Monitoring of cerebral autoregulation during major surgery in adults, including cardiac surgery: mechanisms, anesthetic impacts, and clinical applications.

BACKGROUND: Cerebral autoregulation (CA) is a critical neuroprotective mechanism that maintains stable cerebral blood flow across varying blood pressure (BP). The perioperative period disrupts CA through anesthetic and surgical interventions, yet standardized monitoring protocols are lacking in adult major surgery. FINDINGS: Evidence demonstrates that anesthetic choice significantly modulates CA. Total intravenous anesthesia better preserves autoregulation compared to volatile agents. Surgical factors-including cardiopulmonary bypass, patient positioning, and procedure duration-further influence CA integrity. Near-infrared spectroscopy-derived cerebral oximetry index (COx) provides the most practical approach for routine perioperative CA monitoring. Personalized BP management based on autoregulation thresholds optimizes cerebral perfusion and reduces neurological complications, as shown in cardiac surgery. CONCLUSION: Integrating CA-preserving anesthetic techniques with real-time monitoring represents a promising strategy for precision perioperative care. Future validation through large-scale randomized trials is essential to establish standardized protocols and confirm effects on patient-centered outcomes.