Oximetry-Derived Perfusion Index for Intraoperative Identification of Successful Thoracic Sympathectomy

doi:10.1016/j.athoracsur.2005.02.075

The Annals of Thoracic Surgery

Volume 80, Issue 2, August 2005, Pages 467-470

Presented at the Poster Session of the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

https://doi.org/10.1016/j.athoracsur.2005.02.075 Get rights and content

Background

Endoscopic thoracic sympathectomy treats patients with hyperhidrosis. Laser Doppler flow and changes in palmar temperature have been advocated for intraoperative monitoring. The pulse oximetry-derived perfusion index (PI) is used to quantify pulsatile blood flow at the pulse oximeter. Upper limb sympathectomy is associated with increased flow to the ipsilateral extremity; thus we postulate that it will increase PI. We evaluated changes in intraoperative PI as a monitor of successful thoracic sympathectomy.

Methods

After institutional review board approval and informed consent, 10 adult patients undergoing bilateral endoscopic thoracic sympathectomy under general anesthesia were studied. Finger pulse-oximetry probes were placed on each hand, and reference probes on each earlobe. Hemodynamic variables and PI were continuously monitored. Data were collected immediately before and every minute after sympathectomy for 5 minutes. Anesthetic management remained constant throughout. A successful sympathectomy was defined by a twofold increase in PI on the ipsilateral arm. Data were analyzed with analysis of variance and Student’s t tests; a p < 0.05 was considered significant.

Results

Baseline oximetric waveforms were adequate in all subjects. Right sympathectomy was associated with a 372% increase in PI (p < 0.0001), and left sympathectomy with a 316% increase in PI (p < 0.029). This occurred as early as 1 minute after transection of the sympathetic chain. The PI in the reference probes as well as the hemodynamics remained constant. All patients had postoperative resolution of their hyperhidrosis symptoms.

Conclusions

In patients with hyperhidrosis of the upper extremity, the intraoperative PI derived from pulse oximetry is an additional indicator of successful thoracic sympathectomy.

Section snippets

Material and Methods

After institutional review board approval and signed informed consent, 10 adult subjects were studied. The duration of preoperative symptoms ranged from 1 to 23 years, and all patients had used at least one noninvasive treatment for hyperhidrosis. No patient had previously undergone surgical treatment for hyperhidrosis, and all suffered from bilateral symptoms. All patients underwent surgical thoracic sympathectomy for upper limb hyperhidrosis under general anesthesia.

Results

There were 5 men and 5 women with an average age of 22.4 years (range, 10 to 38 years). Average height for the men was 179 cm (range, 170 to 196 cm), whereas for the women it was 164 cm (range, 150 to 170 cm). Average weight for the male group was 85.3 kg (range, 72.1 to 104 kg), whereas for the female group it was 55.8 kg (range, 41.7 to 65.3 kg). No patient had diabetes, any history of upper extremity trauma, hypertension, Raynaud symptoms, vascular disease, or oral vasodilator use. Oximetric

Comment

Several trials have reported a high success rate for endoscopic thoracic sympathectomy [5, 6, 7, 8]; however, some patients do not experience long-term relief, suggesting the possibility of incomplete sympathectomy [9]. A minimally invasive approach using video thoracoscopy is the most commonly performed surgical procedure in this country for refractory hyperhidrosis [10]. Endoscopic thoracic sympathectomy has an excellent safety record, although its efficacy is only established in the

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Does Radial Artery Cannulation Affect the Perfusion of the Dominant Hand in Adult Patients with Normal Modified Allen's Test Undergoing Cardiac Surgeries? Data Derived from the Peripheral Perfusion Index
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This study aimed to evaluate the effect of radial artery cannulation on hand perfusion in patients with normal modified Allen's test undergoing cardiac surgeries using cardiopulmonary bypass (CPB).
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The primary outcomes were the mean peripheral perfusion index (PPI) >60 seconds (mean PPI₆₀) and the thumb temperature, which were measured at different times before and during the surgery. There was a statistically significant difference in the mean PPI₆₀ between both hands (p = 0.033). Before skin incision, the mean PPI₆₀ was significantly higher in the noncannulated hand (p < 0.001). Also, there was a statistically significant difference in the thumb temperature between both hands (p = 0.013). At low core body temperature, the thumb temperature was significantly lower in the noncannulated hand (p = 0.017).
In adult patients undergoing cardiac surgeries using CPB, even with normal modified Allen's test, radial artery cannulation may affect the perfusion of the dominant hand, especially at low arterial blood pressure or low core body temperature. Since the PPI is one of the noninvasive methods used for intraoperative assessment of the peripheral perfusion, the authors recommend the use of the noncannulated hand for this purpose to not misguide this assessment.
Pulse perfusion index for predicting intrapartum fever during epidural analgesia
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This index is a reliable and sensitive indicator for estimating vasodilation [9] or vasoconstriction [10]. Given the characteristics of the PI, it is clinically used to determine pharmacological sympathetic nerve block depth, including the success of sympathetic ganglion block [11], epidural block [12], and brachial plexus block procedures [13], as well as the depth of general anesthesia [14]. Currently, the mechanisms mediating the occurrence of ERMF remain insufficiently investigated.
To assess whether pulse perfusion index (PI) values could be employed to predict intrapartum fever and to provide a cut-off PI value for predicting intrapartum fever occurrence.
We conducted a single-center, prospective, observational study.
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We found that peak temperature (T_P) occurred at the end of the second or the third stage of labor. Within 30 min after analgesia, the PI showed a significant increase over time and there was a linear correlation between PI₃₀ and T_P values (P < 0.001, r = 0.544). The PI₁₀, PI₂₀, PI₃₀ and PI change rate in febrile parturients were higher than those in afebrile parturients (P < 0.001). The area under the ROC (AUROC) for PI₃₀ was 0.818 (P < 0.001) with a cut-off of 9.30. The AUROC of the PI change rate was 0.738 (P < 0.001) with a cut-off of 3.45.
PI₃₀ and PI change rate values could be used to predict intrapartum fever in parturients after epidural analgesia.
Comparison of vasodilatory properties between desflurane and sevoflurane using perfusion index: a randomised controlled trial
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The perfusion index (PI), calculated from the photoplethysmographic waveform, reflects peripheral vasomotor tone. As such, the PI serves as a surrogate for quantitative measures of drug-induced vasoconstriction or vasodilation. This study aimed to compare the effect on the PI of desflurane and sevoflurane at equi-anaesthetic concentrations in patients undergoing single-agent inhalation anaesthesia, where equi-anaesthetic dose was based on the known minimum alveolar concentration of these agents.
We randomly allocated patients scheduled for arthroscopic knee surgery to receive either desflurane or sevoflurane general anaesthesia after target-controlled induction of anaesthesia with propofol. Anaesthesia was maintained at age-corrected minimum alveolar concentration 1.0, under neuromuscular block (rocuronium). The PI and haemodynamic data were recorded every minute for 35 min after induction of anaesthesia and after standardised nociceptive stimulation. The primary outcome was PI, compared between the groups over time (repeated-measures analysis of variance). Secondary outcomes included MAP and HR.
Sixty-nine participants (mean [range] age: 42 yr [19–65 yr]; 49% females) were assigned to either desflurane (n=34) or sevoflurane (n=35). The PI remained higher under desflurane compared with sevoflurane, both before (mean difference [MD]: 3.3; 95% confidence intervals [CIs]: 2.0–4.7; P<0.001) and after tetanic stimulation (MD: 2.8; 95% CI: 2.0–3.7; P<0.001). Higher PI paralleled lower MAP in participants assigned to desflurane anaesthesia (P<0.001), both before (MD: 8 mm Hg; 95% CI: 4–12) and after nociceptive stimulation (MD: 14 mm Hg; 95% CI: 7–22). HR was similar throughout.
These findings suggest that at equipotent doses, desflurane exerts more potent vasodilatory properties and lowers blood pressure by a magnitude potentially associated with harm.
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Preoperative anxiety is a common psychological state in cancer patients before surgery, inducing stress responses after surgery. Associations between preoperative anxiety and intraoperative nociception, however, have not been evaluated well. In the present study, we investigated the relationship in patients with lung cancer undergoing thoracic surgery.
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Predicting successful supraclavicular brachial plexus block using pulse oximeter perfusion index
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The PI can therefore be considered as an objective measure for peripheral perfusion that can predict peripheral block success. The PI was previously investigated for evaluation of different conditions of vasodilation, such as induction of anaesthesia,9 epidural block,10 stellate ganglion block,11 and successful thoracic sympathectomy.12 The PI was also investigated as a marker of sympathetic stimulation.
Supraclavicular nerve block is a popular approach for anaesthesia for upper limb surgeries. Conventional methods for evaluation of block success are time consuming and need patient cooperation. The aim of this study was to evaluate whether the perfusion index (PI) can be used to predict and provide a cut-off value for ultrasound-guided supraclavicular nerve block success.
The study included 77 patients undergoing elective orthopaedic procedures under ultrasound-guided supraclavicular nerve block. After local anaesthetic injection, sensory block success was assessed every 3 min by pinprick, and motor block success was assessed every 5 min by the ability to flex the elbow and the hand against resistance. The PI was recorded at baseline and at 10, 20, and 30 min after anaesthetic injection in both blocked and non-blocked limbs. The PI ratio was calculated as the PI after 10 min divided by the PI at the baseline. Receiver operating characteristic curves were constructed for the accuracy of the PI in detection of block success.
The PI was higher in the blocked limb at all time points, and this was paralleled by a higher PI ratio compared with the unblocked limb. Both the PI and the PI ratio at 10 min after injection showed a sensitivity and specificity of 100% for block success at cut-off values of 3.3 and 1.4, respectively.
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Perfusion Index: An Indicator of Success During Endoscopic Thoracic Sympathectomy for Hyperhidrosis
2017, Annals of Thoracic Surgery
Endoscopic thoracic sympathectomy (ETS) is indicated for refractory hyperhidrosis. The pulse oximetry–derived perfusion index (PI) quantifies pulsatile blood flow at the oximeter. Thoracic sympathectomy increases blood flow; thus we postulate it will reliably increase PI. We evaluated the ipsilateral finger PI as a predictor of successful sympathectomy during ETS.
After institutional review board approval and informed consent, 100 adult patients undergoing bilateral ETS were studied. Finger and earlobe pulse oximetry probes were placed. Hemodynamic variables and PI were continuously monitored. PI data were collected before and every minute after sympathectomy for 5 minutes and then at 10 minutes. We defined a successful sympathectomy by at least a 50% increase of the PI on the ipsilateral arm. A repeated measures analysis of variance was conducted to determine overall model significance (p ≤ 0.05).
Left sympathectomy was associated with a mean 240% increase in PI (p < 0.0001) during the first consecutive 10 minutes, whereas the right side exhibited a mean 236% increase in PI (p < 0.0001). Statistically significant differences were observed between the mean baseline PI value ± the standard error of the mean and time intervals (1, 2, 3, 4, 5, and 10 minutes after baseline) on both the left and right sides for all time intervals. The hemodynamics remained constant throughout the study period. All patients had postoperative resolution of their hyperhidrosis symptoms.
In patients with hyperhidrosis of the upper extremities, intraoperative PI derived from an ipsilateral finger pulse oximeter is an intraoperative marker for successful thoracic sympathectomy.

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Original articleGeneral thoracicOximetry-Derived Perfusion Index for Intraoperative Identification of Successful Thoracic Sympathectomy

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Auton Neurosci

Doppler-pulsatility index

Pediatrics

Real-time calculation of ultrasonic pulsatility index

Med Biol Eng Comput

A thoracoscopic view of the nerve of Kuntz

Surg Endosc

Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis

Arch Surg

Needlescopic surgery for palmar hyperhidrosis

J Thorac Cardiovasc Surg

Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations

Ann Surg

Original article
General thoracic
Oximetry-Derived Perfusion Index for Intraoperative Identification of Successful Thoracic Sympathectomy