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  3. Cardiopulmonary Bypass
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    • Publisher:
      Cambridge University Press
      Publication date:
      December 2009
      September 2009
      ISBN:
      9780511635564
      DOI:
      https://doi.org/10.1017/CBO9780511635564
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      • Subjects:
      Anesthesia, Intensive Care, Pain Management, Pathology and Laboratory Science, Medicine, Cardiovascular Medicine
      Series:
      Cambridge Clinical Guides
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    • Selected: Digital
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    Subjects:
    Anesthesia, Intensive Care, Pain Management, Pathology and Laboratory Science, Medicine, Cardiovascular Medicine
    Series:
    Cambridge Clinical Guides
    Information

    Book description

    Cardiopulmonary Bypass provides a practical overview of all aspects of clinical perfusion, giving core knowledge and essential background information for those early in their clinical training as well as more specialist information on key areas of clinical practice. Introductory chapters cover equipment and preparation of the cardiopulmonary bypass circuit, routine conduct of bypass, metabolic and hematological management during bypass and weaning from mechanical to physiological circulation. The effect of extracorporeal circulation on the body is described, and separate chapters detail the pathophysiology of the brain and kidney, two major sources of morbidity, in the peri-operative period. Specialist chapters on Mechanical Support, ECMO and Deep Hypothermic Circulatory Arrest are also included. Edited by expert cardiac anesthetists from Papworth Hospital, UK and the Mayo Clinic, USA, and with contributions from leading perfusionists and anesthetists, Cardiopulmonary Bypass is an invaluable practical manual for any clinical perfusionist, anesthetist or surgeons managing bypass.

    Reviews

    '… good value as a introductory, easy-to-read and practical text for junior anaesthetists and trainees who would like a greater understanding of cardiopulmonary bypass.'

    Source: Anaesthesia and Intensive Care

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    Contents

    Contents
    • Chapter 8 - Weaning from cardiopulmonary bypass
      pp 92-105
    • View abstract

      Summary

      This chapter describes the standard equipment and monitoring components of the cardiopulmonary bypass (CPB) machine and extracorporeal circuit as well as additional equipment such as the suckers used to scavenge blood from the operative field, cardioplegia delivery systems and hemofilters. The tubing in the CPB circuit interconnects all of the main components of the circuit. The arterial cannula is used to connect the arterial limb of the CPB circuit to the patient and so deliver oxygenated blood from the heart-lung machine directly into the patient's arterial system. Venous cannulation for CPB allows deoxygenated blood to be drained from the patient into the extracorporeal circuit. The Terumo CDI 500 in-line blood gas analyzer is an optical fluorescence and reflectance based in-line system that continuously monitors 11 critical blood gas parameters with laboratory quality accuracy. Non-invasive simultaneous arterial and venous saturation monitors are also available for use during CPB.
    • Chapter 9 - Mechanical circulatory support
      pp 106-124
    • View abstract

      Summary

      This chapter describes the procedure for setting up the cardiopulmonary bypass (CPB) system and the safety checks that should be undertaken before embarking on a case. Preparing the CPB circuit and machine, attention to the patient's clinical details and the surgical requirements for the procedure all form part of the process of safe provision of CPB. Most operating rooms have an uninterruptible power supply (UPS), essentially a series of batteries linked to the hospital generator that powers the CPB machine, anesthetic machine, intravenous infusion pumps and other vital equipment should there be a mains power failure. The bubble detector is coupled to the CPB machine console so that if air is sensed in the arterial line an alarmed automatic pump cut out facility is activated. The format of the CPB checklist is either written or automated and best signed off by two perfusionists.
    • Chapter 10 - Deep hypothermic circulatory arrest
      pp 125-139
    • View abstract

      Summary

      The cardiopulmonary bypass (CPB) circuit must be primed with a fluid solution. The volume of prime required is either based on a standard empirically derived volume greater than a minimum safe priming volume, or may be guided by the patient's weight or body surface area. The initial hematocrit (HCT) achieved after initiation of CPB is determined by the volume of the prime in relation to the patient's pre-CPB HCT. There are many different recipes for priming solutions using crystalloid, colloid or blood as primary constituents. Blood was used to prime the CPB circuit in an attempt to preserve a high hematocrit; early in the evolution of CPB this was thought to be an important determinant for successful outcome. The idea of using oxygen-carrying solutions as blood substitutes may be an attractive means of maintaining oxygen delivery. They would address the expense, limited supply and disease transmission associated with blood transfusion.
    • Chapter 11 - Organ damage during cardiopulmonary bypass
      pp 140-152
    • View abstract

      Summary

      This chapter describes the coagulation pathway, the pharmacology of heparin, monitoring of anticoagulation status, problems associated with heparin usage, alternatives to heparin, the reversal of anticoagulation following termination of cardiopulmonary bypass (CPB) and the prevention and management of bleeding. Unfractionated heparin (UFH) remains the standard anticoagulant for CBP for several reasons. Activated clotting time (ACT) is a functional assay of heparin anticoagulation and is the most widely employed test. Thrombocytopenia can occur after CPB due to dilution of blood volume with the extracorporeal circuit volume and platelet consumption or sequestration. Platelet function impairment is considered to be the main hemostatic defect during CPB. The synthetic antifibrinolytic agents ε-aminocaparoic acid (EACA) and tranexamic acid (TA) bind to lysine binding sites in both plasminogen and plasmin and produce a structural change. This prevents the conversion of plasminogen to plasmin and also prevents the activation of plasmin.
    • Chapter 12 - Cerebral morbidity in adult cardiac surgery
      pp 153-166
    • View abstract

      Summary

      The management of cardiopulmonary bypass (CPB) involves a multi-disciplinary approach with coordinated actions and precise communication being crucial for a safe, and effective outcome. Before each case the conduct of CPB should be planned. All members of the team need to be aware of the intended method for cannulation, the systemic and myocardial temperatures required during surgery, the technique of myocardial protection to be used, whether deep hypothermic circulatory arrest (DHCA) will be required and the most appropriate sites for monitoring during CPB. The arterial cannula is the narrowest part of the CPB circuit with resultant high resistance, pressure gradients, high velocity jets and turbulence. Venous blood inflow to the CPB circuit is usually achieved by gravity drainage, using the siphon effect, but earlier CPB circuits used suction to aid venous drainage; in pediatric cases, drainage is often aided by applying suction to the venous lines.
    • Chapter 13 - Acute kidney injury (AKI)
      pp 167-175
    • View abstract

      Summary

      The key to metabolic management during cardiopulmonary bypass (CPB) is the maintenance of adequate blood flow and oxygen delivery to the body's tissues. Utilizing the CPB machine, the perfusionist provides the optimum conditions necessary for operations on the heart, lungs or major vessels, while supporting the patient's physiological and metabolic needs. The perfusionist calculates a CPB blood flow utilizing the patient's body surface area (BSA) and cardiac index (CI). Metabolic acidosis during CPB is almost always the result of hypoperfusion leading to oxygen delivery inadequate to meet metabolic demands for aerobic respiration. Oxygen consumption is thus a major determinant of CPB flow requirements. Deep hypothermic circulatory arrest (DHCA) is used to dramatically lower the body's metabolic demand while protecting organs, particularly the brain, during a period in which perfusion is suspended. Some in-line devices provide a continuous calculation of oxygen consumption based on pump flow and the arterio-venous oxygen differential.
    • Chapter 14 - Extracorporeal membrane oxygenation
      pp 176-186
    • View abstract

      Summary

      This chapter reviews the rationale for the use of cardioplegia, techniques of administration, components of different cardioplegia solutions and applications of cardioplegia in different surgical interventions. Myocardial damage can be detected by electrocardiography, echocardiography, radioactive imaging studies and cardiac magnetic resonance imaging. The clinical manifestations of myocardial damage may present as low cardiac output syndrome due to impaired myocardial contractility, dysrhythmias, decreased ventricular compliance or segmental myocardial wall motion abnormalities. The goal of myocardial protection with cardioplegia is to prevent myocardial injury during the periods of intentional ischemia that are required to perform cardiac operations. Cardioplegia delivery systems generally comprise an infusion system with in-line pressure monitors, a cardioplegic heat exchanger for cold and warm perfusion, and cannulae for antegrade and retrograde delivery. Crystalloid cardioplegia solutions are usually delivered at 4°C, cold blood solutions at 10-16°C and warm blood solutions at 37°C.
    • Chapter 15 - Cardiopulmonary bypass in non-cardiac procedures
      pp 187-198
    • View abstract

      Summary

      Weaning, the process of transition from cardiopulmonary bypass (CPB) to normal, physiological circulation, requires excellent communication and teamwork between perfusionist, surgeon and anesthetist. Electrolyte abnormalities should be corrected before separation from CPB in order to optimize myocyte function. Cardiac function should be assessed as far as possible prior to weaning from CPB. This assessment should concentrate on three main areas: rate, rhythm and contractility. During CPB the lungs are allowed to deflate fully or to remain slightly inflated at low levels of positive end expiratory pressure (PEEP). Effective mechanical ventilation of the lungs must be ensured prior to commencing weaning from CPB. Epicardial pacing is commonly required in the immediate and early post-CPB period. The pacing system and pacing and sensing thresholds should be tested prior to weaning. Establishment of an appropriate mode of epicardial pacing is specifically intended to improve cardiac performance.
    References

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