• Philip J Pries, MutchW Alan CWACDepartment of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada., and Duane J Funk.
• Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada.
• J Clin Monit Comput. 2025 Feb 7.

AbstractRegional cerebral oxygen saturation (rSO2) is used to monitor cerebral perfusion with emerging evidence that optimization of rSO2 may improve neurological and non-neurological outcomes. To manipulate rSO2 an understanding of the variables that drive its behavior is necessary, and this can be accomplished using supervised machine learning. This study aimed to establish a hierarchy by which various hemodynamic and ventilatory variables contribute to intraoperative changes in rSO2. A post-hoc analysis 146 patients undergoing high risk surgery. rSO2 was partitioned into segments with a change of at least 3% points over 5 min. Features from hemodynamic and ventilatory variables were used to train a machine learning classification algorithm (XGBoost) for prediction of association with either up or down-sloping rSO2. The classifier was optimized and validated using five-fold cross validation. Feature importance was quantified based on information gain and permutation feature importance. The optimized classifier demonstrated a mean accuracy of 77.1% (SD 8.0%) and a mean area-under-ROC-curve of 0.86 (SD 0.06). The most important features based on information gain were the slope of the associated ETCO2 signal, the slope of the SPO2 signal, and the mean of the MAP signal. CO2 is a significant mediator of changes in rSO2 in an intraoperative setting, through its established effects on cerebral blood flow. This study furthers our overall understanding of the complex physiologic process that governs cerebral oxygenation by quantifying the hierarchy by which rSO2 is affected. Clinical Trial Number NCT01838733 (ClinicalTrials.gov).© 2025. The Author(s), under exclusive licence to Springer Nature B.V.

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