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Cardiopulmonary Bypass
Luc Rondelez, Philippe Linden
Critical Care , 2010, DOI: 10.1186/cc8900
Abstract: This 207-pages work includes 15 chapters, is well illustrated and contains a lot of tables and interesting diagrams. The first chapters present the equipment and the preparation of the cardiopulmonary bypass (CPB) circuit, the conduct of the bypass and the process of weaning from mechanical to physiological circulation. Two chapters describe the management of the hemostatic and metabolic consequences of the CPB circuit. One chapter is dedicated to myocardial protection. The effects of extracorporeal circulation on the body are described, with particular attention to the brain and the kidney, two organs at high risk of complication after CPB. Mechanical circulatory support, deep hypothermic circulatory arrest and extracorporeal membrane oxygenation are described in specific chapters. The last chapter describes CPB in noncardiac procedures, such as thoracic aortic surgery, pulmonary embolism, hepatic and pulmonary transplantation, major oncologic surgery, and trauma. The editors and authors are UK and US anesthetists, perfusionists and surgeons with recognized expertise in the field of CPB.This book covers most of the topics related to the management of CPB - in adults. Unfortunately, there is no chapter dealing specifically with pediatric CPB.The information provided in this book is relatively basic, and is less complete than in many textbooks on the subject. Several chapters refer to relatively old concepts of perfusion that have been challenged since (that is, the use of crystalloids as the priming fluid, management of the on-bypass hematocrit on bypass, overview of the coagulation cascade, and so forth). Little information is provided about new perfusion approaches such as the Heart Port? technique, the mini-bypass technique, the different coating options of the bypass circuitry, the different mechanical circulatory support devices, and so forth. In this field, the more recent strategies are not described.Each chapter ends with suggested further reading that most
Sex steroids in cardiopulmonary bypass
Andreas Trotter, Hans-J?rg Grill, Wolfgang Hemmer, Andreas Hannekum, Dieter Lang
Critical Care , 1997, DOI: 10.1186/cc109
Abstract: Plasma estradiol and progesterone levels before and immediately after CPB were measured in 11 patients. During CPB, mean estradiol levels decreased from 29 to 15 pg/ml and progesterone levels rose from 0.13 to 0.90 ng/ml. These changes were statistically significant.These are the first preliminary results evaluating plasma levels of sex steroids during CPB. Whether alterations in estradiol and progesterone levels influence complement and cytokine activation during bypass or vice versa is currently being investigated.Several studies have shown interactions between sex steroids and cytokines. In female mice, estradiol demonstrated a protective effect on interleukin-1-induced cartilage breakdown [1]. High progesterone levels decreased interleukin-6 production in gingival fibroblasts [2]. In a recent randomized, controlled animal study, polymicrobial sepsis was induced using the model of cecal ligation and subsequent puncture. Splenic immune function and survival rates were significantly better in female animals [3]. The immunomodulatory effects of sex steroids have been confirmed by clinical observation of a higher incidence of mortality in boys after thermal burns [4].We previously studied, in an experimental setting, the ability of 3H-marked estradiol and progesterone, in solution with lipids, to absorb on to synthetic surfaces such as the bypass circuit. Both steroids adsorbed on to the synthetic surface, with a higher adsorption for progesterone than for estradiol (unpublished data). Prior to this study, no data existed on the behavior of sex steroids passing through a bypass circuit during CPB, where a considerable amount of synthetic surface is present.We analyzed 11 patients (three female) with a median age of 66.8 years undergoing cardiac surgery with CPB mainly for coronary repair. The non-pulsatile technique was used, with slight hypothermia of 32–34oC depending on the duration of CPB. The median duration of CPB was 85 min (range 40–115 min). No corticoids we
Trimetazidine and Cellular Response in Cardiopulmonary Bypass*  [PDF]
Gerez Fernandes Martins, Aristarco G. de Siqueira Filho, Jo?o Bosco de F. Santos, Claudio Roberto Cavalcanti Assun??o, Alberto Valência, Gerez Martins
World Journal of Cardiovascular Surgery (WJCS) , 2013, DOI: 10.4236/wjcs.2013.35035
Abstract: Background: Organic cellular inflammatory response constitutes a pathophysiological mechanism present in all Coronary Artery Bypass Graftings (CABGs). In this aspect, the organism brings forth its defenses through answers that involve cellular components. Objectives: To evaluate, in a randomized double-blind prospective study, controlled with placebo, the effects of trimetazidine (Tmz) on cellular response, analyzed through the variation of leukocytes, neutrophils and monocytes. Patients and Method: 30 patients were randomly selected to be studied, with no more than a mild ventricular dysfunction, and divided into two groups (Tmz and placebo) stratified by echocardiography and receiving medication/placebo in a 60 mg/day dose. The samples of leukocytes, neutrophils and monocytes were obtained in the pre-operatory day without medication, at surgery day with 12 to 15 days of medication/placebo, with 5 minutes after the aortic declamping, and within 12, 24 and 48 hours after surgery. Results: The leukocytes and neutrophils levels have decreased significantly in the treated group when compared to the control group, in all analyzed moments (p = 0.012; p = 0.005). Conclusions and Clinical Implications: Trimetazidine has proved to reduce significantly the levels of total leukocytes and neutrophils in patients submitted to CABG.
Hyperlactatemia during cardiopulmonary bypass: determinants and impact on postoperative outcome
Marco Ranucci, Barbara De Toffol, Giuseppe Isgrò, Federica Romitti, Daniela Conti, Maira Vicentini
Critical Care , 2006, DOI: 10.1186/cc5113
Abstract: Five hundred consecutive patients undergoing cardiac surgery with cardiopulmonary bypass were admitted to this prospective observational study. During cardiopulmonary bypass, serial arterial blood gas analyses with blood lactate and glucose determinations were obtained. Hyperlactatemia was defined as a peak arterial blood lactate concentration exceeding 3 mmol/l. Pre- and intraoperative factors were tested for independent association with the peak arterial lactate concentration and hyperlactatemia. The postoperative outcome of patients with or without hyperlactatemia was compared.Factors independently associated with hyperlactatemia were the preoperative serum creatinine value, the presence of active endocarditis, the cardiopulmonary bypass duration, the lowest oxygen delivery during cardiopulmonary bypass, and the peak blood glucose level. Once corrected for other explanatory variables, hyperlactatemia during cardiopulmonary bypass remained significantly associated with an increased morbidity, related mainly to a postoperative low cardiac output syndrome, but not to mortality.Hyperlactatemia during cardiopulmonary bypass appears to be related mainly to a condition of insufficient oxygen delivery (type A hyperlactatemia). During cardiopulmonary bypass, a careful coupling of pump flow and arterial oxygen content therefore seems mandatory to guarantee a sufficient oxygen supply to the peripheral tissues.Hyperlactatemia (HL) is a well-recognized marker of circulatory failure, and its severity has been associated with mortality in different clinical conditions [1,2]. After cardiac surgery, HL is relatively common [3,4] and is associated with morbidity and mortality [4]. During cardiac surgery with cardiopulmonary bypass (CPB) in adult patients, HL is detectable at a considerable (10% to 20%) rate [5,6] and is associated with postoperative morbidity and mortality [5]. At present, the nature of HL during and after cardiac operations is not totally clear, but the majority
Cardiopulmonary Bypass for Tracheal Resection and Repair—A Safe Alternative  [PDF]
Akshay Chauhan, Satish Kumar Aggarwal, Vishnu Dutt, Saket Agarwal, M. A. Geelani
World Journal of Cardiovascular Surgery (WJCS) , 2018, DOI: 10.4236/wjcs.2018.811019
Abstract: Airway management during tracheal surgery is always challenging for the anaesthesia team. Cardiopulmonary bypass (CPB) is generally not required during tracheal surgery on the cervical trachea. However, for tracheal surgeries CPB may be advantageous and give the surgeon more freedom to work. We report three cases of post-intubation tracheal stenosis successfully managed with tracheal resection and reconstruction performed under cardiopulmonary bypass.
Effects of inosine on reperfusion injury after cardiopulmonary bypass
Gábor Veres, Tamás Radovits, Leila Seres, Ferenc Horkay, Matthias Karck, Gábor Szabó
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-106
Abstract: Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass. After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or inosine (100 mg/kg, n = 6). Left ventricular end-systolic pressure volume relationship (ESPVR) was measured by a combined pressure-volume-conductance catheter at baseline and after 60 minutes of reperfusion. Left anterior descendent coronary blood flow (CBF), endothelium-dependent vasodilatation to acetylcholine (ACh) and endothelium-independent vasodilatation to sodium nitroprusside (SNP) were also determined.The administration of inosine led to a significantly better recovery (given as percent of baseline) of ESPVR 90 ± 9% vs. 46 ± 6%, p < 0.05. CBF and was also significantly higher in the inosine group (56 ± 8 vs. 23 ± 4, ml/min, p < 0.05). While the vasodilatatory response to SNP was similar in both groups, ACh resulted in a significantly higher increase in CBF (58 ± 6% vs. 25 ± 5%, p < 0.05) in the inosine group.Application of inosine improves myocardial and endothelial function after cardiopulmonary bypass with hypothermic cardiac arrest.Ischemia-reperfusion injury is a well-known phenomenon after cardiac surgery. Independent of the technique of cardioplegia, temporary dysfunction of biventricular contractility can frequently be observed. Even if cardiac dysfunction is not clinically evident, a reduction of myocardial contractility may occur as described in a study in humans using pressure-volume relationships [1]. In addition, coronary endothelial dysfunction may further complicate the postoperative course.Extra-corporal circulation is also known to induce a systemic inflammatory reaction with free radical release leading to secondary organ injury. During ischemia, cellular ATP is degraded into AMP, adenosine, inosine and hypoxanthine. Adenosine and its primary metabolite inosine are ubiquitous nucleosides that can be released from ischemic or reperfused t
Predicting the need for blood during cardiopulmonary bypass : research
AR Coetzee, JF Coetzee
Southern African Journal of Anaesthesia and Analgesia , 2005,
Abstract: Background: Haematocrit (Hct) values <18%-20% during cardiopulmonary bypass (HctCPB ) are potentially unsafe. Aims: 1. To predict when bankedblood should be pre-issued. 2. To evaluate the sparing-effect of banked-blood by autologous blood transfusions. Methods: An equation for prediction of HctCPB (Hctpred), based on weight and pre-operative haemoglobin concentration was used to forecast which patients would develop HctCPB < 20%. Perioperative blood and fluid administration were recorded in 80 patients requiring CPB. Blood and fluid administration strived for HctCPB >18% on CPB and 33% in the ICU. Results: Hctpred bias and precision were 2.6% and 13.1%. A Hctpred cut-off value of 23% reliably forecast a HctCPB < 20% (15 patients with mean HctCPB 16.5%). Despite a 31% false positive rate (FPR), there is emphasis on safety associated with the 23% Hctpred cutoff-point. (100% negative predictive value; zero negative likelihood ratio). Applying the same predictive criterion to all blood transfusions performed in the OR, increased positive predictive values from 43% to 63% so that the FPR decreased to 24%. Autologous transfusion comprised 72% of transfused blood and was the only transfusion in 67% of patients. Banked-blood recipients weighed less and had lower pre-operative haemoglobin concentrations, Hctpred and HctCPB . They received larger transfusions of which autologous blood formed 46%. Conclusions: 1. It is possible to predict which patients will develop potentially low HctCPB . 2. Autologous transfusions result in considerable reduction of banked blood usage. Key Words: Haematocrit, Blood transfusion, Autologous, Cardiopulmonary bypass, ROC curve, Predictive value of tests Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 7-13
CARDIAC OUTPUT AFTER REVASCULARIZATION OF MYOCARDIUM WITHOUT THE USE OF CARDIOPULMONARY BYPASS
Suad Keranovic,Farid Ljuca,Jasmin Caluk
Acta Medica Saliniana , 2008, DOI: 10.5457/ams.66.08
Abstract: Introduction: Cardiac output is the amount of blood pumped out from left ventricle into systemic circulation within one minute, i.e. product of stroke volume and heart rate. Coronary artery disease occurs as a consequence of reduced blood flow to heart muscle due to partial or total coronary artery obstruction by atherosclerosis or coronary thrombosis. Surgical revascularization of myocardium is performed with or without the use of cardiopulmonary bypass. Goal: to find the values of cardiac output, cardiac index, stroke volume, and heart rate before and after surgical revascularization of myocardium. Patients and methods: research was conducted as a retrospective study in Cardiovascular Clinic of University Clinical Centre in Tuzla on a sample of 60 patients subjected to surgical revascularization of myocardium. The first group consisted of 30 patients in which the revascularization was performed without the use of cardiopulmonary bypass, and the second group consisted of 30 patients in which the revascularization was performed witht the use of cardiopulmonary bypass. Haemodynamic parametres were measured and analyzed in all patients before and after the revascularization procedure. Results and Discussion: cardiac output after revascularization of myocardium without the use of cardiopulmonary bypass was increased by 13.62% (p< .05), cardiac index was increased by 13.64% (p< .05), and stroke volume was increased by 8.24% (p< .05) compared to preoperative values. Heart rate was increased by 5.2% (p< .05). After revascularization of myocardium with the use of cardiopulmonary bypass, cardiac output was decreased by 9.3% (p> .05), and cardiac index was decreased by 9.25% (p> .05) compared to preoperative values. Conclusion: values of haemodynamic parametres after revascularization of myocardium without the use of cardiopulmonary bypass are significantly better compared to the ones after revascularization of myocardium with the use of cardiopulmonary bypass.
Ketamine has no effect on oxygenation indices following elective coronary artery bypass grafting under cardiopulmonary bypass  [cached]
Parthasarathi Gayatri,Raman Suneel,Sinha Prabhat,Singha Subrata
Annals of Cardiac Anaesthesia , 2011,
Abstract: Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.
Effect of cardiopulmonary bypass on the pharmacokinetics of propranolol and atenolol
Carmona, M.J.C.;Pereira, V.A.;Malbouisson, L.M.S.;Auler Jr., J.O.C.;Santos, S.R.C.J.;
Brazilian Journal of Medical and Biological Research , 2009, DOI: 10.1590/S0100-879X2009000600016
Abstract: the pharmacokinetics of some β-blockers are altered by cardiopulmonary bypass (cpb). the objective of this study was to compare the effect of coronary artery bypass graft (cabg) surgery employing cpb on the pharmacokinetics of propranolol and atenolol. we studied patients receiving oral propranolol with doses ranging from 80 to 240 mg (n = 11) or atenolol with doses ranging from 25 to 100 mg (n = 8) in the pre- and postoperative period of cabg with moderately hypothermic cpb (32°c). on the day before and on the first day after surgery, blood samples were collected before β-blocker administration and every 2 h thereafter. plasma levels were determined using high-performance liquid chromatography and data were treated by pharmacokinetics-modelling. statistical analysis was performed using anova or the friedman test, as appropriate, and p < 0.05 was considered to be significant. a prolongation of propranolol biological half-life from 5.41 ± 0.75 to 11.46 ± 1.66 h (p = 0.0028) and an increase in propranolol volume of distribution from 8.70 ± 2.83 to 19.33 ± 6.52 l/kg (p = 0.0032) were observed after cabg with cpb. no significant changes were observed in either atenolol biological half-life (from 11.20 ± 1.60 to 11.44 ± 2.89 h) or atenolol volume of distribution (from 2.90 ± 0.36 to 3.83 ± 0.72 l/kg). total clearance was not changed by surgery. these cpb-induced alterations in propranolol pharmacokinetics may promote unexpected long-lasting effects in the postoperative period while the effects of atenolol were not modified by cpb surgery.
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