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Anesthetic Management
During Cardiopulmonary
Bypass
Dr.N.Kanagarajan
Preparations for Cardiopulmonary
Bypass
 CPB CIRCUIT
 Function
 Oxygenation and Carbon dioxide elimination
 Circulation of blood
 Systemic Cooling
 Diversion of blood from the heart to provide a bloodless
surgical field
 CIRCUIT DESIGN
 Venous circuit
 Venous blood drained by gravity from the right side of the
heart into the reservoir
 Most commonly single venous cannulation followed.
 Arterial Cannula
 Returns oxygenated blood from pump to aorta
 Usually placed in ascending aorta/ femoral artery
 Total CPB
 When all venous blood draining toward the
heart is diverted into the pump oxygenator.
 Partial CPB
 When only a portion of systemic venous
blood drains to the pump oxygenator while
passes through the right heart and lungs
and ejected by the left ventricle.
Anesthesiologist Pre Bypass
Check List
 Anticoagulation
 Generally adequate heparinisation requires a
activated coagulation time > 480 seconds.
 ACT accurately measured within two minutes of
heparin administration.
 Anesthesia
 Concentration of drugs in the blood diluted by the
prime
 Supplemental medication necessary
 Neuromuscular blockers
 Anesthesia,Analgesics and Amnesics
 Cannulations
 Aortic cannula
 Position within the lumen of the aorta should be checked
 Aortic pressure should be pulsatile and correlate with radial
artery pressure
 Check Carotid pulsation
 Drips
 IV lines closed on heparinisation to prevent further
hemodilution.
 Monitoring
 Check the zero and calibration of the arterial pressure
transducer.
 Insert nasopharyngeal temp. probe prior to
heparinisation
 Foley’s catheter to check urine output.
Maintenance Of Bypass
 Anticoagulation
 ACT > 480 seconds
 ACT checked every 30-60 mins
 Perfusion pressure on CPB
 Lower flow and pressure during CPB may optimise
revascularisation while higher flow and pressure may
minimise patient complication.
 Cerebral Autoregulation: Mean ABP of 50-150mm Hg.
 Higher perfusion pressure needed in severe
atheromatous states,advanced age, systemic
hypertension and diabetes
 Pump flow on CPB
 Careful balance between surgical visualization and
adequate oxygen delivery must be maintained
 1-2 L/min/m2
perfuses most of the microcirculation when
Hct is 22% and hypothermic CPB is used.
 Mixed Venous saturation is 70%
 Blood gas and acid base status
 Should be checked soon after intitiation of CPB
 Every 30-60 min
 Arterial oxygenation maintained at 100 - 300mm Hg
 Alpha Stat Vs. pH Stat
 Alpha Stat
Uncorrected (37°C) pH is kept at 7.40
with PCO2 at 40 mm Hg creating a
relative alkalosis at the patient arterial
body temperature.
 pH Stat
 Maintains a pH of 7.40 and PCO2 of 40 mm
Hg when corrected for body temperature,
typically requiring the addition of CO2 during
hypothermic CPB.
 Potent vasodilatory effect  increased
cerebral blood flow.
 May be advantageous in paediatric patients
 Anesthetic Depth
 Should be sufficient to
 Suppress hypertensive or tachycardic responses to surgical
stimuli
 Prevent awareness
 Prevent unconsciousness movement and respiration
 because hypothermia reduces the anesthetic requirement
they are most commonly used during the rewarming periods.
 Ventilation
 Should cease during total CPB
 During partial Bypass occasional ventilation wth
100% O2 may be needed.
 Urine production
 Sign of renal perfusion
 As a guide for fluid management
 >1ml/kg/hr should be maintained
 Fluid management
 Hemodilution
 Lowers the blood viscosity counteracting the deleterious
viscosity changes caused by hypothermia
 Organ blood flow improved
 Optimal hematocrit > 20
 Usually a clear priming(non-blood containing)
solution is utilised.
 Fluid replacement during CPB
 Based on Hb, < 5g/dl – Blood, otherwise usually colloids
used
 Ultrafiltration
 If adequate diuresis cannot be produced an
ultrafiltration device added to CPB circuit t remove
excess water.
 Heparin may be removed during ultrafiltration, so
anticoagulation must be monitored frequently.
Weaning from CPB
Anasthesia during cpb
 Temperature
 Systemic hypothermia is widely used during
CPB,therefore patient must be rewarmed
 Core temp (nasopharnygeal / tympanic/bladder)
> 36°C prior to terminating CPB.
 Order of rewarming: Vessel Rich> Muscle> Fat
 Excessive perfusate heating not advisable
 Denaturation of plasma proteins
 Cerebral hyperthermia
 Air embolism
 Rewarming may be enhanced
 By increasing blood flow
 Use of arterial vasodilators(SNP)
 Analysis and correlation of electrolyte , Acid
base balance and Oxygen transport status
 Acid base status must be optimised
 Acidosis
 Myocardial depressant
 Increased Pulmonary hypertension
 Metabolic acidosis due to inadequate tissue perfusion
 Inadequate perfusion flow
 A low hemoglobin level
 Inadequate oxygenation of blood
 Other causes
 DKA
 Renal Failure
 NaHCO3 can be used to treat the primary cause
 Serum K+ >4.0 meq/l to reduce the incidence f
arrhythmia
 Ca2
+
- to treat hypocalcemia and hyperkalemia
 Dose- 5-15 ml/kg,
can cause coronary spasm, augmentation of
reperfusion injury
 Hematocrit
 Must be adequate to provide oxyge carrying capacity
 HCt > 20% or greater is appropriate for termination of
bypass.
 Coagulation
 Additional heparin may be needed because rewarming
accelerates heparin a metabolism
 Blood products should be readily available to use if
needed(Platelets /FFP / fibrinogen)
 Blood products can be used after termination of CPB
 Re-establish adequate ventilation
 Once ventricular ejection(pulsatile arterial waveform)
is seen, ventilation is started (4 - 6 breaths/min)
 Also help to eliminate air from the pulmonary veins
 Adequate oxygenation and ventilation amust be
nesured while pt is on CPB.
 Lungs should be re-expanded with 2-3 sustained
breaths(15-20 seconds) with visualisation of bilateral
lung expansion and resolution of atelectasis
 tracheal suction done
 Prevent LIMA graft damage caused by lung
overdistension.
 Inspired oxygen fraction should be 1.0
 Predictors
 Preoperative EF>40%
 Ongoing ischemia/Infarct in the pre-CPB period
 Prolonged CPB duration
 Inadequate Surgical Repair
 Incomplete coronary revascularisation
 Residual valvular regurgitation.
 Incomplete Myocardial Preservation
 Incomplete diastolic arrest
 Incomplete Cardioplegia
 Other Drugs / Infusions
 Volume expanders
 Vasopressors and inotropes
 Vasodilators
 Anesthetic State
 Because of the potential for hemodynamic instability during
and shortly after weaning from CPB, it is better to avoid
additional anesthetic adminstration.
 Supplemental medications are best given during
rewarming
 Post ACC removal
 Atleast 10-15 min should elapse after the removal of
the ACC before attempting sepertion from CPB.
 Myocardial injury and edema are reduced by avoiding
myoacrdial perfusion pressures in excess of 60 mm
Hg in the first 10-15 mins after reperfusion.
 Thereafter sustaining coronary perfusion pressure
above above 70 mmHG for the last 5-10 min of CPB
improves outcome.
Final Checklist for Terminating
CPB
 Confirm
 Ventilation – lungs ventilated with 100%
oxygen.
 The patient is sufficiently rewarmed.
 Complete de-airing done from heart/ grafts/
great vessels.
 Optimal metabolic condition.
 All equipment and drugs are ready.
Sequence Of events
 Step1: Retarding the venous return to the pump
 Slowly the venous line is partially occluded
 Blood flow through RV increased - the Heart begins to
eject
 Preload- the amount of venous line occlusion is adjusted
carefully and maintain a certain optimal pre-
load(adequate cardiac output).
 Step 2: Lowering pump flow into aorta
 Attaining partial bypass
 The rise in preload causes the heart to begin to contribute to
the cardiac output.
 Reduced Pump outflow requirement
 The amount of arterial blood returned from the pump to the
patient can be reduced
 Cardiac function And hemodynamics carefully monitored
 Readjusting venous line resistance
 To maintain the constant filling resistance.
 Step 3: Terminating Bypass
 If the heart is generating adequate systolic pressure (90-
100 mm Hg) at an acceptable preload with a pump flow
of 1L/min or less the patient is ready for termination of
CPB.
 The pump is stopped and both pump cannulas are
clamped fully
Immediately After Terminating
CPB
 Preload
 Infusing blood from the pump
 In adult patients, volume is infused at 50-100ml
increments from the venous pump reservoir to the
patient through aortic cannula
 Should be watched for air bubbles in aortic cannula
 W/F blood pressure/ filling pressures/ heart
 Measuring cardiac function
 Cardiac Index > 2.0 L/min/M2
 Measuring patient perfusion
 Adequate tissue perfusion –ABG/ pH after 5 min after CPB
 U/O – normally rise after CPB.
 Removing the venous cannulae
 Removing the aortic cannula
Anasthesia during cpb
Anasthesia during cpb

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Anasthesia during cpb

  • 2. Preparations for Cardiopulmonary Bypass  CPB CIRCUIT  Function  Oxygenation and Carbon dioxide elimination  Circulation of blood  Systemic Cooling  Diversion of blood from the heart to provide a bloodless surgical field
  • 3.  CIRCUIT DESIGN  Venous circuit  Venous blood drained by gravity from the right side of the heart into the reservoir  Most commonly single venous cannulation followed.  Arterial Cannula  Returns oxygenated blood from pump to aorta  Usually placed in ascending aorta/ femoral artery
  • 4.  Total CPB  When all venous blood draining toward the heart is diverted into the pump oxygenator.  Partial CPB  When only a portion of systemic venous blood drains to the pump oxygenator while passes through the right heart and lungs and ejected by the left ventricle.
  • 6.  Anticoagulation  Generally adequate heparinisation requires a activated coagulation time > 480 seconds.  ACT accurately measured within two minutes of heparin administration.  Anesthesia  Concentration of drugs in the blood diluted by the prime  Supplemental medication necessary  Neuromuscular blockers  Anesthesia,Analgesics and Amnesics
  • 7.  Cannulations  Aortic cannula  Position within the lumen of the aorta should be checked  Aortic pressure should be pulsatile and correlate with radial artery pressure  Check Carotid pulsation  Drips  IV lines closed on heparinisation to prevent further hemodilution.
  • 8.  Monitoring  Check the zero and calibration of the arterial pressure transducer.  Insert nasopharyngeal temp. probe prior to heparinisation  Foley’s catheter to check urine output.
  • 9. Maintenance Of Bypass  Anticoagulation  ACT > 480 seconds  ACT checked every 30-60 mins  Perfusion pressure on CPB  Lower flow and pressure during CPB may optimise revascularisation while higher flow and pressure may minimise patient complication.  Cerebral Autoregulation: Mean ABP of 50-150mm Hg.  Higher perfusion pressure needed in severe atheromatous states,advanced age, systemic hypertension and diabetes
  • 10.  Pump flow on CPB  Careful balance between surgical visualization and adequate oxygen delivery must be maintained  1-2 L/min/m2 perfuses most of the microcirculation when Hct is 22% and hypothermic CPB is used.  Mixed Venous saturation is 70%  Blood gas and acid base status  Should be checked soon after intitiation of CPB  Every 30-60 min  Arterial oxygenation maintained at 100 - 300mm Hg
  • 11.  Alpha Stat Vs. pH Stat  Alpha Stat Uncorrected (37°C) pH is kept at 7.40 with PCO2 at 40 mm Hg creating a relative alkalosis at the patient arterial body temperature.
  • 12.  pH Stat  Maintains a pH of 7.40 and PCO2 of 40 mm Hg when corrected for body temperature, typically requiring the addition of CO2 during hypothermic CPB.  Potent vasodilatory effect  increased cerebral blood flow.  May be advantageous in paediatric patients
  • 13.  Anesthetic Depth  Should be sufficient to  Suppress hypertensive or tachycardic responses to surgical stimuli  Prevent awareness  Prevent unconsciousness movement and respiration  because hypothermia reduces the anesthetic requirement they are most commonly used during the rewarming periods.
  • 14.  Ventilation  Should cease during total CPB  During partial Bypass occasional ventilation wth 100% O2 may be needed.  Urine production  Sign of renal perfusion  As a guide for fluid management  >1ml/kg/hr should be maintained
  • 15.  Fluid management  Hemodilution  Lowers the blood viscosity counteracting the deleterious viscosity changes caused by hypothermia  Organ blood flow improved  Optimal hematocrit > 20  Usually a clear priming(non-blood containing) solution is utilised.  Fluid replacement during CPB  Based on Hb, < 5g/dl – Blood, otherwise usually colloids used
  • 16.  Ultrafiltration  If adequate diuresis cannot be produced an ultrafiltration device added to CPB circuit t remove excess water.  Heparin may be removed during ultrafiltration, so anticoagulation must be monitored frequently.
  • 19.  Temperature  Systemic hypothermia is widely used during CPB,therefore patient must be rewarmed  Core temp (nasopharnygeal / tympanic/bladder) > 36°C prior to terminating CPB.  Order of rewarming: Vessel Rich> Muscle> Fat  Excessive perfusate heating not advisable  Denaturation of plasma proteins  Cerebral hyperthermia  Air embolism  Rewarming may be enhanced  By increasing blood flow  Use of arterial vasodilators(SNP)
  • 20.  Analysis and correlation of electrolyte , Acid base balance and Oxygen transport status  Acid base status must be optimised  Acidosis  Myocardial depressant  Increased Pulmonary hypertension  Metabolic acidosis due to inadequate tissue perfusion  Inadequate perfusion flow  A low hemoglobin level  Inadequate oxygenation of blood
  • 21.  Other causes  DKA  Renal Failure  NaHCO3 can be used to treat the primary cause  Serum K+ >4.0 meq/l to reduce the incidence f arrhythmia  Ca2 + - to treat hypocalcemia and hyperkalemia  Dose- 5-15 ml/kg, can cause coronary spasm, augmentation of reperfusion injury
  • 22.  Hematocrit  Must be adequate to provide oxyge carrying capacity  HCt > 20% or greater is appropriate for termination of bypass.  Coagulation  Additional heparin may be needed because rewarming accelerates heparin a metabolism  Blood products should be readily available to use if needed(Platelets /FFP / fibrinogen)  Blood products can be used after termination of CPB
  • 23.  Re-establish adequate ventilation  Once ventricular ejection(pulsatile arterial waveform) is seen, ventilation is started (4 - 6 breaths/min)  Also help to eliminate air from the pulmonary veins  Adequate oxygenation and ventilation amust be nesured while pt is on CPB.
  • 24.  Lungs should be re-expanded with 2-3 sustained breaths(15-20 seconds) with visualisation of bilateral lung expansion and resolution of atelectasis  tracheal suction done  Prevent LIMA graft damage caused by lung overdistension.  Inspired oxygen fraction should be 1.0
  • 25.  Predictors  Preoperative EF>40%  Ongoing ischemia/Infarct in the pre-CPB period  Prolonged CPB duration  Inadequate Surgical Repair  Incomplete coronary revascularisation  Residual valvular regurgitation.  Incomplete Myocardial Preservation  Incomplete diastolic arrest  Incomplete Cardioplegia
  • 26.  Other Drugs / Infusions  Volume expanders  Vasopressors and inotropes  Vasodilators  Anesthetic State  Because of the potential for hemodynamic instability during and shortly after weaning from CPB, it is better to avoid additional anesthetic adminstration.  Supplemental medications are best given during rewarming
  • 27.  Post ACC removal  Atleast 10-15 min should elapse after the removal of the ACC before attempting sepertion from CPB.  Myocardial injury and edema are reduced by avoiding myoacrdial perfusion pressures in excess of 60 mm Hg in the first 10-15 mins after reperfusion.  Thereafter sustaining coronary perfusion pressure above above 70 mmHG for the last 5-10 min of CPB improves outcome.
  • 28. Final Checklist for Terminating CPB  Confirm  Ventilation – lungs ventilated with 100% oxygen.  The patient is sufficiently rewarmed.  Complete de-airing done from heart/ grafts/ great vessels.  Optimal metabolic condition.  All equipment and drugs are ready.
  • 29. Sequence Of events  Step1: Retarding the venous return to the pump  Slowly the venous line is partially occluded  Blood flow through RV increased - the Heart begins to eject  Preload- the amount of venous line occlusion is adjusted carefully and maintain a certain optimal pre- load(adequate cardiac output).
  • 30.  Step 2: Lowering pump flow into aorta  Attaining partial bypass  The rise in preload causes the heart to begin to contribute to the cardiac output.  Reduced Pump outflow requirement  The amount of arterial blood returned from the pump to the patient can be reduced  Cardiac function And hemodynamics carefully monitored  Readjusting venous line resistance  To maintain the constant filling resistance.
  • 31.  Step 3: Terminating Bypass  If the heart is generating adequate systolic pressure (90- 100 mm Hg) at an acceptable preload with a pump flow of 1L/min or less the patient is ready for termination of CPB.  The pump is stopped and both pump cannulas are clamped fully
  • 32. Immediately After Terminating CPB  Preload  Infusing blood from the pump  In adult patients, volume is infused at 50-100ml increments from the venous pump reservoir to the patient through aortic cannula  Should be watched for air bubbles in aortic cannula  W/F blood pressure/ filling pressures/ heart
  • 33.  Measuring cardiac function  Cardiac Index > 2.0 L/min/M2  Measuring patient perfusion  Adequate tissue perfusion –ABG/ pH after 5 min after CPB  U/O – normally rise after CPB.  Removing the venous cannulae  Removing the aortic cannula