of cerebral ischemia with awake neurologic assess-
ments as the gold standard, demonstrating moderate-to-good
sensitivity (60%-100%) and good specificity (94%-98%).51,52
In addition to the assessment of single desaturation events,
depth and duration of desaturation during general anesthesia
also often are considered, using an “area under the curve”
(AUC) methodology to assess the “desaturation load.”10,49,53-58
NIRS monitoring has been incorporated into goal-directed
optimization algorithms for cerebral oxygenation, and this
technology-intervention package has been assessed in numer-
ous studies.59 One of the first interventional trials, of 200
patients undergoing coronary artery bypass graft (CABG) sur-
gery on cardiopulmonary bypass (CPB), used an algorithm
designed to keep rSO2 75% of the baseline level, which
included: optimization of head and neck position, increasing
arterial partial pressure of carbon dioxide to 40 mmHg (if
previously <35 mmHg, or <40 mmHg on CPB), maintenance
of mean arterial pressure (MAP) >60 mmHg (if previously
<50 mmHg), increasing pump flow to 2.5 L/m2/min (if previ-
ously <2.0 L/m2/min), increasing inspired oxygen fraction
and transfusion of packed red cells (if hematocrit <20%).60
This algorithm, or similar interventions, was used in subse-
quent studies, and reduction of the “desaturation load” has
been possible in the majority of episodes.61-63
The main clinical trials examining the impact of NIRS-
based interventions on neurocognitive outcomes are summa-
rized in Supplemental Tables 1 a-c.9,42-50,58,60,64-71
NIRS and Postoperative Delirium (Supplemental Table 1a)
Preoperative rSO2 measurement has demonstrable value
given the correlation between a low rSO2 value and increased
POD in cardiac surgical patients undergoing CPB.72-75 The
significant difference in rSO2 values between POD patients
and their nondelirious counterparts persists when supplemental
oxygen is applied, and in the absence of disparity in arterial
saturation monitoring, suggesting additional value for this
modality.73 Further observational evidence, from a large
(n = 815), single-center, retrospective study, demonstrated that
with intraoperative monitoring of patients undergoing off-
pump CABG (OPCAB) surgery, duration of rSO2 <50% was
associated with increased incidence of POD.49
A single-center, randomized controlled trial (RCT) of 249
older patients undergoing surgery on CPB further confirmed
the predictive importance of a low baseline rSO2 value for
POD and evaluated a NIRS-based interventional algorithm to
counteract desaturation (rSO2 <75% of baseline for at least
one minute). The intervention did not reduce the incidence of
Table 1
A Comparison of Five FDA-Approved Near-Infrared Spectroscopy Devices
Device and Manufacturer
C-Flow (predecessor: CerOx), Ornim Medical
Ltd, Israel
INVOS (multiple iterations)
Covidien, CO/Medtronic, Minnesota, USA
EQUANOX (multiple iterations), Nonin
Medical Inc, Minnesota, USA
Key Features
Acousto-optic device (UT-NIRS; near-infrared
EMR is modulated by 1-MHz ultrasound
waves, allowing temporal interpretation of
detected signal, and permitting derivation of
flow values).
Modified unit calculates state of
autoregulation (based on CBF index and
MAP).
Emits 2 wavelengths of EMR (730 and 810 nm).
Provides absolute rSO2 value and percentage
change from baseline.
Integration with bispectral index is possible
for depth of anesthesia monitoring.
Device assumes a 25%/75% arterial/venous
contribution to cerebral saturation.
2-, 3-, and 4-wavelength devices available (730,
760, 810, and 880 nm)
Provides an absolute value of rSO2 and a trend
value.
Device assumes a 30%/70% arterial/venous
contribution to cerebral saturation.
Advantages
Provides microcirculatory CBF values, as well
as saturation values.
Displays arbitrary flow units, and change from
baseline value.
Global and regional CBF values correlate with
nuclear medicine-based techniques.
CBF autoregulation calculated by CerOx
moderately correlates with TCD-derived
values.
CBF index may function better as a monitor of
malperfusion than cerebral saturation.
First FDA-approved cerebral oximetry device,
with largest evidence base.
Demonstrates good correlation between
sensors for different age ranges (neonatal,
pediatric, and adult) as trend monitors (albeit
with different absolute values depending on
sensor).
8004CA 4-wavelength sensor has been validated
in a physiological study to provide absolute
rSO2 values, as well as trend values.
Lowest impact of extracranial contamination
on saturation value (compared with INVOS
and FORE-SIGHT).
EQUANOX 3- and 4-wavelength devices
appear less subject to between-patient
variability than INVOS devices.
Disadvantages
Requires adequate light and acoustic coupling.
B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
Ultrasonography requires refreshing of probe
contact gel every few hours.
CBF index accuracy may be affected by
hemodilution during CPB.
Inability to detect absent CBF (in brain-dead
patients) via this modality raises questions
regarding use of noninvasive CBF assessment.
Potentially more sensitive to interpatient
variability, which complicates defining
clinically relevant threshold values.
Distal sensing depth is only 20 mm, so low
saturation values may occur with a scalp-
cortex distance greater than 20 mm.
Extracranial contamination has a more sizable
mean reduction in saturation value than
FORE-SIGHT and EQUANOX (16.6% v
11.8% v 6.8%).
More negative bias of saturation values for
female patients (compared with FORE-SIGHT
and EQUANOX)
Fewer studies in this device, compared with
INVOS.
Poor interchangeability of absolute values
with other devices limits generalizability of
research in other devices, and device-specific
threshold values are required.
Different iterations of the device have shown
different saturation values in the same subject,
likely relating to technical and algorithm
differences, which may limit generalizability
of previous research.
More negative bias of saturation values for
female patients (compared with FORE-
SIGHT).
(continued on next page)
2101

Table 1 (continued )
Device and Manufacturer Key Features
FORE-SIGHT ELITE Emits 5 wavelengths of EMR (685, 730, 770,
(predecessor: FORE-SIGHT) 810, and 870 nm).
CAS Medical Systems, CT/Edwards Provides an absolute value of rSO2.
Lifesciences, California, USA Device assumes a 30%/70% arterial/venous
contribution to cerebral saturation.
Integration with advanced hemodynamic
monitoring is possible.
O3 Masimo, California, USA Emits 4 wavelengths of EMR (730, 760, 805,
and 880 nm).
Provides absolute rSO2 value and change from
baseline.
Provides indices relating to change in oxy- and
deoxyhemoglobin values, as components of
rSO2.
Integration with depth of anesthesia metric is
available.
Abbreviations: CBF, cerebral blood flow; CPB, cardiopulmonary bypass; EMR, electromagnetic radiation; FDA, US Food and Drug Administration; MAP, mean arterial pressure; MHz, megahertz; NIRS, near-
infrared spectroscopy; nm, nanometer; rSO2, regional cerebral oxygen saturation; TCD, transcranial Doppler; UT-NIRS, ultrasound-tagged near-infrared spectroscopy.
Advantages
Additional wavelengths can compensate for
scattering or diffusion of light, with reduced
extracranial contamination compared with
INVOS 5100C.
Distal sensing depth greater than INVOS (25
mm).
In most extensive comparative study, FORE-
SIGHT had the lowest root-mean squared
error (compared with EQUANOX 3- and 4-
wavelength, and INVOS) and lowest
percentage variation attributable to patient
variability.
Bias of values appears to be affected by
gender least of all (compared with INVOS and
EQUANOX).
Demonstrated good accuracy of absolute rSO2
value (root-mean squared error of 4%), and
trend value (relative root-mean-squared error
of 2.1%) in volunteers during controlled
hypoxia, with good correlation (coefficient
0.95) with reference values from arterial and
venous samples.
2102
Disadvantages
Fewer studies in this device, compared with
INVOS.
Poor interchangeability of absolute values
with other devices limits generalizability of
research in other devices, and device-specific
threshold values are required.
Previous iteration had more negative bias in
saturation value for patients with dark skin
B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
pigment.
Very few studies using this device currently.
Little comparative data available, but
comparison with EQUANOX device suggests
absolute values are not interchangeable.
 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
POD, or duration of desaturation, compared with standard
care.64 However, the intervention failed to restore normal
rSO2 values in about 20% of intraoperative patients, and 12%
of intensive care unit (ICU) patients, reflecting a much lower
reversal rate than previously described.60,62-64 The failure to
reduce the incidence of POD likely reflects the low rSO2 resto-
ration rates in the intervention group, and there may have been
suboptimal protocol compliance, or a “learning effect” carried
over from the intervention group to the control group.76
A further RCT of 128 higher-risk cardiac patients failed to
demonstrate a benefit on the incidence of POD, with an algo-
rithm to maintain rSO2 >80% of baseline, as part of a bundle
of individualized physiologic targets. Regardless of study arm,
the incidence of POD was significantly lower in patients
achieving their physiologic targets, including rSO2, than those
who did not (24% v 53%, p = 0.001). Although this study was
not powered for POD as the primary outcome, the importance
of individualized targets was reinforced, and should be the
topic of further research.50 In this respect, ultrasound-tagged
(UT) NIRS, which has demonstrated use in establishing indi-
vidual intraoperative cerebral autoregulation, may be of use,
with MAP deviations beyond the autoregulatory range associ-
ated with POD.18,77
Considering the uncertain evidence for the value of NIRS-
based intervention in reducing POD, a pairwise meta-analysis
of seven RCTs showed benefit in cardiac surgery for a com-
bined outcome of POD and POCD (pooled odds ratio [OR]
0.34 [0.14-0.85]), with the authors advocating maintenance of
>80% of baseline saturation.78 There is less evidence consid-
ering the continuation of monitoring on the ICU following car-
diac surgery, despite a high (53%) incidence of cerebral
desaturation.79 Observational evidence suggests that the use of
NIRS may be appropriate in assessing severity, and monitoring
resolution, of delirium, with absolute and relative postopera-
tive desaturations significantly associated with an increased
incidence of delirium.48,80 However, there was no significant
difference in NIRS values prior to the onset of delirium, weak-
ening the suggestion of causation, and implying that this was a
consequence of the neuropathology.48
NIRS and Postoperative Cognitive Decline (Supplemental
Table 1b)
An early observational study of 47 patients undergoing
CABG on CPB found no association between NIRS-detected
cerebral desaturation and POCD, although it is likely that this
study, and similar subsequent ones, was underpowered.65,81
Debate surrounding the association of cerebral desaturation
with POCD has continued, and the authors of a more recent
prospective study have argued against the use of NIRS moni-
toring for all low-risk cardiac surgery patients, on the basis of
similar rates of cerebral desaturation between on-pump and
off-pump patients, but significantly different incidence of
POCD. However, small patient numbers (n = 60), low inci-
dence of cerebral desaturation, and the low-risk nature of the
patients have limited the generalizability of their findings.68 In
contrast, there is an evolving body of evidence, first
2103
observational, and then from three randomized, prospective
studies, that has shown an association between intraoperative
cerebral desaturation and POCD.42-44,66,67
Observational evidence supports an AUC for desaturation
<40% as the key predictor for POCD.66,82-85 Furthermore,
prospective RCT data from patients (n = 265) undergoing on-
pump CABG showed no significant incidence of POCD with-
out desaturation <50%, and reinforced that desaturation load
was associated with significant increased incidence of early
POCD.67 Subsequent studies have reiterated this association,
with an OR of 12 (95% CI, 2.4-60.7; p = 0.003) for POCD
given prolonged cerebral desaturation.9,43,44
Of more clinical relevance than the association between
cerebral desaturation and POCD, is the use of NIRS-based
interventional algorithms to reduce the burden of POCD when
compared with standard care. The same RCT reporting the
importance of desaturation load failed to detect a significant
difference from standard care with use of NIRS-based inter-
ventions, although there were concerns regarding poor proto-
col compliance.67 Once again, there have been numerous
subsequent studies, using RCT methodology, with positive
outcomes relating to incidence of POCD.9,43,44,47,70 One RCT
of 200 CABG surgery patients demonstrated that a NIRS-
based interventional bundle aimed at maintaining rSO2 >80%
of baseline value, or >50% absolute value, significantly
reduced the incidence of POCD compared with the control
group (28% v 52%, p = 0.002), although no monitoring of the
control group occurred for comparison rSO2 values.44
Intervention at similar thresholds of desaturation have been
associated with significant outcome differences in other ran-
domized studies.9 At a relatively more conservative rSO2
intervention threshold of 60%, one RCT of 134 patients under-
going on-pump cardiac surgery reported significantly
improved memory scores at six months postoperatively in the
intervention arm, despite presence of numerous protective fac-
tors in the whole cohort, including a young average age, good
underlying cardiac contractile function, and an absence of
deep hypothermic cardiac arrest.70,86 This study failed to dem-
onstrate a desaturation severity-time burden on POCD, which
may relate to the presence of protective factors and the inter-
vention bundle, as well as possible genuine absence of associa-
tion. However, the use of RCT methodology with clearly
defined consensus cognitive outcome measures make the find-
ings important in the context of evaluating this modality.86,87
The most concerning limitation of many of these studies
was the nonstandardized methodology for POCD assessments,
such as antisaccadic eye movement tests, Mini-Mental State
Examination, and the Montreal Cognitive Assessment
(MoCA).9,43,66 This has significant ramifications for the valid-
ity of individual studies, as well as reducing the suitability for
meaningful meta-analyses, and further compounded by poor
standardization of the postoperative assessment periods. This
failure of standardization highlights the importance of certain
findings, such as those of Colak et al, in which despite non-
blinding of the control group, there was appropriate use of the
cognitive assessment modalities approved by the Consensus
Statement for the Assessment of Neurocognitive Function in
2104 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
Cardiac Surgery.44,88 To emphasize the importance of these
cognitive assessment modalities, in one multicenter RCT, the
only significant difference in the incidence of POCD was
detected in nonapproved POCD assessment modalities, with
no significant difference in approved modalities between con-
trol and intervention arms (although a low incidence of desatu-
ration and a small proportion of high-risk patients raised
questions regarding generalizability of these findings).45,88
Furthermore, numerous trials are beset by being underpow-
ered, or not designed, for incidence of POCD as a primary out-
come, limiting the application of findings to clinical practice.69
Suitability of systematic reviews and meta-analyses of indi-
vidual trial data unfortunately are limited by the aforementioned
heterogeneity in reported outcomes. One systematic review,
with POCD as a secondary outcome, judged only two of ten
studies as low-risk for bias, and only two used consensus state-
mentapproved cognitive testing modalities, with any signifi-
cant difference detected absent when only these methods were
considered.59 The aforementioned network analysis reported
reduced pooled OR for combined POD/POCD with the use of
patient-specific NIRS-based algorithms to maintain rSO2 in car-
diac surgical patients, identifying the critical threshold of desatu-
ration as <80% of baseline.78 Similarly, in a Cochrane Database
systematic review of perioperative NIRS monitoring in adult
surgery, ten of the 15 included studies involved aortic or cardiac
surgery patients, with varied outcome measures.16 They
highlighted one cardiac study reporting an increase of POCD in
the control arm at one week (mild impairment in 44.4% v
16.3%, p = 0.01).9 Across all surgical patients, only a low-qual-
ity recommendation could be made supporting the use of NIRS
monitoring in reducing early POCD.16
NIRS and Stroke (Supplemental Table 1c)
Reporting of other neurologic outcomes has been variable,
with conflicting evidence regarding perioperative optimization
of rSO2 and the incidence of postoperative stroke, and a meta-
analysis found no significant difference between intervention
and control arms.50,59,60,71 The dichotomous evidence may relate
to the etiology of perioperative stroke, as measures to intervene
in desaturation will involve attempts to increase cerebral blood
flow (CBF), which will be beneficial in hypoperfusion, but dele-
terious if increasing flow delivers a greater embolic load.
One secondary analysis of an RCT demonstrated an association
between an increased number of new postoperative ischemic cere-
bral lesions (diagnosed by diffusion-weighted magnetic resonance
imaging) in cardiac surgery patients with a significantly longer
time of cerebral desaturation >10% from baseline. The presence
of new cerebral ischemic lesions also was associated with a higher
accumulated desaturation load, although there was no clear rSO2
threshold for an increased incidence of new lesions.46 Again, there
is a clear need for further high-quality RCTs.
Conclusion—NIRS Monitoring
A recent survey of cardiac anesthesiologists revealed that
27% routinely use cerebral oximetry monitoring, increasing to
Table 2
American Society for Enhanced Recovery and Perioperative Quality Joint
Consensus Statement Recommendations for Use of Cerebral Near-Infrared
Spectroscopy in Cardiac Surgery
Perioperative Timepoint Action
Preoperative Record baseline measurement (Strength of
Statement—Strong, Quality of Evidence—B).
Identify patient at higher-risk of adverse outcome
after cardiac surgery (Weak, B).
Intraoperative Measure intraoperatively and index to baseline to
identify high-risk patients (Weak, C).
Measure to identify acute cerebral malperfusion
and guide management (Weak, D).
Cerebral oximetry-guided interventional
algorithm should be used to reduce intensive care
unit length of stay (Weak, C).
Postoperative More research needed
59% in aortic arch surgery, which may reflect a paucity of
high-quality evidence.89 Detractors of NIRS-based interven-
tions may point to findings, such as the inability for UT-NIRS
to identify absent cerebral circulation in adults with brain
death.23 However, there appears to be enough evidence to sug-
gest that a low preoperative value is associated with POD, and
there is reasonable agreement that cerebral desaturation intrao-
peratively is associated with both POD and POCD. This is
reflected in the incorporation of this technology into recent
clinical expert recommendations for use in cardiac surgery,
which are listed in Table 2.90,91
The precise role of perioperative NIRS monitoring will con-
tinue to be debated. There is a spectrum of problems that it can
detect, from incorrect aortic or right atrial bypass cannulae
positioning (which may be detected with unilateral desatura-
tion, and which is easily rectified) to global desaturation
(which is less completely understood from a single numerical
value), which will require more extensive management, and
may not be remediable. Although future directions for cerebral
oximetry include entropy and trend analyses, as well as inte-
grated cerebral autoregulatory blood pressure threshold assess-
ments, the most crucial steps toward more clearly establishing
its role in cardiac surgery, and in optimizing neurocognitive
outcomes, will be the conduct of more high-quality trials,
using standardized outcome assessments at homogenized time
points, in line with consensus definitions.92-94
Jugular Venous Bulb Saturation Monitoring
This neuromonitoring technique requires retrograde place-
ment of a specialized catheter into the jugular venous bulb via
the internal jugular vein.3 Cardiac anesthesiologists may not
be familiar with the placement of this catheter. Jugular bulb
oxygen saturation (SjO2) measures global oxygenation (con-
tinuously or intermittently), the product of oxygen supply and
demand, with a normal range of 55% to 75%.95,96 Measure-
ment has a high specificity, but a low sensitivity, for regional
ischemia, and anatomic variations can lead to unpredictable
contamination.3,95
 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
A SjO2 value <50% suggests inadequate cerebral oxygen-
ation, due to increased metabolic rate of oxygen consumption,
reduced CBF, or diminished arterial oxygen concentration.95
SjO2 has been demonstrated to be a better marker of cerebral
oxygenation than SvO2 (mixed venous oxygen saturation).97
The multiple potential sources of low values, and aforemen-
tioned shortcomings, mean it may be used best as a trend mon-
itor.3 Accurate clinical interpretation requires that arterial
oxygen saturation, hemoglobin concentration, and other physi-
ologic factors influencing the position of the oxyhemoglobin
dissociation curve (OHDC) remain constant, so that deranged
values can be considered the result of an alteration to either
CBF or cerebral oxygen consumption.95
SjO2 values <50% during warm CPB have been associated
with POD/POCD following cardiac surgery.84,98 Desaturation
<50% occurs in roughly a quarter of patients during rewarm-
ing from hypothermic CPB, and has been associated with
POCD in numerous studies.83,99,100 Impaired neurocognitive
test performance has been associated with reduced CBF and
higher cerebral oxygen consumption prior to rewarming, sug-
gesting the presence of a prewarming metabolic deficit.101,102
Therefore, low SjO2 caused by cerebral hypoperfusion may
have some use as a screening tool for patients at risk of
POCD.102,103 Interestingly, one single-center study of 187
patients showed that SjO2 desaturations were more frequent
during off-pump cardiac surgery, rather than during on-pump
procedures; however, it is unclear whether the desaturations
resulted in POCD.79 The clinical relevance of this observation
can be questioned, particularly as neurocognitive outcomes
after off-pump procedures are not more common.104,105
In contrast to the evidence of an association of low intrao-
perative SjO2 measurements with POD/POCD, but potentially
in agreement with the aforementioned results in off-pump sur-
gery, a small single-center study in 35 patients undergoing
CABG and valve surgery with CPB (at 28˚C), demonstrated
that increased SjO2 saturations before and during CPB were
associated with POCD.106,107 This potentially contradictory
finding may have been due to (1) increased CBF with higher
SjO2 being associated with a higher delivery of emboli to the
brain, (2) shift of the OHDC to the left during CPB with
increased oxygen affinity for hemoglobin, resulting in higher
SjO2 but inadequate tissue oxygenation, or (3) shunt of oxy-
genated arterial blood to the venous side.107-111 Care must be
taken in interpretation of these values, as SjO2 measurements
are likely to be higher during hypothermic CPB than during
normothermic CPB, reflecting the oxygen consumption being
reduced disproportionately to CBF during hypothermia.95,112
Conclusion—Jugular Venous Bulb Saturation Monitoring
This invasive technique can be used as a trend monitor to
assess cerebral oxygenation, with high specificity for regional
ischemia, but accurate interpretation is dependent on a con-
stant physiologic milieu. Lower SjO2 values during warm
CPB and during rewarming from hypothermic CPB, indicating
hypoperfusion, have been associated with increased POD/
POCD. However, the complex interaction of oxygen extraction
2105
and the drastic, and evolving, physiologic derangement of
hypothermic CPB, including shunting and emboli, which are
associated with potential hyperperfusion and increased SjO2
values, may make interpretation particularly complicated. The
majority of studies assessing this modality are relatively older
than for other monitoring techniques, and should be interpreted
with this in mind. Finally, this technique is of declining famil-
iarity to anesthesiologists, which has implications for ongoing
clinical and research practice.
Transcranial Doppler
Transcranial Doppler (TCD) emits ultrasound waves in the
frequency range of 1-to-2.5 MHz, placed in various acoustic
windows to monitor the presence, velocity, and direction of
flow, in a selected cerebral artery.3,96,113 Measurement of
MCA velocity (MCAV) has shown good correlation with
changes in CBF, and a reduced value is associated with cere-
bral ischemia in carotid endarterectomy patients.3,96,114
TCD has been used during cardiac surgery for the correction
of mechanical causes of reduced flow velocity and hemi-
spheric flow asymmetry, and may be of use in selecting the
most appropriate strategy for delivering anterograde cerebral
perfusion during aortic arch surgery.3,115 Furthermore, it has
been used for monitoring high-intensity transient signals,
which are indicative of microemboli during cardiac
surgery.3,96 However, multiple systematic reviews have
described insufficient evidence to demonstrate causality
between intraoperative embolic events and POCD, despite a
degree of association, with analysis hampered by the methods
used to classify the signals, as well as neurocognitive testing
modalities and study underpowering.116-118 As such, routine
clinical use of TCD during CPB is not supported by evidence-
based guidelines.3,119 The decline in use also likely is related
to the limitations of TCD, which include the requirement for
skilled placement and interpretation, and the potential for sig-
nal loss during surgery.3,96,120
A recent small, single-center study of TCD assessment of
MCAV prior to, and during CPB, demonstrated that patients
with POD had significantly higher flow velocities compared
with baseline, suggesting relative cerebral hyperperfusion,
which was present for a greater time-averaged period. In addi-
tion, patients with relatively low baseline velocities, who then
subsequently experienced hyperperfusion, were significantly
more likely to be delirious postoperatively than their normo-
perfused counterparts.121 However, enthusiasm for identifying
patients at risk of developing POD by this method may be tem-
pered by concerns regarding the external validity of using
MCAV values as markers of CBF, despite good correlation,
given the high number of variables affecting this value.121 A
similar potential preoperative role has been suggested, as left
MCA hypoperfusion is an independent risk factor for POCD,
but evidence for this is limited.122
Further research has been conducted into the use of TCD to
demarcate, in realtime, the limits of cerebral autoregulation, of
particular pertinence given the association of POCD with flow
outside this range.123-127 Furthermore, the absence of cerebral
2106 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
autoregulation in about 20% of patients undergoing cardiac
surgery has been demonstrated with combined TCD and
NIRS, and these patients are at higher risk of postoperative
stroke.21,128 An RCT of 460 patients used TCD to establish
individualized CPB MAP targets before CPB. There was no
reduction in the incidence of a composite neurologic outcome,
but there were a 45% reduction in POD and a significant
improvement in memory scores at four-to-six weeks after sur-
gery in the intervention arm.129
Conclusion—Transcranial Doppler
TCD has been used in identifying the presence of cerebral
artery flow during cardiac procedures, and in detecting cere-
bral microemboli. Currently, inconclusive evidence for the
clinical relevance of abnormal findings, combined with the
technical skill required to perform such monitoring, explain
the limited uptake. However, its use to assess individual limits
of cerebral autoregulation, with subsequently adjusted blood
pressures during CPB, demonstrated convincingly improved
neurologic outcomes.
Cerebral Function Monitoring
Electroencephalography (EEG) is a multifaceted neuromo-
nitor and includes the use of raw, unaltered EEG waveforms,
or processed data (processed EEG or pEEG). Furthermore, the
EEG, or a pEEG-based monitor, can be considered as direct
neuromonitors or as depth of anesthesia monitors, with the
potential effects that titration of anesthesia has on neurocogni-
tive outcomes.
Unprocessed EEG
The EEG is the surface recording of cortical activity, and the
trace produced unsurprisingly is affected by cerebral oxygen-
ation.3 Reduced oxygen delivery, for example due to CBF
below critical threshold (<22 mL/100g brain tissue/minute),
can present as slowing of the EEG, with decreased amplitude
of alpha and beta waves, and increased amplitude of theta and
delta waves.3,96 Further reduction of CBF, to 7-to-15 mL/
100g/min, can produce an isoelectric EEG, indicating extreme
suppression of neural activity, which has been used as an end-
point in deep hypothermic cardiac arrest for aortic
surgery.96,130 These changes enable detection of cerebral
ischemia, with sensitivity improved by maintenance of a con-
stant anesthetic dose, as well as other physiologic, pharmaco-
logic, and environmental influences.3
Distinct EEG findings have been characterized in delirious
postcardiac surgery patients in the ICU; however, even the
appearance of EEG slowing may represent subclinical
derangement, occurring in the absence of abnormal neuropsy-
chologic test performance.131,132 Furthermore, it very recently
was shown that postoperative cardiac surgery patients demon-
strated a relatively high incidence (9%) of electrographic seiz-
ures (and abnormal EEG patterns in 33% of patients), which
are associated with POD.133
Duration of EEG burst suppression has been linked both
directly and inversely with POD and POCD.134-138 Known
POD risk factors, including limited physical function, lowest
body temperature on CPB, and EEG alpha power, may
increase the risk of delirium by means of their impact on burst
suppression during CPB.139 Given the relationship between
hypotension and neurologic insult during cardiac surgery,
some have advocated the use of EEG for monitoring of burst
suppression, particularly given the increased postoperative
mortality associated with concurrent hypotension and wave-
form suppression in a recent large RCT (ENGAGES trial),
although no difference in POD incidence was noted.140-142
EEG use for neuromonitoring is limited by the cumbersome
application of the electrodes, requiring skill to interpret, and
its primary function as a monitor of the superficial layers of
the cerebral cortex. It is used best if there have been a normal
preoperative trace and stable depth of anesthesia, and detection
of reduced oxygen delivery is improved when the insult is sud-
den. It also is prone to interference from surgical equipment,
such as diathermy, hypothermia, or concomitant medication
administration.3
Processed EEG
Processed EEG (pEEG) monitors use surface electrodes and
a proprietary algorithm to produce a dimensionless number,
relating to depth of anesthesia.3 Evidence for pEEG in reduc-
ing episodes of awareness under anesthesia has been mixed in
the general surgical population.143-146 pEEG indices will be
influenced by pharmacologic regimens, degree of surgical
stimulus, and preexisting cognitive function, as well as physio-
logic and metabolic derangements, both intentional and unin-
tentional, which are commonplace in cardiovascular
anesthesia.141
Intraoperative bispectral index (BIS) monitoring, in noncar-
diac surgery, has been demonstrated to have anesthesia-spar-
ing effects and both propofol and volatile agents have been
shown to be associated with increased incidence of POD,
POCD, and dementia, as well as biochemical antecedents of
these outcomes.147-158 This sparing effect may explain how
pEEG monitoring can reduce intraoperative vasopressor
requirements, which, in turn, may influence cerebral perfu-
sion.159 There is mixed evidence from patients undergoing
carotid endarterectomy regarding the use of BIS monitoring in
detecting cerebral ischemia.160-163
Large RCTs and a Cochrane Review suggested that BIS-
guided anesthesia may reduce POD, largely based on noncar-
diac surgery data.158,164,165 A small single-center study in car-
diac surgical patients found a trend for a reduced incidence of
POD in patients undergoing BIS-guided anesthesia, but this
did not reach statistical significance.166 Somewhat counterintu-
itively, in this study reduced anesthetic dose was associated
with increased POD, which the authors attributed to the attend-
ing anesthesiologist correctly identifying the high-risk patient,
and exposing the patient to lower-dose anesthesia, without a
necessary improvement in outcome.166
 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
Bilaterally monitored BIS has been shown to be signifi-
cantly lower in cardiac surgery patients developing POD than
in their nondelirious counterparts.167 However, it should be
remembered that hypnotic depth is not necessarily represented
by a linear scale, due to neural hysteresis and neurobiologic
differences among individuals.141,168,169 The most recent
reviews and meta-analyses have demonstrated contrasting
findings in the ability of EEG-guided anesthesia to reduce
POD and POCD.170-172 Nevertheless, pEEG-guided anesthesia
still may prove appealing to clinicians, with other objective
clinical signs being unreliable during CPB.173
Aside from specifically guiding depth of anesthesia, pEEG
devices can be used to detect cortical burst suppression, which
is associated with POD in cardiac surgery patients.136 Prior to
the onset of burst suppression in CPB patients, there markedly
decreased alpha- and beta-wave power, which could poten-
tially be used as a marker for susceptibility for burst suppres-
sion and hence POD, and, thus, denotes a point at which to
intervene.174 However, alpha power can be altered by comor-
bid conditions in cardiac surgical patients under general anes-
thesia, with profound implications for its use in guiding depth
of hypnosis.175 Similarly, elderly patients, who represent a
sizeable proportion of cardiac surgical patients, often display
reduced frontal alpha power under anesthesia, which can lead
to misinterpretation of depth of anesthesia.141
Conclusion—EEG
The unprocessed EEG can be used to detect cerebral
ischemia but requires skilled interpretation, a normal pre-
operative waveform, stable depth of anesthesia, and a lack
of external interference. These factors currently limit its
use as a neuromonitor, despite its potential to intra- and
postoperatively detect both clinical and subclinical
derangement of electrophysiology.
Processed EEG devices provide a markedly simpler clini-
cian-monitor interface, but remain susceptible to the influence
of preexisting cognitive function and pharmacologic and phys-
iologic factors, as well as surgical stimulus. However, in con-
trast to the apparent simplicity of the dimensionless number
supplied by the device, is the complicated neurobiologic pro-
cess it is meant to represent, and this perhaps explains the lack
of definitive evidence for or against its use in cardiac surgery.
There is marked heterogeneity in the data collected in the car-
diac surgery cohort, and observational data and the results of a
recent systematic review suggest that it should be examined
further.
Multimodality Monitoring and Other Monitoring
Techniques
There is no current ideal single neuromonitor, and each
device has strengths and limitations. Although some call to
abandon such devices, others advocate the use of single devi-
ces, or even multimodality monitoring strategies, the virtues of
which have been espoused by a recent review in pediatric car-
diac surgery.64,68,176
2107
One large retrospective, observational study of 1,721
patients demonstrated a significantly lower incidence of major
perioperative neurologic complications when multimodal
monitoring (including bipolar EEG, compressed spectral anal-
ysis of EEG, bilateral somatosensory-evoked potentials
[SSEPs], TCD, and SjO2 monitoring) was used, compared
with no monitoring.177 A subsequent study examined a moni-
toring array of NIRS, TCD, and BIS in a cohort of patients
undergoing cardiac surgery on CPB, reporting a complex inter-
play among the individual device readings, and concluding
that cerebral oxygenation and hemodynamics and prediction
of postoperative function were too complex for a single modal-
ity. Delineating the shortcomings of each device, they reported
that TCD values had a wide interindividual variability, NIRS
had low spatial resolution, and BIS, unsurprisingly, was
markedly affected by interaction with anesthetic agents.120
Concomitant use of pEEG and NIRS was shown to have use
in predicting POD, with delirious patients having longer and
more frequent periods of EEG suppression or significantly
lower nadir rSO2 values. However, there was no impact of
combined desaturation and EEG suppression on POD or
POCD incidence (although there was intervention to reduce
cerebral desaturation), and, therefore, the use of both monitors
simultaneously may not be for identifying a characteristic mul-
timodal pattern that predicts POD/POCD, but rather in detect-
ing the individual abnormality that places that patient at
risk.178 Similarly, NIRS and SjO2 monitoring have been used
concomitantly, with both measuring cerebral oxygenation and
helping predict POCD, but this does not imply interchange-
ability.179 Furthermore, a recent pilot study examining simul-
taneous use of BIS and NIRS monitoring demonstrated a
significant reduction in the incidence of POD, which crucially
was targeted individually to maintain satisfactory readings in
both modalities.180 A multicenter RCT will be of great interest
to the development of any multimodality strategies.
Other neuromonitoring modalities include somatosensory-
evoked potentials, auditory-evoked potentials, and intravenous
microdialysis of cerebral venous outflow blood. These have
limited evidence for reducing incidence of neurocognitive dys-
function, and, given their current largely experimental value,
lie outside the scope of this review.172,181,182
Conclusions
Neurocognitive dysfunction following cardiac surgery, pre-
senting in any of its various guises, poses a significant burden
to healthcare services and individual patients. The use of
advanced monitoring techniques, if they can reduce this bur-
den of disease, would be highly desirable. Comparison across
these modalities is made in Table 3.
The authors have considered the most recent clinical trials in
this review, including meta-analyses and guidelines, and con-
clude that there is still a paucity of high-quality RCT evidence
for any of the discussed modalities. NIRS has been investi-
gated most extensively, and has understandable appeal, being
noninvasive and simple to interpret. Furthermore, it has a
rational algorithm-based response to an unsatisfactory value

Table 3
Comparison Across the Different Modalities of Cerebral Monitoring, Including Advantages and Disadvantages
Facets of Assessment
NIRS
Assessment and Provided Value Regional cerebral oxygen saturation
Output Value Numerical percentage saturation
Output Requiring Action rSO2 declines 20% from baseline or
<50% absolute value
Site Unilateral or bilateral frontal region
Invasiveness Noninvasive; adhesive emitter/
detector (except UT-NIRS)
Continuous Monitor Yes
Additional Technical Support/Skill No
Required
Association with Neurocognitive Preoperative value indicates high-risk
Outcomes for POD.
Cerebral desaturation associated
with POD/POCD.
Intervention to improve rSO2 is
associated with reduced incidence
of POCD.
Conflicting evidence regarding
CVA.
Other Advantages Simple interface/interpretation.
Trend or absolute rSO2 values
depending on device.
Most extensive literature base for
significance of desaturation and
interventions.
Association with outcomes as
previously noted, as well as
potential to delineate limits of
cerebral autoregulation.
Other Disadvantages Poor interchangeability of devices
(and values)
Studies assess both technology and
intervention, which may confound
assessment
Study conclusions are limited by
chosen outcomes, follow-up
windows, and underpowering.
rSO2 value reflects a small area of
cortical tissue (in watershed area).
Does not indicate the likely site/
cause of low saturation.
Potential for extracerebral
contamination.
Abbreviations: CVA, cerebrovascular accident; EEG, electroencephalography; MCA, middle cerebral artery; NIRS, near-infrared spectroscopy; POCD, postoperative cognitive dysfunction; POD, postoperative
delirium; rSO2, regional cerebral saturation; SjO2, jugular venous bulb saturation; UT-NIRS, ultrasound-tagged near-infrared spectroscopy.
Jugular Venous Bulb Saturation
Global brain venous saturation
Numerical percentage saturation
SjO2 <50% warrants intervention
Unilateral (dominant internal jugular
vein)
Invasive (sited in internal jugular
vein)
Yes (if oximeter-tipped catheter used)
Not necessary, but placement may be
unfamiliar
Low intraoperative values are
associated with POCD.
Sampling via catheter permits
measurement of oxygen tension.
Anesthesiologists unlikely to be
familiar with placement of catheter.
Measures global oxygenation,
without reference to specific cause,
and interpretation is more complex
than rSO2 (and requires consistent
physiological status).
Susceptible to anatomical variants.
Best considered as a trend monitor.
Neuromonitoring Modality
Transcranial Doppler
Localized cerebral blood flow
Flow velocity
Reduction in flow velocity
Unilateral, usually over MCA
Noninvasive; transducer
Yes
Requires skill to find correct
insonation window and interpret
Hyperperfusion may be associated
with POD.
MCA hypoperfusion is associated
with POCD.
Unclear significance of emboli
detection.
Useful for correction of mechanical
causes of reduced flow velocity and
hemispheric flow asymmetry.
Detects spectrum of abnormalities
(embolic material, hypo  and
hyperperfusion).
Requires skilled placement and
interpretation.
Signal may be lost during surgery.
EEG
Global superficial cortex electrical
activity
Unprocessed electroencephalograph
Slowing of EEG/burst suppression,
characteristic patterns have been
described
Over whole cranium
Noninvasive; adhesive electrodes
Yes
Requires skilled interpretation, time-
consuming to site
Burst suppression is associated with
POD and POCD.
Detects global and regional ischemia,
with relative specificity.
More extensive assessment of the
cortex than NIRS.
Despite advantages, it remains a
monitor of the superficial layer of
the cortex.
For optimal use requires stable
depth of anesthesia, and normal
preoperative trace, and trace will be
affected by hypothermia and
medications.
Interference can occur from
equipment.
2108
Processed EEG
Regional cortical electrical activity
Numerical (dimensionless) value
Burst suppression
B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
Frontal/temporal region
Noninvasive; adhesive electrodes
Yes
No
Anesthesia-sparing may be protective
against POD/POCD.
Burst suppression is associated with
POD.
Simple to set up and interpret.
Already part of the “anesthetic
cockpit” as part of depth of
anesthesia monitoring.
Anesthesia-sparing effect may have
other (non-neurocognitive) benefits,
including cardiovascular stability.
Relies on proprietary algorithms.
Influenced by medications, as well
as metabolic and physiological
status.
Most evidence from noncardiac
studies.
Likely to have relatively low
sensitivity for ischemia.
 B. Milne et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 20982113
that has become commonplace not only in academic but also in
clinical practice. However, therein lies one of the complicating
factors of this technology. Although low preoperative values
suggest a tendency to develop POD, and a significant desatura-
tion-time load is associated with development of POD and
POCD, the ability to reduce the incidence of neurocognitive
dysfunction is not reproducible across all studies, even when
the intraoperative numeric values have been improved. Evalu-
ation of NIRS technology is a simultaneous assessment of the
significance of the cerebral desaturation, the effect of reversing
the desaturation, and the interventional bundle with which this
is achieved, all while the threshold values remain somewhat
unclear. Given the potential benefits of this modality, the
promising findings of some studies, and the results of recent
(but small) systematic reviews and a network meta-analysis, it
appears reasonable not to abandon NIRS monitoring until large
RCT evidence suggests this course of action.
The evidence for TCD and jugular venous bulb saturation
monitoring currently appears somewhat dated or removed
from immediate clinical relevance. However, the EEG, in
processed and unprocessed formats, is becoming an increas-
ingly examined topic, as a pure monitor of cerebral function, a
surrogate monitor of cerebral oxygenation, and as a depth-of-
anesthesia monitor. Recent evidence relating to the use of
BIS-guided depth of anesthesia and its impact on POD and
POCD in the cardiac surgical cohort suggests that this would
be an appropriate topic for further investigation, certainly
given that, similar to the NIRS monitors, it is noninvasive,
simple to interpret, and a suboptimal value prompts a very sim-
ple response. Indeed, if multimodality monitoring is to be fur-
ther explored, these two techniques may improve
postoperative outcomes, if simultaneously used.
Furthermore, although additional high-quality investigation
of these devices, in isolation or concurrently, would be most
welcome, future trials should ensure the use of consensus defi-
nitions of postoperative neurocognitive pathologies, follow
standardized batteries of neuropsychometric testing, and
ensure homogeneous patterns of follow-up. In doing so, this
will increase the relevance of individual studies, and enable
post-hoc larger-scale systematic review and meta-analysis,
thus rectifying the deficiencies of the current evidence base.
Conflict of Interest
Gudrun Kunst has received speaker fees from Liva Nova
and Edwards.
Supplementary materials
Supplementary material associated with this article can be
found in the online version at doi:10.1053/j.jvca.2021.07.029.
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