Going on Bypass
What happens before, during and after CPB.
Perfusion Dept. Royal Children’s Hospital
Melbourne, Australia
Circulation
Aorta
Lungs
Brain
Liver
R.A. L.V.
Kidneys IVC, SVC
Viscera
Muscle
Skin R.V. L.A.
Pump
Oxygenator
Membrane Oxygenator
Arterial Filter
Bypass Circuit
Cardio-pulmonary Bypass Prime
Aim: to have enough fluid volume to prime the circuit, whilst
not overdiluting the total haemoglobin pool.
Weight(kg) Blood Prime Ratio
Volume Volume (ml)
(ml)
2 200 400-500 >2 : 1
4 400 500 1.5 : 1
6 600 600 1:1
16 1300 1100 .85 : 1
70 4900 1600 .32 : 1
Cardio-pulmonary Bypass Prime
At RCH: * Tailored individually.
* Aim for a final, combined Hb
(ie Patient + pump) of 8-9 gm/dL.
* Computer generated.
3 Basic Types of Prime:
1. Using fresh heparinised blood.
2. Using fresh citrated blood or packed cells.
3. Using no blood.
Heparinised Blood Prime
* Fresh - ;less than 24 hrs since donation
* Anticoagulated with 25mg of heparin
* “Normal “ K, H, Lactate. Na, etc.
* High yield of robust RBCs.
In practice:
* 1/2 or 1 unit of blood + crystalloid.
* No citrate no NaHCO3, “normal” Na+
* Lower dextrose
* for patients < 6 kg
* priming volume 400 - 500 mls
Fresh Blood Prime
* 2 - 5 days post donation
* either whole blood or packed cells
* contains 13% citrate as anticoagulant (CPD or ADC)
In practice:
* must be buffered with NaHCO3
* must use water to [Na+]
* use 1 unit + crystalloid (+ albumin) + water if required.
* patients 6 kg - 15 kg
* prime volume 500 - 1100 mls
Bloodless (Clear) Prime
* Dilution up to 40 ml/kg
* Crystalloid = Haemaccel or 4% Albumin
* Contains Heparin
* For patients > 15 kg (with adequate Hb) may
be used for smaller patients with high Hb.
* Blood remaining in the circuit at the end
of surgery is reinfused.
* prime volume 500 - 1600 mls
Bicaval Cannulation
Atrial Cannulation
At Initiation of Bypass…...
* Abrupt reduction in haematocrit & protein leads to:
Viscosity
Systemic Venous Resistance (SVR)
Blood pressure
Reflex in catecholamine release
At Initiation of Bypass…...
Right and Left atrial pressures 0 mmHg
which leads to:
ADH and aldosterone
Urine output
And ? Inadequate blood volume
Reflex in catecholamine release
At Initiation of Bypass…...
Flow < previously which leads to:
Haematocrit
Pulsatility
Blood Pressure
Systemic oxygen delivery
Reflex in catecholamine release
At Initiation of Bypass…...
Blood is exposed to foreign surfaces, etc.
this leads to:
* complement activation
* platelet release reaction
* leucocyte activation
* fibrinolysis
* kininogen byproducts
* coagulation
Increased Complement Activation
• Via alternate pathway C3a
• Also caused by Protamine
• C5 attaches to neutrophils (sequestered in lungs)
• General in serum complement concentration
• Greatly risk of infection
• Greatly enhanced inflammatory response
Platelet Release Reaction
• release, adhesion and aggregation
• “ Promotes ” coagulation
• Thromboxane release inflammatory response
• Results in : platelet numbers
platelet function
Leucocytosis
• The “defence” against “invasion”
• An integral part of the inflammatory response
• Activation and subsequent adhesion occurs
• sequestration (especially in pulmonary tree)
• Oxygen free-radical & leucotriene production
• Phagocytic activity
• Elastase & myeloperoxidase production
• Tissue damage & risk of infection
Kininogen By-products
• Bradykinin & Kinin are both inflammatory
• Vascular permeability
• SVR
both directly & by cytocine production
• Activation of leucocytes sequestration
Adequate/Optimal Perfusion
Dilated, well perfused, not shut down,
warm, not acidotic, not water loaded,
urine producing, non bleeding patients.
Adequate/Optimal Perfusion
Use vasodilators when appropriate.
Use vasoconstrictors when appropriate.
Avoid hypotensive pathophysiology
* substantial haemorrhage, rapid in Hct
* rapid loss of pulsatility, rapid transfusion
* low flow
Maintain high flows
* 150 ml/kg/min
* 2.4 l/m2/min
Moderate blood pressures
* not too low, not too high
Elective Cardiac Arrest & Cardioplegia
During cardiac surgery utilising CPB if a procedure
involves:
intra-cardiac anatomy or,
there is communication between the left and
right sides of the hear or,
the procedure involves the ascending aorta,
the aorta is cross-clamped and the heart arrested.
The only organ not receiving a blood supply is the heart.
Elective Cardiac Arrest & Cardioplegia
Physiological requirements Cardioplegia requirements
* Still, relaxed myocardium. * Prompt & complete cessation
of electromechanical activity
* Protection of myocardium * Preservation & protection
throughout the ischaemic
(arrest) period.
* Prompt resumption of * Normalised myocardial function
effective cardiac activity after the aortic cross-clamp is
and rhythm. removed.
Elective Cardiac Arrest & Cardioplegia
Myocardial Protection:
* K+ induced arrest and asystole using
cardioplegia solution (CPS).
* Hypothermia induced by CPS and
cold Ringers solution applied topically.
* Maintained by regular application and use
of Ringers slush around the myocardium.
Cardioplegia Solution
Cardioplegia solution generally contains:
* K+
* HCO3-
* Ca2+
* Glucose
CPS can be crystalloid, colloid or blood based.
They can be delivered at a variety of temperatures
and pressures dependent upon the patient and procedure.
Cardioplegia Solution
Blood Cardioplegia Base Solution (500 ml)
Sodium – 77 mmol
Potassium – 40 mmol
Magnesium – 15 mmol
Chloride – 149 mmol
Glucose – 11 mmol
Lidocaine – 1 mmol
To this is added 25 ml of 8.4% Sodium Bicarbonate and
28 mmol of Monosodium L-Aspartate. The induction dose
is mixed in a ratio of 1:4, Base solution:blood. The
maintenance dose is delivered at 1:6, Base solution:blood.
Cardioplegia Circuit
Circulatory Arrest
Used primarily when the surgeon’s field of vision
is compromised or there is a major procedure involving
the aortic arch. Now isolated cerebral perfusion is usually
used.
The patients are generally neonates ( < 3kg).
It is always performed under some degree of hypothermia.
The period of circulatory arrest is limited by the degree
of hypothermia.
Circulatory Arrest
In practice:
The patient is cooled on CPB to the appropriate temperature.
Temperature Safe period without circulation
<18º C. 45 minutes
22º C. 30 minutes
28º C. 13 minutes
30º C. 5 minutes
Kirklin & Barret-Boyes; Ch 2.
The use of steroids stabilises cell membranes and
limits end organ oedema.
Weaning from Bypass
While on full support via venous occlusion start volume loading
Ventilating
Ra > 5 mmHg
LA > 4 mmHg
PA < 1/2 systemic pressure
Volume Requirements after CPB
Maintain adequate pressures.
Maintain or improve haematocrit
Control bleeding using appropriate fluids/drug
combinations.
Modified Ultrafiltration (MUF)
The increase in extravascular fluid which tends to accompany
cardiopulmonary bypass (CPB), is in part due to increased
capillary permeability, as a result of the inflammatory
response initiated by CPB.
Perioperative ultrafiltration and more specifically post CPB
modified ultrafiltration (MUF), can be used to decrease total
body water thereby minimising these deleterious effects
Our aim is to remove 100ml/kg of filtrate and this usually
requires a period of 12 to 20 minutes in the neonatal
population. Time taken and amount of filtrate removed will
vary in larger children.
Modified Ultrafiltration (MUF)
Donor or Pump Blood Post-Op
Donor blood Pump blood
Hb ICU 1 Hr 11.7 10.6 N.S.
Hb ICU 12 Hr 12.2±1.3 11.9±1.6 N.S.
[Link],FFP,Plt 234 ml 242 ml N.S.
Urine ml/kg/12hr 26.7 22.2 N.S.
Tot Heparin 7.2 7.3 N.S.
mg/kg
Tot Protamine 4.5 4.4 N.S.
mg/kg
ICU hours 36.4±33.6 26.9±13.8 N.S.
Post-op hosp 9.5±3.8 11.6±6.7 N.S.
days
“Undesirable” Features of CPB
• Haematology / Haemostasis
• Use of suction
• Blood contact with CPB circuit
• Perfusion imbalances
• Haemodilution
• Prolonged cross-clamp times
• Use of relatively large amounts of donor blood
and blood products
• Emboli
Complications of CPB
• Sleep deprivation.
• Potential for exposure to communicable diseases
• Terrible “bad hair” days
• Pale skin
• Forced association with staff of debatable character
• Your children wonder who you are
• Moderate levels of stress, sometimes very high levels
• ECMO and VAD
• Requirement to lecture
