Cannula Misplacement Causing Cerebral Desaturation

Mechanism of Injury

• Misplacement of cerebral perfusion cannula occurs more frequently than clinicians may be aware. Without continuous monitoring of cerebral regional oxygen saturation, there may be no mechanism to diagnose it.([FOOTNOTE=Rubio A, Hakami L, Munch F, Tandler R, Harig F, Weyand M. Noninvasive control of adequate cerebral oxygenation during low-flow antegrade selective cerebral perfusion on adults and infants in the aortic arch surgery. J Card Surg. 2008;23(5):474-479.],[ANCHOR=View Abstract],[LINK=/content/mitg/websites/languagemasters/emea/en-gb/support/clinical-evidence.html?id=297660])
• In 35 consecutive patients undergoing surgical repair of aortic arch aneurysm, cerebral oximetry detected acute cerebral desaturation due cannula malposition in 11.4% of patients. Cannula malposition was confirmed via orbital ultrasound.([FOOTNOTE=Orihashi K, Sueda T, Okada K, Imai K. Malposition of selective cerebral perfusion catheter is not a rare event. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2005;27(4):644-648.],[ANCHOR=View Abstract],[LINK=/content/mitg/websites/languagemasters/emea/en-gb/support/clinical-evidence.html?id=883086])
• In patient undergoing aortic arch surgery, Rubio et al determined that incorrect placement of the arterial cannula was correlated with cerebral desaturation.¹

Associated Outcome

• Cannula malposition, if undetected, may lead to cerebral ischemia and potentially irreversible brain damage.²