The conduct of CPB

CIRCUIT
Assembly
After Such preassembled circuits may be used for regularly scheduled procedures so
that an extended period of time does not elapse before the circuit is use
Oserved for integrity and absence of water leas into the blood!contacting sections"
The circuit may be briefly flushed with filtered #$$% carbon dioxide to displace room air"
This techni&ue was originally used as an aid for arterial filter priming
but is also advantageous with membrane oxygenators
because carbon dioxide is approximately '$ times more soluble than the nitrogen in
room air thereby facilitating debubbling the circuit when it is primed with fluid"
(riming
)alanced electrolyte solution and additives* excluding blood products* are then added to
the C() circuit +usually via the cardiotomy or venous reservoir, and recirculated through
a pre!bypass filter +$"- to . m pore si/e,"
The pre!bypass filter is often positioned as a connection between the arterial and venous
lines and is part of the sterile tubing placed on the surgical field" Its purpose is to remove
any potential small debris that may be present from the manufacture or assembly of
devices or tubing +#-," After an appropriate period of recirculation* the pre!bypass filter is
removed* most often when separating the arterial and venous lines 0ust before
cannulation* in a way that avoids reintroduction of any captured debris into the circuit"
1xcept for small adults with a low starting hematocrit or some pediatric patients* ban
blood is infre&uently used in the C() priming solution2 if it is re&uired* it should be added
after removal of the pre!bypass filter and recirculated to ensure ade&uate mixing with the
crystalloid solution and any drug additives" Recirculation of perfusate also allows the
circuit to be 3stressed3 at flows and pressures at or exceeding those expected to be
used during C() to ensure circuit integrity" Recirculation also allows for ad0ustment of
the perfusate p4* (CO-* (O-* and electrolyte composition"
Setting occlusion and verifying accuracy of pump flow
To ensure accurate delivery of systemic blood flow* roller pump occlusion should be set
before bypass* but first the proper blood flow direction must be verified by tracing the
tubing from the operative field to the C() circuit and bac to ensure proper tubing
assembly" A small gap +#56 to #5#7 inch, should exist between the tubing and the roller
pump bacing plate* and the tubing should be aligned so that it does not ride up or down
within the pump housing with normal rotation" (roperly assembled roller pump tubing
resembles a 3U3 shape maintained by securing it at the inlet and outlet with correctly
si/ed tubing inserts or holders"
The traditional method for setting occlusion is to allow a '$! to 8$!inch vertical column of
fluid in the outlet side of the tubing to drop slightly +at a rate less than # inch5min, by
ad0usting roller occlusion against the bacing plate +#'," The occlusion should be set by
moving the rollers toward the pump bacing plate to accommodate any free play in the
occlusion ad0ustment mechanism2 if the occlusion is set by moving the rollers away from
the bacing plate* underocclusion may result" 1ach roller should be checed in three
positions +typically* at 6* 7* and 8 o9cloc where ## and # o9cloc approximate the
positions of the inlet and outlet* respectively," In the event that the two rollers in the
pump head do not yield the same rate of fluid drop* the occlusion should be set to the
roller that is tightest"
A second method for setting roller pump occlusion +#8, is to fill the systemic flow tubing
+subse&uently referred to herein as a 3line3 by convention, with priming fluid and then
pressuri/e the line by applying a tubing clamp beyond a pressure!monitoring port and
slightly advancing and then stopping the roller pump" The occlusion can be assessed by
observing a slow decline in pressure"
A third method +#., for setting roller pump head occlusion is the so!called dynamic
method whereby the occlusion is ad0usted while the roller pump rotates" A pressure
monitor is re&uired* as is a pressure!activated* valved shunt between the outlet and inlet
tubing to prevent overpressuri/ation" :ie the second method* a tubing clamp is applied
to the fluid!filled arterial line downstream of the pump head" ;ith the pump rotating at 7
to #$ revolutions per minute +rpm,* the occlusion is ad0usted to maintain a pressure
above that anticipated during C()" Using this method* fluid displaced will flow across the
valved shunt while the desired pressure is maintained"
)ecause a centrifugal pump is afterload sensitive in flow output and functions differently
from a roller pump* occlusion setting is not re&uired" 4owever* lie the roller pump* the
inlet and outlet lines must be correctly identified and connected to ensure proper flow"
;hen a centrifugal pump is used for systemic blood flow* a flow probe must also be
calibrated and /eroed before C() to ensure accurate flow readings" A centrifugal pump
cannot be used for suction or venting because possible air entrainment will effectively
deprime the pump and stop its suction effect and forward flow"
The occlusion of suction and vent roller pumps is set when the tubing is fluid free by
clamping the inlet tubing* starting the roller pump at moderate rpm and ad0usting the
degree of occlusion until the tubing in the roller pump 0ust collapses" This is assessed
visually or by hearing a 3smacing3 sound as the tubing in the pump repeatedly
collapses as negative pressure is created and then released with rotation of the rollers"
After setting the occlusion but before removing the inlet clamp* each roller should be
stopped at three positions to verify that the tubing remains collapsed* thus ensuring
occlusion" The response will depend on tubing wall thicness and type +polyvinyl
chloride or silicone rubber," Suction pumps should then also be tested with water" If a
suction or vent pump is nonocclusive* there is a ris of air embolism should the
cardiotomy reservoir become pressuri/ed +#7,"
A conventional blood cardioplegia delivery pump contains two segments of tubing* one
for blood and the other for the crystalloid component of cardioplegic solution" )ecause
those tubes often have different diameters* setting the occlusion for this pump is more
complex" The two segments of tubing are <!ed together after the roller pump to deliver
the mixed cardioplegic solution in the appropriate ratio +typically 8=# blood to crystalloid,"
A shunt connecting both sets of tubing may be located before the pump to allow delivery
of blood alone" The occlusion must be set to the segment of tubing with the smaller
diameter* which necessitates that the larger blood!containing segment is 0ust occlusive"
Setting the appropriate occlusion can be accomplished by observing a slow drop and
then cessation of fluid drop from a spied bag of crystalloid solution when the delivery
system is initially primed" This should be performed while recirculating fluid through the
arterial5venous loop with the systemic flow pump so that the cardioplegia pump is under
pressure" :ie the method outlined earlier* each roller should be checed in three
positions" Alternatively* the cardioplegia pump occlusion can be set by clamping the
delivery line after the cardioplegia heat exchanger5bubble trap and slowly rotating the
rollers to pressuri/e the system and then stopping the pump" If the occlusion is properly
set* there will be no decline in pressure measured between the pump assembly and
clamp"
Regardless of how the occlusion is set on the cardioplegia pump* a second way to
assess proper occlusion is to verify that no fluid leas past the roller pump and begins to
fill the crystalloid bag when the systemic pump is rotating and the cardioplegia pump is
stopped" ;hen two tubing segments are placed in a single roller pump* it is important
that both segments are approximately e&ual in length to avoid ining* excessive
stretching* or overriding of one segment upon the other* all of which can interfere with
effective pump function"
(ositioning the pump and arrangement of lines
;hen the surgeon is ready to begin C()* the heart>lung machine console is positioned
near the operating table" Some surgeons prefer that the pump is placed opposite them*
most often parallel to the table and on the patient9s left side* whereas others prefer to
have the pump positioned on the patient9s right side directly behind the primary surgeon"
?epending on other e&uipment in the room or institutional preference* the pump may
also be positioned at an angle to the patient or at the foot of the table" ;hatever the
chosen position* the pump should be placed to minimi/e tubing lengths to the
cannulation sites to decrease the re&uired crystalloid priming volume and its
commensurate hemodilution upon initiation of bypass"
Sterile pump lines are most often passed from the sterile surgical field to the perfusionist
for connection to the C() circuit* but alternatively the perfusionist may wear a sterile
gown and gloves and pass the sterile lines to personnel at the operative field" The
console position and line arrangement also should permit easy line identification and
visuali/ation and allow surgical personnel to move during the procedure without
compromising operative field sterility or ining the C() lines" Sufficient lengths of
tubing should be provided between the oxygenator* venous reservoir* and systemic
blood pump to enable C() component change!out or hand!craning if they are re&uired"
(re!cardiopulmonary bypass checlist
)etween the times of pump assembly and cannulation for C()* the primary perfusionist
completes a pre!bypass checlist to verify proper assembly and function +#@," Checlist
formats include memori/ed* written* and automated types +#6," The written type is most
common and consists of items that are checed off a list se&uentially" This exercise can
be conducted as a 3do!list3 format in which the checlist item triggers a response as a
series of tass are performed or as a 3done!list3 whereby the tas is either verified to
have been completed or it is repeated" The redundancy incorporated into the second
method increases the chance of the tas being completed" The checlist procedure may
be conducted either 3silent*3 in which one person performs both the checlist and tass*
or it may be carried out as a 3challenge and response3 where either two people or one
person and a computer prompt and then record tas performance"
Checlists can be abbreviated or all inclusive" All!inclusive checlists tend to be long and
are sub0ect to misuse because of the demands of checing each item on a long list"
Checlists are most effective if they contain only those items* which if omitted* would
have a direct and adverse effect on the safe conduct of C()" In aviation checlists* such
items are referred to as 3iller3 items" 1xamples of such items in perfusion practice
would be failure to securely connect the ventilating gas delivery line to the oxygenator*
failure to properly set the occlusion on a roller pump* or assembly of vent tubing in a
roller pump in the incorrect direction" Aeneric checlists have been published and
promoted by the American Society of 1xtra!Corporeal Technology +AmS1CT, +#B, +Cig"
-@"#,* but in practice checlists are most often customi/ed for specific hospital or
surgeon protocol"
Diew Cigure
CIA -@"#" Suggested pre!bypass perfusion checlist" +Courtesy American Society of
1xtra!Corporeal Technology* 4erndon* DA",
The sections of a checlist should include items related to= patient and procedure2
sterility of C() components2 proper pump assembly and function2 ade&uacy of electrical
connections2 ade&uacy of oxygenator ventilating gas supply2 arrangement and integrity
of C() lines2 composition of cardioplegic solution2 testing and engagement of alarms2
calibration and placement of monitors and probes2 operational capacity of water supply
system2 verification of anticoagulation2 and availability of bacup supplies and
e&uipment"
IEITIATIOE OC )<(ASS
)ac to Fuic :ins
Connection of patient to circuit
After administration of systemic heparin and verification that the patient is ade&uately
anticoagulated* perfusate is recirculated through the C() circuit one final time while the
lines are tapped and inspected by the surgeon or an assistant to verify absence of any
visible gas bubbles" Recirculation is stopped and the arterial and venous lines are then
clamped at the pump and table" The surgeon or assistant divides the arterial5venous
recirculation loop" Gost often* the surgeon connects the arterial cannula first after
securing it in the ascending aorta with purse!string sutures" After the cannula is filled
retrograde with the patient9s blood* an air!free connection is made between the C()
arterial flow line and the arterial cannula" 4aving the perfusionist slowly advance the
perfusate by activating the systemic flow pump will facilitate an air!free connection2
alternatively* an assistant can add sterile fluid from a syringe as the C() line and
cannula are 0oined" If the latter techni&ue is used* the arterial flow line must be identified
and distinguished from the venous drainage line to avoid the ris of reversed lines"
After removal of the arterial line clamp at the field* the perfusionist should manually
palpate or observe pulsation on an arterial flow line pressure monitor" The pressure
transmitted from the aortic cannula through the arterial flow line will reasonably ensure
that the cannula has been placed in the lumen of the aorta +or other arterial site,"
Absence of ade&uate pulsation may indicate malposition or insertion of the cannula into
the vessel wall that could lead to arterial wall hematoma or dissection upon initiation of
C()"
Cluid balance and circuit priming volume
It is often prudent to obtain an estimation of the patient9s fluid balance from their time of
arrival in the operating room by checing and recording the estimated blood loss* urine
output* and volume of fluids administered by anesthesia personnel" Hnowing the
patient9s estimated blood volume and hematocrit allows calculation of an estimated
hematocrit after initiation of C()" This will give the perfusionist and anesthesiologist
some indication of C() fluid or blood re&uirements"
To reduce circuit priming volume and the resultant hemodilution upon starting C()* a
techni&ue called retrograde autologous priming has been introduced +-$," After
connecting the arterial line and cannula but before starting bypass* priming fluid can be
removed from the circuit via a stopcoc on the arterial filter or arterial sampling manifold
by allowing the patient9s arterial blood to displace the crystalloid priming solution" This
procedure can be accomplished relatively &uicly while carefully monitoring the patient9s
hemodynamics" The volume of priming solution displaced in this manner is -$$ to 7$$
m:"
Another method for reducing priming volume relies on vacuum!assisted venous drainage
+-#," After final pre!C() recirculation* priming fluid in the venous line can be discarded
or se&uestered in a sterile intravenous bag for later administration on C()* leaving the
venous line devoid of fluid and containing only room air" ;hen this techni&ue is used* a
clamp must remain in place on the venous cannula until immediately before starting
bypass" )ecause the techni&ue of vacuum!assisted venous drainage does not rely on
gravity siphon drainage but instead on a regulated vacuum applied to a hard!shell
venous reservoir* removal of the venous line clamp will allow the negative pressure
created in the reservoir to actively withdraw venous blood from the patient upon initiation
of C()" This approach eliminates 8$$ to #*$$$ m: of priming solution"
The anticipated result of these circuit prime reduction techni&ues is a higher hematocrit
during C() and a possible reduced need for administration of homologous blood after
bypass +--," This exercise will fail to achieve this goal if the patient9s blood volume is
marginal before C()* because ultimately this will present as a reduced blood level in the
venous reservoir mandating the addition of crystalloid or blood" Reduction of the
hyperdynamic response often seen after C() has been reported when using minimal
C() priming volumes +-',"
1stablishing extracorporeal blood flow
Upon instruction from the surgeon* C() begins by removing the clamp+s, on the arterial
line and activating the systemic pump speed control" If a centrifugal pump is used* the
pump speed control should be increased to sufficient rpm to avoid retrograde flow before
unclamping the arterial line because such retrograde flow has been associated with air
entry into the arterial flow line from the aortic cannulation site +-8,"
The rationale for starting flow in the systemic pump before releasing the venous line
clamp is to avoid exsanguinating the patient into the C() circuit in the event of a pump
malfunction" As the volume of perfusate in the C() reservoir decreases* the venous line
clamp or occluder is released +partially or totally depending on whether the surgeon
wishes to maintain some cardiac e0ection or have the heart immediately decompressed,*
allowing venous blood to flow into the C() reservoir" Cull C() flow can be established in
most cases within '$ seconds" Systemic flow is most often indexed to the patient body
surface area +in m-, or weight +in g," Aenerally accepted indices are -"- to -"8
:5min5m- or .$ to 7. m:5g when normothermic or when cooling" 4igher indices often
are used in pediatric patients or when rewarming the adult patient" Once the patient is
hypothermic* these indices may be reduced proportionate to the degree of hypothermia
because of decreased oxygen consumption +-., +see )lood Clow and (erfusion
(ressure* below* and Chapters #- and '$,"
The arterial filter purge line stopcoc is opened to provide a low!pressure vent for
removal of any potential gas emboli in the systemic flow line" The volume of arterial
blood shunted bac into the venous reservoir or cardiotomy reservoir through such a
purge is generally #.$ to '$$ m:5min but can be greater than .$$ m:5min depending on
purge line diameter and length and the arterial line pressure" )y connecting the purge
line to the cardiotomy reservoir* the volume flow per minute can be measured by
clamping the cardiotomy drain line for #$ seconds* noting the volume rise in the
reservoir* and then multiplying by 7 to get m:5min shunt flow" Although the effect of this
shunt volume is generally insignificant in adults* it can be clinically important in infants or
small children* potentially leading to hypoperfusion +-7," Conse&uently* in the latter
clinical scenario* the purge line is ept closed or only partially open with brief intermittent
periods of unrestricted flow for purging"
Ganagement of gas flow
Oxygenators from various manufacturers have different operating characteristics and the
instructions for use should be followed for initial gas settings" The ventilating gas flow to
the oxygenator is started 0ust before or simultaneously with initiation of C()" Once
ade&uate oxygenation is verified by observing bright red blood or satisfactory in!line
arterial (O- or SvO- values* ad0ustments in gas flow and mixture are made" A useful
techni&ue for managing and assessing oxygenator ventilating gas flow settings is to
express it in a ratio to the systemic blood flow" Typical gas!to!blood flow ratios with
current membrane oxygenators are in the range $". to #"$=#* depending on patient si/e
and temperature* SvO-* and desired arterial (CO- values"
Inhalational anesthetics may be delivered to the patient via the oxygenator ventilating
gas if a vapori/er is mounted on the C() console and placed in!line with the oxygenator
ventilating gas* which can facilitate systemic blood pressure control in addition to
maintaining anesthesia" It is important to mount vapori/ers away from disposable circuit
components because spilled volatile anesthetic fluid can structurally degrade plastics
+-@>-B," )ecause incorporation of a vapori/er in the oxygenator ventilating gas line
re&uires additional tubing connections* the integrity of the entire gas line should be
verified before starting bypass by clamping the gas line 0ust proximal to its 0unction with
the oxygenator and running a gas flow sufficient to generate a measured gas line
pressure of 8$ cm 4-O* thus ensuring that this pressure can be maintained at minimal
+e"g"* less than -$$ m:5min, gas flow +'$," The controversial issue of blood gas
management techni&ues +alpha!stat and p4!stat, during hypothermia is more fully
discussed in Chapters 8 and Chapter #-"
(lacement and use of vents and cardioplegia cannulae
The site of placement and use of vents is discussed more thoroughly in Chapter 7" All
vents should be tested before use by briefly immersing the tip of the vent in a basin of
saline or pool of blood at the operative site to verify its suctioning effect +Cig" -@"-," It is
important to avoid excessive negative pressures* which can cause hemolysis" This may
be accomplished by use of a one!way negative pressure relief valve in the vent line"
(ersonnel at the operative field should also verify the direction of flow for correct
placement of such valves" Sometimes a small!gauge needle is inserted in the vent line
to relieve pressure2 the necessity for placement of the needle in the proper +vent, line is
extremely important"
Diew Cigure
CIA -@"-" Gethod for testing the vent before use" Alternatively* the vent tip may be
placed in a pool of blood by the surgeon or assistant to verify proper suctioning before its
insertion in the heart or vessels"
Ideally* the perfusionist should be notified when vents are placed* and the surgeon
should announce when they are needed for use" This is particularly important if the vent
is placed in a nonroutine manner" ?iscontinuation and5or removal of the vent+s, also
should be communicated to the perfusionist* because a significant portion of blood return
to the C() reservoir may be through a vent2 thus* its removal may be accompanied by
an abrupt decrease in the C() reservoir level"
Operator safety
4ealth riss to all open heart team members include percutaneous needle stics* blade
cuts or other exposures to blood* and bac in0uries" Of these* exposure to bloodborne
pathogens represents the most serious ris" Cardiac surgery and C() pose a high ris
of blood exposure* and so!called universal precautions have been developed and
promulgated +'#, to decrease the ris of ac&uiring 4ID and hepatitis ) and C viruses"
4owever* health care worer awareness and compliance with such precautions appears
to be highly variable +'->'7," According to a recent multicenter study involving surgeons
+'@,* the lifetime ris of ac&uiring hepatitis ) or C is far greater than that of ac&uiring 4ID
+'$% to 8$% versus $".%," The 4ID seroconversion rate from a percutaneous needle
stic is $"-% to $".% +'6," )ecause preoperative universal testing of patients is
controversial and more expensive than practicing universal precautions +'B,* it is prudent
for all who have patient contact during open heart surgery to adhere to universal
precautions +8$," These include the use of personal protective e&uipment +gloves*
gowns* face mass* and eyeshields,* avoidance of procedures such as recapping used
needles* and proper disposal or cleaning of blood contaminated e&uipment after the
C() procedure"
GOEITORIEA ?URIEA )<(ASS
)ac to Fuic :ins
(hysiologic variables
)ecause the C() circuit and the patient9s circulation are contiguous during bypass*
circuit performance must be monitored and managed continuously to maintain ade&uate
perfusion and organ system viability" Hirlin and )arratt!)oyes +8#, distinguished
between those physiologic variables under direct external control and other variables
determined primarily by patient response" The first type include= total systemic blood
flow2 input pressure waveform2 systemic venous pressure2 hematocrit and composition
of priming fluid2 arterial blood oxygen* carbon dioxide* and nitrogen levels2 and
temperature of the perfusate and patient" The patient determines other variables* some
of which are still* in part* determined by external control= systemic vascular resistance2
total body oxygen consumption2 mixed venous blood oxygen levels2 lactic acidemia and
p42 regional and organ blood flow2 and organ function"
Gonitoring physiologic function during C() differs little in principle from normal
intraoperative monitoring practices for surgical procedures of similar magnitude without
C()" )ecause C() occupies only a portion of the total operative interval* management
of patients for surgical procedures re&uiring C() must include physiologic monitoring
appropriate to the patient9s condition in addition to the routine monitoring associated with
all anesthetic procedures" Cor example* the pre! and post!C() course for a patient
undergoing a second aortocoronary bypass surgery with a left ventricular
aneurysmectomy would be expected to be more complex than that for an otherwise
healthy child undergoing closure of a secundum atrial septal defect" Accordingly* the
intensity of physiologic monitoring should be based on patient condition* procedural
re&uirements* and expected problems"
Crom a practical standpoint* in addition to monitoring patient blood pressures +including
central venous ICD(J* pulmonary artery I(AJ* and5or left atrial I:AJ, and temperatures
+including myocardium,* the perfusionist and anesthesiologist should monitor the
electrocardiogram +1CA, and* if used* the electroencephalogram +11A," )oth can warn
of abnormal or unexpected conditions" Cor example* the development of cardiac
electrical activity manifested by a slow but regular wide FRS waveform may indicate
myocardial rewarming and inade&uate cardioplegia and the need for another infusion of
cardioplegic solution" Urine output should be monitored periodically during bypass as a
relative indication of ade&uate perfusion" )lood coagulation status is also monitored
throughout bypass +see Chapter --," Gost often a simple activated coagulation test is
performed periodically depending on previous test results* patient temperature* or
elapsed time" A less specific assessment should be made of patient neuromuscular
blocade or anesthetic depth" ?ecreasing mixed SvO- or overt patient movement may
indicate that additional anesthetic drugs are re&uired"
Circuit variables
Circuit parameters that should be continuously monitored by the perfusionist include the
systemic blood flow by calibrated roller pump or by electronic flowmeter when using a
centrifugal pump" Denous blood drainage to the C() circuit is assessed indirectly by
monitoring the volume of perfusate in the reservoir" The perfusionist should always be
aware whether this blood volume is increasing +indicating venous or other blood return in
excess of systemic blood flow,* decreasing +indicating the reverse situation,* or relatively
stable" Awareness of the rate of rise or fall of volume in the reservoir should be
anticipated so that appropriate changes in systemic blood flow can be made in a timely
manner before a dangerously low volume situation occurs" It has been suggested that
the venous reservoir volume should be e&ual to -.% of the systemic blood flow +:5min,
to allow for a #.!second reaction time +8-," Recommendations from device
manufacturers on minimum blood levels for safe operation to avoid entrainment of air
should be considered as well" Cigure -@"' shows reaction times for various reservoir
blood volumes at different blood flow rates"
Diew Cigure
CIA -@"'" Reaction times with various C() reservoir volumes" 1ach curve depicts
decreasing reservoir volume plotted as a function of flow rate and time +in seconds, in
the event there is a cessation in venous drainage" As the flow rate is increased* the
perfusionist9s time to mae an appropriate reduction in C() systemic flow is reduced"
The dashed hori/ontal line shows the flow rate that should not be exceeded for a given
reservoir volume to maintain #. seconds9 reaction time"
The perfusionist should try to anticipate the surgeon9s needs during bypass +8', not only
by being aware of C() circuit function and the various monitored patient parameters*
but also by the progression of the operation and activity and movements of personnel at
the sterile field" It is useful to establish a pattern of continuous scanning of C()
functions and monitors and the activities of other personnel in the operating room"
?istractions and interruptions extraneous to patient management during C() can lead to
errors" In this regard* the perfusionist would be well advised to adopt a 3curious and
suspicious3 attitude any time C() is being used" This is a philosophy practiced by many
airplane pilots to anticipate and avoid potential problems +88, +see Chapter -6,"
The perfusionist ad0usts the flow and composition of ventilating gas to the oxygenator in
response to changing patient temperature and blood gas results" This gas flow is
monitored by an in!line flowmeter and oxygen monitor* which should have ad0ustable
upper and lower alarm settings" Inhalational anesthetics* if used* should be scavenged
via suction from the oxygenator exhaust port* and the degree of suction applied should
be regulated to avoid problems with oxygenator gas transfer +8.*87, or air embolism
+8@," (ressure transducers or aneroid gauges on the systemic blood flow line can warn
of arterial cannula malposition or ins in the arterial line" Some C() consoles are
servoregulated to stop designated roller pumps if a preset line pressure is exceeded"
Geasuring pre! and postmembrane oxygenator blood pressures allows calculation of
pressure drop and may warn of oxygenator failure +86,"
Control over patient cooling and warming rates re&uires the perfusionist to monitor a
variety of temperatures* including arterial blood* venous blood* and water sources for the
oxygenator and cardioplegia delivery system" Induction and reversal of hypothermia
should be guided by maintenance of an 6 to #-KC gradient between the arterial blood
and patient temperature when cooling and between the venous blood and heat
exchanger water source when rewarming to avoid the potential for free gas to come out
of solution +8B," It is advisable to monitor at least two patient temperatures +e"g"* bladder*
nasopharyngeal* tympanic* rectal* and5or esophageal, in the event there is a probe
failure or malposition +.$," There also should be some periodic assessment of the
ade&uacy of water flow to the oxygenator9s heat exchanger and cardioplegia delivery
system* which can be assessed by listening to the flow and monitoring the water
temperature" Cerebral hyperthermia +.#*.-, should be avoided by careful monitoring of
patient and blood temperatures and by not allowing the perfusate temperature to exceed
'@".KC when on total C() and '6KC when on partial C() with reestablishment of
pulmonary blood flow"
Suction pump speed should be regulated to achieve ade&uate blood and5or air removal
without excessive pump speed that can cause the lines to 3chatter3 or obstruct*
potentially resulting in hemolysis" :iewise* when a roller pump is used for a vent* its
speed must be regulated to prevent possible air embolism* which can occur with high
negative pulmonary venous pressures that can pull air across the alveolar membranes
+#7,
The next section presents a more detailed discussion of physiologic aspects of patient
monitoring commonly used to assess abnormalities produced specifically by C()"
(4<SIO:OAIC R1S(OES1
)ac to Fuic :ins
Cardiovascular monitoring
Systemic blood flow and perfusion pressure
Eote #= The precise value for the hemoglobin oxygen content of whole blood at #$$%
saturation is not definitely nown and may not be a constant" (ure hemoglobin in
solution +molecular weight 78*8.6, can combine with #"'B m: of O- per gram* but whole
blood contains other hemoglobin subtypes such as methemoglobin* carboxyhemoglobin*
and so forth that decrease the net oxygen!carrying capacity +.'*.8," The value of #"'8 is
commonly cited* but in fact one study has shown that #"'$7 m: O- per gram hemoglobin
was the most applicable number clinically +..,"
Eote -= There is disagreement regarding the declining cardiac output with increasing age
that may also apply to the relationship of O- to increasing age" 1arly studies
demonstrated a clear inverse relationship between increasing age and cardiac output
+.7," 4owever* the study populations were unselected and the increasing prevalence of
cardiovascular disease with advancing age maes the interpretation of the data unclear"
Gore recent studies have confirmed the earlier data for sedentary individuals but show
well!preserved cardiac function* including cardiac output* in physically fit elderly persons
free of overt cardiovascular disease +.@*.6,"
Gaintenance of cardiovascular stability during C() re&uires the obvious interplay of
machine +C(), function for blood flow and patient factors such as systemic vascular
resistance and venous compliance" <et despite the ease of blood flow control and the
sophisticated pharmacologic agents available for manipulation of vascular smooth
muscle tone* there is no uniformly accepted standard for either C() systemic blood flow
rate or perfusion pressure" Any discussion of optimum flow rates and perfusion pressure
during C() should be based on an understanding of oxygen consumption* blood flow
distribution* and intrinsic autoregulatory capability of specific vascular beds"
Cortunately* in some of these areas a reasonable body of nowledge has developed
over the nearly .$!year history of clinical C()" Unfortunately* there are large gaps in the
data" Cor example* clinically the regional distribution of blood flow during hypothermic
C() and the regional vascular autoregulatory capability remain relatively poorly
understood* with some notable exceptions as discussed below"
Oxygen consumption
Ginute oxygen consumption +O-, is the ma0or determinant of blood flow re&uirement
normally and during C()" The well!nown Cic e&uation describes O- in the readily
understandable and clinically measurable terms of cardiac output and arteriovenous
oxygen content difference"
where C+a>v,,O- +#"'8, +4b, L +(+a>v,,O-, +$"$$'#, and O- M minute oxygen
consumption +mlNmin5>#,* M cardiac output +literNmin5>#," Also* 4b is the hemoglobin
concentration +gNliter5>#,* #"'8 M hemoglobin oxygen content +ml O-Ngm5>#, at #$$%
saturation +mlNg5>#,* S+a>v,,O- M arteriovenous hemoglobin oxygen saturation difference
+mlNliter5>#,* (+a>v,,O- M arteriovenous oxygen partial pressure difference +mm 4g,* and
$"$$'# M solubility of oxygen in blood +ml O-Nmm 4g5>#N#$$ ml blood5>#* at '@KC,
increased by hypothermia"
Thus* nowledge of O- allows reasonable prediction of effective blood flow re&uirement
during C() for any given level of hemoglobin concentration +hemodilution, and
arteriovenous oxygen content difference +oxygen extraction," Two important caveats
apply to this simplistic approach" Cirst* there is a re&uirement for accurate nowledge of
O- and second* the ey phrase is 3effective flow"3
?eterminants of O-
Total systemic O- is primarily a function of age* si/e +body surface area or lean body
mass,* and temperature" In the newborn infant* O- in proportion to body weight is
approximately twice that of the average adult +6 versus 8 m:5g5min," This proportion
rises over the first - months of life to a pea of B to #$ m:5g5min" Thereafter* there is an
exponential decline in O- per unit mass* as age increases* which parallels the change in
cardiac index with age" The relationship between O- and si/e is similar to that for O-
and age in that as body mass increases +beyond an age of approximately 7 months,* the
O- per unit mass actually decreases" The influence of temperature on O- is fully
discussed in Chapter #-" In the present context it is important to remember that the
relation is nonlinear and O- approaches a minimum of #$% to #.% of the normothermic
value at approximately #.KC +Cig" -@"8," Importantly however* this decline in O- with
decreasing temperature may not be the same in all organs" Cor example* the duration of
3safe3 circulatory arrest time at #6KC is 8. to 7$ minutes regarding neurologic outcome*
yet for renal function at #6KC the safe limit is significantly longer" The transplantation
literature would suggest even longer 3circulatory arrest3 times for transplanted organs +8
to . hours for the heart* -8 or more hours for the idney and the liver,* recogni/ing of
course that graft organs are stored at more profound levels of hypothermia +less than
8KC, than are clinically applied in C()" 4owever* factors other than decreased O-Ofor
example* variable* tissue!specific tolerance for hypoxiaOmay also contribute to the
variability of safe arrest time in different organs maintained at the same temperature"
Diew Cigure
CIA -@"8" Relationship between oxygen consumption +O-,* as a percent of the value at
'@KC* and body temperature" The dotted lines show the @$% confidence limits" +Crom
Hirlin P;* )arratt!)oyes )A" Cardiac surgery * -nd ed " Dol" #" Eew <or= Churchill
:ivingstone* #BB'=78* with permission",
1ffective flow
?uring C()* effective blood flow is blood flow from the oxygenator that actually results in
tissue perfusion" It must be understood that arterial blood aspirated from the surgical
field represents a loss of effective flow from total C() flow" In this context* all physiologic
and anatomic shunting of arteriali/ed blood around capillary beds to the venous
circulation also detracts from effective perfusion" Cor example* bronchial blood flow*
which is normally the ma0or component of 3physiologic3 right!to!left shunting of blood
+-% to 8% of cardiac output,* may be significantly increased in certain congenital lesions
associated with decreased pulmonary arterial blood flow and correspondingly increased
pulmonary collateral blood flow" In adults with significant chronic obstructive lung
disease* bronchial blood flow may also be significantly increased" At a total flow rate of 8
to . :5min during C()* this physiologic shunting may normally be -.$ to .$$ m:5min
that is lost from effective systemic perfusion and pathologic increases in bronchial or
pulmonary collateral flow may substantially increase that amount of lost effective blood
flow"
:eft atrial* left ventricular* or aortic root vents are another common source of loss of
effective flow" )lood returned to the oxygenator from these vent lines is lost from
effective systemic perfusion" (arenthetically* the re&uirement for such vents is largely
created by the existence of physiologic and anatomic shunts" Cinally* if the
microcirculation is inhomogenously perfused* for example because of an increased
interstitial fluid compartment either locally or systemically* then the net result is an
increased effective diffusion distance for oxygen from the capillaries to the cells that
results in a loss of effective perfusion" Thus* determination of effective blood flow is not
altogether straightforward* and it may be at times significantly less than total C()
systemic output"
Organ autoregulation
Autoregulation of blood flow to various organ vascular beds during C() obviously
pertains to any discussion of blood flow rate and perfusion pressure re&uirements during
C()" (hysiologically* autoregulation of blood flow refers to the ability of organ
vasculature* through neural* chemical* and direct smooth muscle effects* to regulate
local resistance to maintain relatively constant flow despite significant changes in
perfusion pressure +.B," This capability is preserved in some organ vascular beds during
C() despite the superimposition of a nonpulsatile flow pattern* hemodilution* and
hypothermia" Cor example* Aovier et al" +7$,* (rough et al" +7#,* and Gurin et al" +7-,
independently examined cerebral blood flow responsiveness to changed perfusion
pressure and carbon dioxide tension during C()" The conclusion from these studies is
that CO- responsiveness of the cerebral vasculature is maintained during C() even at
-$KC" Also* autoregulation of cerebral blood flow to changes in perfusion pressure is
preserved during C() and the response curve may even be shifted to the left* indicating
a decrease of the autoregulatory pressure threshold from the normal of about .$ mm 4g
to approximately '$ mm 4g" As discussed by Thomson +7',* this lowering of the
pressure threshold for autoregulation is lined to the decreased cerebral metabolic rate
for oxygen produced by hypothermia" The cerebral perfusion pressure intercept with the
maximal vasodilation blood flow line would be expected to be lower as temperature
decreases if blood flow and metabolic rate remain coupled during hypothermia* as has
been shown by Gurin et al" +7-, for alpha!stat p4 management +Cig" -@".," Others have
shown in animal studies that cerebral blood flow during moderate hypothermia is
primarily regulated by arterial blood pressure and not C() systemic flow rate +78,"
Diew Cigure
CIA -@"." Theoretic effect of hypothermic bypass on the autoregulatory threshold" The
solid lineis the pressure flow relation for the maximally vasodilated state" The
autoregulatory threshold is the point where the autoregulatory plateau +represented by
the dashed lines, intersects the maximal vasodilation pressure flow relation" Aiven
maintained coupling between cerebral metabolic rate and blood flow* a decreased
metabolic rate such as that produced by hypothermia will effectively produce a leftward
shift of the autoregulatory threshold +lower dashed line* solid line intersection," C)C*
cerebral blood flow2 C((* cerebral perfusion pressure" +Crom Gurin PG* Carrar PH*
Tweed A* et al" Cerebral autoregulation and flow5metabolism coupling during
cardiopulmonary bypass= the influence of carbon dioxide" Anesth Analg #B6@27#=6-.*
with permission",
The effect of C() on autoregulation in other organs is clinically less well documented"
:iewise* the effect of C() on distribution of blood flow to +and within, specific organs
re&uires further study in humans despite nearly .$ years of clinical experience and many
millions of cases with C()* as well as a substantial experimental data base"
1xperimentally* with systemic blood flow in the range of -"$ to -". :5min5m-* systemic
blood flow distribution remains essentially normal +7.," 1xperimentally* hypothermia
during C() is associated with altered local O-* and the associated change in vascular
resistance tends to promote regional blood flow distribution in proportion to the local O-
produced by hypothermia"
Gonitoring perfusion ade&uacy
Systemic measurements that may indicate the ade&uacy of total blood flow relative to
total O- during C() include SvO-* p4* and lactate concentration" The latter two are
closely lined because accumulation of lactic acid in blood leads to hydrogen ion
accumulation through dissociation +C4'C4O4COO4 C4'C4O4COO> L 4L," 4owever*
there are other sources of hydrogen ion production during oxygen +blood flow,
deprivation such as ongoing glycolysis +anaerobic glucose metabolism, and continued
adenosine triphosphate hydrolysis* both of which produce a net accumulation of
hydrogen ion"
Geasurement of hemoglobin oxygen saturation in the venous blood +or venous oxygen
partial pressure, during C() has the same significance as the corresponding (A +mixed
venous, measurement during normal circulation" Aiven steady!state conditions of
hemoglobin concentration* (.$ +primarily a function of -*'!diphosphoglyceric acid
concentration* temperature* and p4, and arterial oxygenation and then SvO- will change
in direct proportion to systemic blood flow at constant O-" Unfortunately* the inverse
relationship between SvO- and O- +predictable from the Cic e&uation, confounds the
simple interpretation of SvO- data" Cor example* if blood flow and arterial oxygen
content are held constant* then SvO- will increase as O- decreases +77," In the case of
a capillary bed that is hypoperfused relative to the local level of O-* the contribution to
the systemic SvO- +or p4 or lactic acid concentration* for that matter, is a function of the
ratio between systemic blood flow volume and the local area blood flow volume"
Importantly* an intense hypoxic insult in a focal area of considerable clinical importance
+e"g"* brain* heart* idney, may well not produce a ma0or change in SvO-" Accordingly*
although monitoring SvO- during C() is a common practice* a normal or increased
SvO- value during C() does not ensure that the C() systemic blood flow is necessarily
meeting regional oxygen delivery +?O-, re&uirements" 4owever* a low SvO- during C()
does indicate a problem with systemic ?O- that may be due to insufficient blood flow*
hemoglobin function or concentration* arterial oxygenation* or excessive oxygen
consumption due to inade&uate anesthesia or hyperthermia"
Relationship between perfusion and O- consumption
One method for individuali/ing blood flow volume relative to O- during C() was termed
oxygen consumption plateauing by its original describers* Gandl and Gotley +7@," Using
this method* O- is calculated during C() and the perfusion is increased until there is no
further increase in O-* the O- plateau" (erfusion is then maintained at this level until an
intervention occurs that would be expected to alter O-* for example rewarming* at which
point the plateau must be reestablished" One theoretic advantage to this techni&ue is
that it calls attention to variables other than flow that have an effect on O-" Cor example*
pharmacologic manipulation of perfusion pressure* if excessive vasoconstriction or
vasodilation exist* may improve O-* presumably by improving perfusion to previously
under perfused areas" The concept then becomes one of O- optimi/ation"
The chief difficulty of the techni&ue is the lac of a gold standard against which to
compare any given clinical O- calculation during C()" The steady!state awae or
anestheti/ed pre!bypass value may be calculated and used as the baseline for C()*
when corrected for the expected temperature effect* but using the uncorrected awae
O- as the baseline would yield excess perfusion during C()" The anestheti/ed*
paraly/ed* mechanically ventilated patient has a substantially lower O- than the awae
patient" Another difficulty is that clinically there is not as clear a plateau to O- as would
be theoretically predicted" (arolari et al" +76, have further studied O- and the influence
of hemodynamics during C() in #$# patients managed with conventional systemic flow
indices +-"8 :5min5m- during cooling and rewarming and -"$ :5min5m- when
hypothermic at -6 to '$KC," There was a direct relationship between ?O- and O- during
the three phases of bypass" ?uring cooling* there was no relationship between O- and
either mean arterial pressure or peripheral vascular resistance* but during warming
these parameters were inversely related2 hence* lower mean arterial pressure and
peripheral vascular resistance values were associated with higher O-" This may be
attributable to the natural tendency for patients to vasodilate as they rewarm" They could
not demonstrate a plateau effect in any patient but acnowledged that only a narrow
range of C() flows and deliveries was used" They recommended higher C() systemic
flows during all phases of C() but particularly during rewarming to achieve an optimal
whole body oxygen metabolism" Optimi/ation of O- during C() may provide the best
means of assessing ade&uacy of perfusion during C()2 however* this represents an
untested hypothesis* at least as measured against the standard of clinical outcome"
Clow recommendations
;hat then are reasonable flow recommendations for C()Q In adults at normothermia*
progressive acidosis and increased lactate production are seen with total flows less than
#"7 :5min5m- or .$ m:5g5min +7B*@$," Clinical and experimental data support a total
flow of #"6 :5min5m- as predictive of the O- plateau in normothermic adults +@#*@-,"
Hirlin and )arratt!)oyes +@', recommended a flow of -"- :5min5m- in adults -6KC or
warmer" In patients greater than -"$ m-* a systemic flow of #"6 to -"$ :5min5m- is
recommended to avoid excessively high flows through the C() circuit that can increase
blood damage and lessen the perfusionist9s reaction time" ?uring hypothermia* various
nomograms have been proposed +Cig" -@"7, that predominantly rely on the plateauing of
O- to indicate overall ade&uacy of perfusion for any given temperature" The
recommended flow in infants and children is higher at -". :5min5m-" Hern et al" +@8,
delineated minimum flow rates of '$ m:5g5min at #6KC and '$ to '. m:5g5min at -@ to
-6KC in pediatric patients for maintenance of ade&uate cerebral blood flow and unaltered
cerebral oxygen consumption using xenon!#'' clearance methods"
Diew Cigure
CIA -@"7" Relationship of oxygen consumption +O-, to perfusion flow rate and
temperature" The small Rs represent commonly clinically used flow rates at the various
temperatures" +Crom Hirlin P;* )arratt!)oyes )A" Cardiac surgery * -nd ed" Dol" #"
Eew <or= Churchill :ivingstone* #BB'=B#* with permission",
(erfusion pressure and vascular resistance
(erfusion +arterial, pressure during C()* lie blood flow* remains a topic of some
controversy in the management of C()" In general* blood flow probably outweighs
perfusion pressure as a guide to ade&uacy of perfusion during C()* especially with
hemodilution* but solid data supporting this contention are lacing" In a prospective
randomi/ed study investigating outcomes* Aold et al" +@., reported that maintenance of
higher perfusion pressures in the range 6$ to #$$ mm 4g +actually achieving a mean
perfusion pressure of @$ mm 4g, using flow indices of #"B to -"' :5min5m- and
vasoactive drugs was associated with a reduced combined incidence of cardiac and
neurologic complications when compared with patients whose pressures were
maintained at .$ to 7$ mm 4g" (erfusion pressure is determined by the interaction of
blood flow and overall arterial impedance" Impedance* in this case* is primarily related to
actual friction resistance because the steady!state nonpulsatile nature of most C()
largely negates the elastance* inertial* and reflection components that influence aortic
input impedance during pulsatile flow" Criction resistance is primarily a function of the
vasomotor tone +cross!sectional area of the arterial system, and blood viscosity"
Discosity* in turn* is a function of temperature +see Chapter #-, and the degree of
hemodilution +see Chapter ##," The interaction of temperature and hematocrit with
regard to viscosity is depicted graphically in Cigure -@"@"
Diew Cigure
CIA -@"@" Changes in viscosity of human blood measured in vitrowith varying
temperatures and hematocrit +4tcrt," +Crom Robicse C* Gasters TE* Eiesluchowsi ;*
et al" Dasomotor activity during cardiopulmonary bypass" In= Utley PR* ed"
(athophysiology and techni&ues of cardiopulmonary bypass " )altimore= ;illiams S
;ilins* #B6'=7* with permission",
Cor any given level of hematocrit* viscosity +and therefore resistance to blood flow,
increases substantially as temperature decreases" Eormal viscosity at '@KC and a
hematocrit of 8$% approximates that seen at -.KC with hematocrit of -.%" This
relationship indicates the importance of hemodilution in C()* especially with
hypothermia" ;ith the onset of C()* using an asanguineous prime solution there is an
immediate fall in systemic vascular resistance that is not seen with a blood prime +Cig"
-@"6," This drop in resistance with the onset of C() is primarily due to the acute
decrease in viscosity produced by the hemodilution from the prime solution +@7,"
Cortunately* this usually transient hypotension appears to have little clinical effect"
Diew Cigure
CIA -@"6" Changes in circulatory resistance comparing data from #. patients undergoing
normothermic bypass with a crystalloid prime +solid line, to 6 patients undergoing
normothermic bypass with a blood prime" R:* Ranger9s lactate solution" +Crom Robisce
C* Gasters TE* Eiesluchowsi ;* et al" Dasomotor activity during cardiopulmonary
bypass" In= Utley PR* ed" (athophysiology and techni&ues of cardiopulmonary bypass "
)altimore= ;illiams S ;ilins* #B6'=8* with permission",
A more complex phenomenon pertaining to perfusion pressure during C() is the
increasing vascular resistance seen over time" )ecause of the third space e&uilibration
of crystalloid prime solutions and the hemoconcentrating effect of the diuresis commonly
seen during C()* the initial drop in viscosity is corrected as the excess crystalloid is
removed from the vasculature" Add to this the physical increase in viscosity produced by
even moderate hypothermia +Cig" -@"@, and it would seem attractive to accept that
viscosity change accounts for both the precipitous drop in vascular resistance with the
onset of C() and the steady increase of resistance over time during C()" 4owever*
even if temperature and blood composition +viscosity, are held constant during C()*
calculated vascular resistance still increases with time +@7,"
The increase in circulating catecholamines that occurs during C() is well documented
and is to some extent modifiable by the type and depth of the anesthetic* but there
remains in most clinical circumstances a significant increase in plasma catecholamines
during C() +@@*@6," This catecholamine release is but one manifestation of a ma0or
stress response elicited by C() +see Chapters #. and #@," It is liely that the additive
vasomotor effects of circulating catecholamines and other vasoactive mediators of the
stress response are responsible for the increased vascular resistance found during and
after C()" Indirect evidence that reflex sympathetic neural activation may also play a
role in this response is provided by the observation that unilateral stellate ganglion
blocade ameliorates the hypertensive response after C() +@B,"
Arterial pressure measurement artifacts
Another practical point regarding perfusion pressure during and immediately after C() is
the relatively common occurrence of significant measurement artifacts" 1specially when
hypothermia has been used during C()* a significant underestimation of central aortic
pressure is seen in measured radial artery pressures* sometimes by as much as '$% to
8$%" This is counter to the normal state where actual radial artery systolic pressure
exceeds central aortic pressure by #$% to #.% or more* largely due to the amplification
of effects of pressure waves reflected from the periphery +6$,"
This artifact is associated with rewarming at the end of C() and often continues for '$
minutes or more into the post!C() interval" The physiologic cause of the artifact is not
completely understood" In the past* persistent vasoconstriction was often stated to be
the cause" 4owever* sufficient proximal conductance vessel constriction to dampen the
radial pressure is unliely* and the effect of distal constriction should be an enhancement
of the normal gradient" A more liely explanation is that rewarming initiates uneven
vasodilation and intense seletal muscle vasodilation in the forearm and hand may have
the effect of a large arteriovenous shunt* thereby decreasing the pressure measured at
the radial artery +6#," The final solution to this interesting pu//le remains" )ut the
important clinical message is that apparent hypotension* as measured at the radial
artery* at the conclusion of C() should be confirmed* preferably by a central aortic or
femoral arterial pressure measurement* before instituting inotropic or vasoconstrictor
therapy" This is easily accomplished using an #6! or -$!gauge needle with pressure
tubing connected to a transducer" As an alternative* use of a ?oppler probe placed over
the brachial artery in con0unction with an ordinary blood pressure cuff and manometer
may provide more accurate measurement of arterial pressure than an indwelling radial
artery catheter in this situation"
Other common causes of low pressure artifact from the radial artery measurement
include surgical retraction and patient si/e" Significantly obese patients positioned with
their arms tuced to the sides will fre&uently have enough tissue compression of the
axillary artery to cause dampening of the radial artery waveform" 1ven with nonobese
patients* this positioning coupled with aggressive use of a sternal retractor for internal
mammary artery dissection can lead to axillary artery compression and radial artery
waveform dampening" Cor completeness* the potential disaster of aortic dissection must
be mentioned +see Chapter -6 for further discussion," A sudden precipitous drop of
radial artery pressure +either left or right* but more classically left, coincident with the
onset of C() should at least raise the &uestion of aortic dissection caused by aortic
cannula malposition at the onset of perfusion" Cortunately* the associated findings of a
tensely distended aorta with obvious intramural hematoma formation are sufficiently
pronounced to mae the diagnosis of the problem relatively straightforward"
Unfortunately* the treatment of the problem is substantially more complex +see Chapter
'8,"
:ess common* but of e&ual or greater importance* is the artifact of radial artery pressure
measurement during C() caused by inappropriate aortic perfusion cannula placement
so that the flow of blood out of the cannula is directed preferentially into one of the great
vessels of the aortic arch" The artifact produced is a high and very pulsatile radial arterial
pressure when the radial catheter is ipsilateral to the inadvertent cannulation in the case
of either the innominate or left subclavian artery +Cig" -@"B," Another clinical sign of this
same complication is laterali/ed blanching of the face with the onset of C() in the case
of the left carotid artery perfusion +6-," The clinical problem presented is one of gross
hyperperfusion of the cerebral arterial system leading to cerebral edema or fran
neurologic in0ury and also the probability of significant systemic hypoperfusion"
Awareness of the potential problem by perfusionists* surgeons* and anesthesiologists
coupled with vigilance for these signs is the ey to preventing this potential disaster"
Diew Cigure
CIA -@"B" :eft radial artery pressure waveform during cardiopulmonary bypass" The high
pulsatile pressure is due to the arterial cannula inadvertently directed into the left
subclavian system" At the arrow* the cannula was redirected into the aortic lumen" +Crom
GcClesey C4* Cheney C;" A correctable complication of cardiopulmonary bypass"
Anesthesiology #B6-2'7=-#8>-#7* with permission",
(ulmonary artery and left atrial pressure monitoring
)oth (A and :A pressure monitoring have a ma0or role in clinical care decisions in
cardiac surgical patients" The most important components of this role are found in the
pre! and post!C() intervals* and both measurements feature prominently in decisions
regarding weaning from C() +see Chapter -B," 4owever* both monitors can be useful
during C()" The :A pressure and* less directly* (A pressure give the same information
regarding left ventricular filling during C() as off C()" )ut rather than the usual clinical
context of using the measured :A or (A pressure to guide the ad0ustment of ventricular
filling to appropriate physiologic levels* during C() the expectation is that both (A and
:A pressures should be near /ero and the monitoring is used to prevent overdistension
of the left ventricle" Cor example* a patient with maredly increased bronchial blood flow
due to chronic lung disease or cyanotic congenital heart disease can maredly
overdistend the left ventricle if venting is not ade&uate" Another example is the patient
with aortic valve insufficiency" As left ventricular emptying decreases +on C() and
cooling, or stops +on C() with fibrillation,* massive overdistension can rapidly result
from blood flow through the incompetent aortic valve" ?uring ventricular fibrillation*
surgical manipulation of the heart can result in significant incompetence of even an
anatomically normal aortic valve" In most cases* this type of abnormal filling of the left
ventricle during C() can be detected by monitoring either the :A or (A pressure"
Importantly* however* because of compliance variation among patients* there is no
&uantitative predictability of left ventricular volume based on :A or (A pressure"
Therefore* one should expect near /ero pressures and be wary of any increase during
C()"
As with radial artery catheter pressure measurement* one must be aware of
measurement artifacts during C() in :A and (A pressures" )oth :A and (A catheters
can be inadvertently ined or obstructed2 :A catheters are more vulnerable to
inadvertent dislodgment than are (A catheters* but both are vulnerable" There is a
tendency during C() for a (A catheter that has been properly positioned in the pre!
bypass period to migrate distally into the (A by ' to . cm or more as blood volume is
taen from the right ventricle into the venous reservoir and the heart empties with
initiation of C()" This can produce a 3permanent wedge3 phenomenon that has been
implicated in (A rupture or pulmonary infarction" Often this malposition is indicated by a
distinct increase in the (A pressure reading or SvO- in the case of an oximeter (A
catheter" This malposition is sufficiently predictable that it may be clinically prudent to
arbitrarily withdraw the (A catheter by ' to . cm at the commencement of C()" The
routine use of a catheter introducer and a sterile protective sheath allows sterile
repositioning of the (A catheter at the end of C()" Some experienced clinicians
recommend withdrawal of the (A catheter further* into the superior vena cava +SDC,*
during C()" 4owever* refloating the (A catheter at the end of C() is not always easily
accomplished* and difficulty is most liely in the low output management problems where
the (A catheter is most useful" ?espite the seemingly sound arguments for withdrawing
the (A catheter during C()* it has not been conclusively shown that this practice
decreases the already small incidence of (A catheter!induced (A rupture"
CD( measurement is also helpful in guiding clinical decisions during C()" As with :A
and (A pressures* the expectation is that pressure in the vena cava Iboth SDC and
inferior vena cava +IDC,J should be at or near /ero or even slightly negative during C()"
In contrast to :A and (A pressure increase* an increased SDC or IDC pressure is not
usually associated with cardiac distension" Rather* the increased CD( indicates impaired
venous drainage to the venous reservoir due to either venous cannulas of insufficient
si/e* malpositioned venous cannulas* venous cannulas or drainage line obstruction* or
insufficient height differential between the heart and the venous reservoir to promote an
ade&uate siphon effect"
The ma0or adverse physiologic effect of elevated venous pressure during C() is a
reduction in effective perfusion pressure for critical organs such as brain* idneys* and
abdominal viscera and an enhanced tendency for edema production" Cor example* if the
mean arterial pressure is 7$ mm 4g during C() and if SDC and IDC pressures are near
/ero* then the brain* the idneys* and the splanchnic arterial bed have an effective
perfusion pressure of 7$ mm 4g" 4owever* if SDC or IDC pressure is elevated to -$ mm
4g* for example* then the net perfusion pressure in these same areas is only 8$ mm 4g
and the increased bac pressure will promote accumulation of edema" Crom this
perspective* the liver is theoretically particularly vulnerable because approximately @.%
of hepatic blood flow occurs at venous pressure via the portal vein" An elevated venous
outflow pressure +i"e"* IDC pressure, could theoretically have a ma0or adverse effect on
hepatic blood flow during bypass"
It is important to recogni/e that SDC and IDC pressures are not necessarily e&ual during
C() even with a single two!stage venous drainage cannula" Goreover* there is little
visible evidence of IDC engorgement with a median sternotomy incision" 1specially with
cardiac retraction and a single two!stage venous cannula* it is common to have venous
drainage impairment and an increased measured CD(" Denous pressure measurement
is also sub0ect to significant artifact during bypass" Cor example* during total C()
+bicaval cannulation with tourni&uets around the cavae,* the venous catheter may be
entrapped in the tourni&uet" If the venous catheter is occluded* the constant flush
infusion device on the transducer will rapidly overpressuri/e the transducer" On the other
hand* if the catheter remains patent and passes beyond the tourni&uet* then* with the
heart open* an artifactually low venous pressure will be measured" In this situation* SDC
and IDC pressure can each vary independently" A further CD( measurement artifact* not
specific for C()* is produced when the pressure port of a (A catheter remains within the
lumen of the introducer sheath* then an infusion into the sheath via the sidearm can
produce a pressure in excess of SDC pressure that is measured at the right atrial port of
the (A catheter +Cig" -@"#$, +6',"
Diew Cigure
CIA -@"#$" Right atrial pressure +RA(, is increased at the onset of the venous infusion
port infusion +solid arrow, and returns to the preinfusion level when the infusion stops"
A(* arterial pressure2 (A(* pulmonary artery pressure2 CA)A* coronary artery bypass
graft" +Crom ?avis RC" <et another CD( artifact" Anesthesiology #B6827$=-7-* with
permission",
The mixed SvO-* as measured from a (A catheter* loses most of its clinical utility during
C() because of the diversion of venous return into the venous reservoir" 4owever* as
previously mentioned* a very high (A catheter SvO- can be an indicator of a catheter in
3wedged3 position during C()" The value of SvO- measurement of venous blood
drained into the venous reservoir is considerable* having much the same significance as
the corresponding (A catheter measurement off bypass" As described above in the
section on blood flow and perfusion pressure re&uirements during C()* if one is aware
of the ma0or determinants of the SvO- value +hemoglobin concentration* blood flow*
hemoglobin (.$* arterial oxygenation* and systemic oxygen consumption,* then the
SvO- can be used as a guide to ade&uacy of oxygen delivery during C()"
Other cardiovascular monitors
Another increasingly commonly used clinical cardiovascular monitor is transesophageal
echocardiography" Unfortunately* a substantial portion of transesophageal
echocardiography utility is lost during C() with cardioplegia" )lood loss from the cardiac
chambers obscures the ultrasound definition of the chambers2 there is little or no cavity
and therefore little or no ultrasound contrast to define cardiac structures" :iewise*
during C() there is little or no intracardiac blood flow* so that ?oppler information on
blood flow velocity and direction and on valvular function is largely irrelevant" 4owever*
as the heart is filled near the conclusion of C()* transesophageal echocardiography
regains its ability to visually display intracardiac structures* wall motion* and blood flow
direction and velocity and can also be a useful guide to effective air evacuation from the
cardiac chambers"
1lectrocardiographic monitoring must be continued during C()" ?uring periods of
cardioplegic arrest* it is important to verify that the 1CA is isoelectric" After surgical
repair* the 1CA should return to the baseline state before weaning from C() +see
Chapter -B," Abrupt changes of the ST segment deviation from isoelectric should raise
the immediate &uestion of intracoronary emboli/ation of air +particularly to the right
coronary artery as typically reflected in leads II* III* and aDC, or particulates" (ersistent
ST segment deviation should raise the &uestion of ongoing ischemia that should be
investigated and corrected before terminating C()" One should not overloo the value of
direct observation of the heart as an ad0unct to 1CA diagnosis* especially in patients
with dysrhythmias"
Eeurologic monitoring
Eeurologic monitoring during C() is directed primarily toward the myoneural 0unction to
confirm ade&uacy of muscle paralysis and toward the central nervous system +CES, to
detect functional abnormalities developing during C()" The former is straightforward
and needs little attention here except to say that unnecessary oxygen consumption and
CO- production during moderate hypothermic C() are decreased when a complete
level of seletal muscle paralysis is maintained" This* coupled with the decreased
effective concentration of neuromuscular blocing agents produced by the blood volume
expansion from the C() priming volume +see Chapter ##,* explain the common clinical
recommendation to redose relaxants with approximately one!half of an expected
3intubating dose3 at the time of initiating C()" In this regard there is perhaps some
theoretic advantage to the use of d!tubocurarine because its ganglionic blocing side
effects may help control the increase in vascular resistance during hypothermia and
C()"
CES monitoring has traditionally relied on electrophysiologic measurement of neurologic
activity measured from the body surface and exemplified by the 11A" An enhancement
of this passive measurement is the evoed potential" Typically* an evoed potential is
measured as the surface electrophysiologic manifestation of the transmission of a
stimulus along a given neural pathway" Other nonelectrophysiologic CES monitoring
includes transcranial ?oppler and reflectance spectrometry" Transcranial ?oppler
ultrasound measures blood flow velocity in ma0or arterial segments in the brain and can
detect transient artifacts in the velocity signal attributable to particulate or gas emboli"
Reflectance spectrometry developments now allow measurement of the signal produced
by the mean venous oxygen hemoglobin saturation at discrete loci in the brain" Although
the CES monitoring capabilities applicable to patients undergoing C() are significant*
their clinical use is relatively small compared with the total scope of C() monitoring"
Also* the ability of more intensive CES monitoring to decrease the fre&uency of adverse
neurologic outcome after C() remains largely untested"
Recording of a full standard 11A electrode montage on a strip chart with an experienced
11A analyst observing the signals is the ideal method for 11A monitoring" The value of
this approach intraoperatively is debated for certain procedures such as carotid
endarterectomy2 however* application of such techni&ue to C() is rarely seen outside of
specific focused clinical investigation" The processed 11A* either compressed spectral
array or density modulated spectral array* provides a smaller volume of data than the
raw 11A" 4owever* the data are presented in a user!friendlier format* which allows
clinicians to detect laterali/ed +or global, change in both the dominant fre&uency and the
power of the 11A* even with intermittent observation of the record" 1xcellent
comprehensive reviews of this sub0ect are readily available +68>67,"
The process of C() presents many physiologic changes that maredly complicate the
interpretation of the 11A" The primary changes in the 11A indicating hypoperfusion or
hypoxia are slowing of the dominant fre&uency and loss of power in the signal* and
similar changes can be produced in the 11A by hemodilution* hypothermia* anesthetics*
C() systemic flow changes* and pulsatility changes* in addition to any imputed hypoxic
CES insult +68," Cor example* anesthetics have well!nown 11A effects* including the
ability to produce burst suppression or an isoelectric pattern with barbiturates and with
the volatile anesthetic isoflurane" Gild hypothermia itself produces slowing of the 11A*
which proceeds through burst suppression to an isoelectric pattern as temperature is
further decreased" 4owever* comparing temperature!related 11A changes to hypoxia*
there are differences that may become clinically useful +6@," Significant hypoxia is
mared by a rapid decrease in high!fre&uency 11A activity" Also* although the burst
suppression pattern of hypothermia tends to be regular* that seen with hypoxia is more
irregular" (erhaps the situation is analogous to ST segment depression in the 1CA"
4ere* the unproven but hopeful hypothesis is discrete 11A patterns exist* detectable
during C() and distinguishable from other effects* which reliably indicate CES hypoxia
at a treatable point before fran cytologic in0ury"
Currently* the use of evoed potentials during C() is largely limited to surgery involving
the descending thoracic aorta* generally repair of aortic coarctation* aortic dissection*
and aortic aneurysm repair" )ecause of the anatomy of the ma0or blood supply to the
spinal cord +the anterior spinal artery and the communicating artery of Adamewic/, +Cig"
-@"##,* the spinal cord is at ris of ischemic in0ury when the descending thoracic aorta is
clamped to permit surgical repair" )y monitoring the progress of an evoed signal at
several sites from the periphery to the cerebral cortex* one can monitor the function of
each component of the transmission se&uence from peripheral nerve through the spinal
cord to the cerebral cortex" Theoretically* observation of increased latency or decreased
amplitude of the evoed potential signal at any site along the path would allow
intervention before neurologic in0ury" In aortic coarctation* for example* observation of an
abnormal evoed potential after application of the aortic clamp could then trigger
removal and replacement of the clamp or some other +pharmacologic, maneuver to
increase perfusion pressure or cardiac output in an attempt to improve spinal cord blood
flow before the repair is undertaen" Unfortunately* the caveats regarding the interaction
of C()* hypothermia* anesthesia* hemodilution* and the 11A also apply to evoed
potentials" Also* the predominant type of evoed potential used clinically is currently the
sensory evoed potential" In the case of the somatosensory evoed potential* the motor
component of the spinal cord is relatively silent" Cases exist of dense motor paraplegia
after thoracic aortic surgery despite persistently normal somatosensory evoed
potentials throughout the aortic cross!clamp interval +66,"
Diew Cigure
CIA -@"##" Dariation in blood supply to the spinal cord" The variation diagrammed on the
right presents a higher ris for spinal cord ischemia with descending aortic surgery"
+Crom ?embitsy ;(" Central nervous system in0ury during surgery of the descending
aorta" In= Utley PR* ed" (athophysiology and techni&ues of cardiopulmonary bypass "
Dol" #")altimore= ;illiams S ;ilins* #B6-=6$* with permission",
Temperature monitoring
)ecause of the integral relationship between temperature control +manipulation, and
C()* temperature measurement is a core physiologic monitor during C()" A ma0or
difficulty* however* is the simple definition of 3core3 temperature" The technology
available for temperature measurement during C() is nothing less than abundant" The
problem is not how to measure2 the technologic capability exceeds the clinical need for
accuracy or adaptability" Geasurement of nasopharyngeal* esophageal* tracheal* mixed
venous blood* arterial blood* bladder urine* rectal* tympanic membrane* and even great
toe temperature are readily available for clinical use" In many cardiac surgical units*
measurement of two or more of these is common practice" )ut what is core
temperatureQ The concept of a single core body temperature is 0ust thatOa concept
rather than a reality" Cigure -@"#- is instructive in this regard" The expectation is that
especially during cooling or rewarming* temperature is site!specific and the variability
from site to site is significant"
Diew Cigure
CIA -@"#-" Relationships of temperatures measured at various sites over time during
cooling and rewarming from cardiopulmonary bypass" +Crom Stefanis/yn 4P* Eovic RP*
Heith CG* et al" Is the brain ade&uately cooled during deep hypothermic
cardiopulmonary bypassQ Curr Surg #B6'28$=-B8>-B@* with permission",
Temperatures are measured during cooling to ensure that the organs believed most
vulnerable to potential hypoperfusion actually receive the benefit of the desired degree
of hypothermia" In this regard the brain is usually the target* and nasopharyngeal +not
airway,* tympanic membrane* or esophageal +below tracheal bifurcation, are the usually
accepted best estimates of brain temperature" Tympanic membrane temperature
monitoring is less popular because of the occurrence of probe!related tympanic
membrane in0ury" Gixed venous temperature in the extracorporeal circuit is a reasonable
indicator of average body temperature directly analogous to an SvO- measurement"
?uring rewarming* the target* obviously* is a normothermic patient at the end of C()"
Success is both time and temperature dependent" Cor example* the total caloric loss in a
series of adult patients cooled to '$KC for #'$ minutes on C() was calculated at -'6
cal +6B," The net return during rewarming was approximately #7$ cal* leaving a heat
debt of @6 cal or approximately the e&uivalent of #". hours of the basal metabolic heat
output" This deficit is liely the explanation for the common clinical observation of
rebound hypothermia* sometimes termed afterdrop* after termination of C()" In this
regard* the use of vasodilators* nitroprusside or nitroglycerin* to force a vasodilation
during C() theoretically promotes a more uniform rewarming and has been clinically
shown to decrease the incidence and severity of rebound hypothermia after C() +B$,"
Important considerations for temperature measurement during rewarming are prevention
of liberation of free gas bubbles and blood damage" )ecause of the inverse relationship
between gas solubility in blood +or any li&uid, and temperature* dissolved gases tend to
come out of solution as a fluid is warmed" If this happens clinically* the conse&uences of
gaseous emboli/ation +even microemboli, can be significant" In general* maintenance of
a temperature gradient from the heat exchanger to the venous blood of not more than
approximately #$KC will prevent significant microbubble formation" Although heat
exchangers are highly efficient* there is a temperature gradient produced within the heat
exchanger" A boundary layer forms immediately ad0acent to the heat exchanger in which
blood temperature will e&ual heat exchanger water temperature* whereas blood farther
away from the exchange surface will not fully e&uilibrate with water temperature"
)ecause blood damage +both cellular elements and protein denaturation, increases with
temperature greater than 8-KC* this temperature forms the practical upper limit to water
temperature within the heat exchanger +B#," )ut as previously mentioned* the minimum
exchanger water temperature* approximately 8KC* appears not to damage blood"
Urinary volume and renal function
A detailed discussion of the effect of C() on renal function is found in Chapter #B" Gost
cardiac surgical teams closely follow the urine flow of patients during C() as an
indicator of normal renal function" Although a bris flow of urine during C() may be
comforting and may* in fact* facilitate fluid management during C()* existing clinical data
do not support a close relationship between urine flow while on bypass and
postoperative renal function" In the mid!#B@$s* Abel et al" +B-, examined a large number
of patients for factors predictive of postoperative renal failure" Two ma0or factors
emerged as significant correlates of postoperative renal failure= time on bypass and
preexisting renal failure" Other factors* including urine volume on bypass* were not
significantly related to postoperative renal failure"
;hat is the place of diuretic medications* either osmotic +i"e"* mannitol, or loop +i"e"*
furosemide and congeners,* in the management of the oliguric patient during C()Q
Several considerations are pertinent" The first is to ensure catheter patency" This may
seem simplistic* but clinical experience indicates that the bladder is remarably
compliant and that pharmacologic diuresis will rarely fill it to a pressure sufficient to
overcome an obstructed catheter" In general* a physiologic urine volume of $". to #"$
m:5g5hr re&uires no treatment" Oliguric or anuric patients may or may not benefit from
diuretic therapy" Again* available clinical data do not relate urine volume during C() to
postoperative renal dysfunction" 4owever* oliguria or even normal urine flow in the face
of hyperalemia* hemoglobinemia +presumed hemolysis,* or suspected volume overload
+excessive hemodilution, are indications for diuresis" Theoretically* in the case of
hyperalemia* loop diuretics would provide the greatest potassium loss" In the case of
hemoglobinuria* a large volume of alaline urine is desired* so either loop or osmotic
diuretics +or both, may be useful"
Coagulation status
Coagulation monitoring is an obviously ma0or area of patient monitoring during C()"
Chapters -- through -. provide a detailed review of all relevant aspects of coagulation
and C()"
:aboratory data
The fre&uency and type of laboratory data monitored during C() are relatively institution
specific* but laboratory support should minimally include blood gas and p4 measurement
and rapid access to electrolytes* especially potassium and calcium* and glucose and
perhaps lactate" ;hether these data are available from a satellite laboratory in close
proximity to the operating room* from in!line or in!room monitors* or from the main
hospital laboratory is less important than the rapid availability of data" The rapidity and
magnitude of intraoperative changes in these parameters in cardiac surgical patients
maes their rapid +.! to #$!minute, availability a virtual re&uirement for safe cardiac
surgery"
A common area of controversy in blood gas data interpretation during C() is the
management of (aCO- and p4 during hypothermia" The discussion of alpha!stat versus
p4!stat management schemes is well presented in Chapters 8 and #- and does not
need to be recapitulated here" The use of potassium!based cardioplegic solutions
mandates the capability for rapid and accurate assessment of serum potassium
concentration" The metabolic conse&uences of C()* especially those involving glucose
utili/ation +see Chapter #@,* create the re&uirement for fre&uent glucose +and optimally
lactate, measurement during and after C()"
Technologies for in!line* on!line* or local laboratory measurements include cartridge!
based electrode systems and intravascular* usually fluorochrome* catheter!based
technology" The latter generally couples intensity of fluorescence of the fluorochrome
when stimulated by light at a specific wavelength to fiberoptic technology for
transmission of the emitted fluorescent light to an analytic instrument" The intensity of
fluorescence is proportional to the concentration of the parameter being measured
+(aO-* (aCO-* or p4," Current capabilities in this area include systems that will pass
through a -$!gauge catheter* are capable of giving near!continuous (aO-* (aCO-* and
p4 data at ambient patient temperature* and still permit pressure measurement via the
same catheter" ?epending on institutional practices regarding fre&uency of blood gas
analysis and cost of the testing* this new approach may prove to be cost effective* but
the clinical value +despite widespread use, of continuous measurement of blood gas
data as opposed to intermittent sampling remains to be established"
The cartridge electrode systems are more conventional in that electrochemical reactions
form the basis for measurement" The advantage is that the cartridge is a self!contained
unit with electrodes and calibration solutions capable of maing a defined number of
measurements over a defined timespan" Cor institutions capable of using the full
capacity of the cartridge within its lifespan* the result is also often cost effective"
Cartridge!based systems are often small enough to be physically attached to the C()
circuit and may be e&uipped with automatic sampling capability" Although this is not
actually a continuous measurement* the sampling fre&uency is programmable and
limited only by the time re&uired for the actual electrode measurement" These
instruments also may provide &uality management functions such as documentation of
&uality control testing and control over instrument use by uncertified or untrained
individuals* in addition to providing needed laboratory data"
1FUI(G1ET GOEITORIEA ?URIEA CAR?IO(U:GOEAR< )<(ASS
)ac to Fuic :ins
Oxygenator function
Arguably* the single most important item of e&uipment in the C() setup is the
oxygenator" Oxygenators in current use are manufactured as single!use disposable
items sub0ect to stringent &uality control" (roblems do occur nevertheless* although
rarely" The immediate life!sustaining function of the oxygenator is oxygenation of the
blood2 ventilation follows" Therefore* the single best monitor of oxygenator function is
oxygenation" As 0ust discussed* a variety of instrumentation is available for blood gas
+(aO-* in this case, analysis ranging from laboratory benchmar instruments to in!line
C() sensors or catheter!based systems" The point is that the ade&uacy of oxygenation
must be reliably determined both early and throughout the C() course" The emphasis
on laboratory determination does not discount clinical observation" Cor example* a
cyanotic surgical field should be noticed &uicly" 4aving established ade&uate initial
oxygenator function* it is prudent to reassess blood gases at regular intervals throughout
C() or whenever changes are made in oxygenator gas flow or composition or C()
systemic blood flow" Also* recalling the earlier discussion of the value of SvO-
measurement to guide perfusion ade&uacy* C() venous blood oximetry is a useful
monitor used by most perfusionists today"
;hat then is an appropriate level for arterial blood gas (O- during C()Q Two recent
studies would suggest hyperoxemia +defined as arterial (O- greater than #6. mm 4g,
might be deleterious during normothermic and hypothermic C() +B'*B8," ;ith the
current availability* accuracy and reliability of in!line blood gas sensors* it is relatively
easy to maintain the (ao- in the #8$! to #6$!mm 4g range" Although it is acnowledged
that these values are not normoxemic* maintaining blood gas values in this range with
in!line sensors displaying contemporary data will provide a margin of safety during C()*
particularly when the aortic cross!clamp is removed and during reversal of hypothermia
when the patient9s oxygen needs increase"
Cardioplegia delivery
;hen cardioplegic solution is delivered by the perfusionist* the flow* pressure* and
temperature should be monitored" ?epending on the pressure drop through the delivery
system and cannula* the aortic root pressure can be monitored and regulated to
appropriate levels by ad0usting the flow rate" It is particularly important to monitor
pressures when cardioplegic solution is delivered directly into coronary ostia or
retrograde into the coronary sinus to avoid tissue damage from excessively high
pressures and to ensure proper cannula placement" Some cardioplegia cannulas
provide for direct measurement of infusion pressure through a second pressure
monitoring line or lumen +B.," If aortic infusion pressure is not measured directly* the
aortic root pressure can be estimated by subtracting the pressure drop of the delivery
system from the cardioplegia line pressure" Gonitoring the temperatures of both the
cardioplegic solution and myocardium can reasonably ensure ade&uate cardioplegia and
guide intervals for reinfusion"
Cluid management
Cluid administration during C() in response to decreased circulating volume usually
consists of crystalloid solution added directly into the circuit" 1xtravascular loss of blood
at the operative field* fluid shifts within the patient9s tissues and organs* and urine output
can contribute to the need for supplemental fluid administration" ?epending on the
patient9s recent hematocrit* paced red blood cells may be added per protocol or
surgeon or anesthesiologist order" The choice of type of fluid administration +crystalloid
or blood products, may be governed by stage of the operation* patient condition* or
protocol" Cor example* if the patient has good diuresis and patient weaning from C() is
expected shortly* blood products may be withheld to avoid donor blood exposure" In
other cases such as the elderly* children* or those patients with reduced cardiac function*
the threshold for administration of ban blood may be lower" All blood administered
should be double checed against the patient name and identification number before
administration* with the time of administration recorded on the perfusion record"
;hen a hemoconcentrator is used during bypass* the volume of plasma water removed
should be monitored to avoid excessive fluid removal with concomitant decreases in
circulating volume +B7," In some settings* a cell!salvage device is used in con0unction
with C() to wash suctioned blood" The time and volume re&uired for such blood
processing must be taen into account during C() because blood being processed may
not be immediately available for administration" ;ith hemoconcentration* plasma
proteins and platelets are preserved* and use of this device is technically simpler and
more cost effective than routine cell salvage during C() +B@*B6,"
Circuit alarms
Gost C() circuits have alarms to warn of potentially dangerous conditions such as low
reservoir volume or high systemic line pressure" An air bubble detector placed on the
arterial line will automatically alarm and shut off the systemic roller pump in the event a
bolus of air inadvertently enters the line proximal to the sensor" The location of the air
bubble detector within the circuit can vary +BB,* but for most prompt air detection* the
sensor should be placed between the C() reservoir and systemic pump" Ganufacturer
recommendations and some practitioners place the sensor after all devices on the
arterial flow line* including the arterial line filter" This configuration has the advantage of
detecting bubbles that may inadvertently enter this line after all C() components but the
disadvantage of having to remove all air from the arterial line filter before restarting C()*
which can be difficult" :ow!level reservoir alarms have a long history of use* and they
can be used to warn of low reservoir volume conditions or shut off the systemic blood
flow pump if the C() reservoir volume is too low" 4owever* the use of the alarm is not a
substitute for an alert perfusionist monitoring the reservoir level"
(erfusion record
Record eeping provides permanent documentation of the patient9s hemodynamics and
metabolic parameters during the period of C() support" The perfusion record should
contain information regarding personnel* patient diagnosis and operation performed*
e&uipment used* and time of administration of drugs* fluids* and blood products" The
perfusion record also may provide information for other health care personnel
responsible for care of the patient after surgery" As such* the perfusion record contains
information that may become part of a larger database or serve as documentation for
further medical study" The perfusion record also is an important document if legal
proceedings arise +#$$," A complete and legible record can be used in defense if the
hospital or perfusionist is named in a lawsuit or the perfusionist is called as a witness"
(erhaps one of the most important functions of the perfusion record is to prompt the
perfusionist to mae observations and in some cases document patient physiologic
variables and circuit performance" In this sense* the perfusion record can be viewed as
an ongoing checlist during C()"
The format of the perfusion record varies and may be of the commonly used random
time and entry or chart type where data regarding systemic blood flow* patient arterial
blood pressure+s,* temperature+s,* oxygenator ventilating gas flow and composition* and
results of laboratory tests such as hemoglobin* arterial and venous blood gases* and
electrolytes are recorded"
A second less fre&uently used perfusion record is the combination flow with time and
entry type* which is similar to an anesthesia record" This record also contains
information on patient physiologic parameters* but because notations are made at fixed
intervals on a grid* it is conceptually easier to determine trends and view in its entirety
what occurred during the period of bypass" In practice* the timing of entries should occur
every #. minutes or less in a random entry or a timed entry record"
?uring C()* an entry also should be made every time a change is made by the
perfusionist in any of the perfusion controls or parameters or any time one of the
monitored values change" Use of -8!hour time entries +3military time3, is recommended
and can clarify the time of day or night for the various entries" )lood gas and other
laboratory values should be recorded on the perfusion record at the time they were
drawn and not when the results were received" )lood gas samples should be drawn
shortly after maing a change in systemic blood flow or if there is a ma0or change in
patient temperature" :iewise* tests for electrolyte levels should be done after
administration of solutions or drugs that can affect such values such as potassium
chloride* glucose* or insulin" The use of in!line monitors for arterial and venous blood gas
and5or chemistry values may decrease the need for more fre&uent sampling and
documentation" 4owever* the in!line monitor should be calibrated according to the
manufacturer9s instruction and against a sample using standard laboratory
measurements to verify its accuracy"
All fluids added to the C() circuit should be recorded at the time they are added" These
notations* when combined with estimated blood loss and urinary output on bypass* will
allow calculation of an estimated fluid balance at the conclusion of bypass and may
guide patient management decisions after C()" Gedications added by the perfusionist*
whether by protocol or on direction from the surgeon or other physician* should be noted
along with who ordered it or whether it was given according to protocol"
COGGUEICATIOE
)ac to Fuic :ins
It should be apparent from the preceding sections that any medical procedure as
invasive* life!sustaining* and complex in execution as C() depends on close
coordination of activities by all team members" 1ssential and effective communication
provides a means to facilitate such coordination" Instructions or announcements from the
surgeon to the perfusionist or anesthesia personnel are necessary during conduct of the
operation because C() is being used to facilitate a surgical procedure" Instructions from
the anesthesiologist to the perfusionist also often occur during the period of C()" All
instructions or announcements should be followed by an acnowledgment from the
person to whom it was directed" In this manner* errors of omission will be minimi/ed and
the surgical procedure can proceed expediently" If acnowledgment does not occur* the
communication should be repeated until a response is heard* most often by the intended
recipient repeating the instruction to avoid possible errors in interpretation"
The perfusionist should communicate to the surgeon activities that are performed
according to protocol or according to surgeon preference" :iewise* the anesthesiologist
should communicate activities to the perfusionist that also can affect the conduct of C()
and vice versa" An example would be administration of a vasodilator that can alter the
circulating volume of blood and C() reservoir level" Cluid additions to the C() circuit
should be communicated from the perfusionist to the anesthesiologist because of
implications for fluid management after C()"
)oth perfusionist and anesthesiologist are obligated to communicate to the surgeon any
significant abnormal conditions they observe" Guch of the surgeon9s attention may be
focused on the surgical procedure* and the perfusionist and anesthesiologist are better
able to monitor the ey parameters outlined earlier"
Some conditions can occur unexpectedly that may potentially 0eopardi/e patient well!
being* including= increased C() arterial line pressure2 sustained decreased venous
drainage2 nonfunctioning vent or sucer2 sustained elevated or low patient arterial blood
pressure2 elevated CD(* :A* or (A pressures2 elevated delivery pressure and5or lower
than expected flow during cardioplegia administration2 and any potentially life!
threatening e&uipment malfunction or failure" In such instances* immediate
communication is re&uired"
Often abnormal situations can occur that are less acute but potentially damaging*
including= elevated serum potassium2 lower than expected hemoglobin or hematocrit
+with or without the expected need for blood transfusion that should be ordered by a
physician,2 higher than expected fluid volume re&uirements2 higher than expected use of
vasopressors or need for increased systemic blood flow for decreased systemic vascular
resistance2 lower than expected mixed SvO-2 resumption of cardiac electrical or
mechanical activity during cardioplegic arrest2 and air entrainment in the venous line"
If deep hypothermia and low flow or elective circulatory arrest are re&uired* the surgeon
should be notified of the duration of cooling* patient temperature+s,* and elapsed times of
low flow or circulatory arrest" The fre&uency for such notification should be
communicated to the perfusionist before the procedure or at the time of initiation of low
flow or circulatory arrest"
Surgical manipulations of the heart or ma0or vessels may affect C()" Cor example*
retraction of the heart for surgical exposure may restrict venous drainage or allow air to
enter the venous line at the venous cannulation site+s, or through side holes in the
cannula exposed to atmosphere if the cannula becomes displaced" Such retraction also
may distort the aortic valve* causing aortic incompetence with possible left ventricular
distention from flow exiting the arterial cannula" Retraction of the heart may increase or
decrease vent return" These conditions should be communicated to the surgeon when
they occur* and surgeons should alert the perfusionist when they are displacing the
unarrested heart such as when a circumflex coronary artery graft anastamoses is
checed for bleeding" Collateral blood flow may partially obstruct the surgical field*
necessitating a decrease in C() systemic flow" Application of the aortic cross!clamp
usually is preceded by instruction from the surgeon to the perfusionist to momentarily
decrease the systemic blood flow to lower pressure in the aorta" The perfusionist should
communicate all changes in systemic blood flow* whether in response to direct
instruction or by protocol"
(OST!CAR?IO(U:GOEAR< )<(ASS ACTIDITI1S
)ac to Fuic :ins
The perfusionist should be prepared to transfuse residual perfusate through the arterial
cannula as re&uired and instructed by the surgeon or anesthesiologist" It is important
that before any such transfusion occur* the surgeon should chec the arterial cannula for
any residual air bubbles that may have been liberated from cardiac chambers or vessels
since stopping bypass +Cig" -@"#'," Often the arterial cannulation site is in the uppermost
position the aorta and will become the site of lodgment of residual air due to buoyancy
effects"
Diew Cigure
CIA -@"#'" Common site of air lodgment in arterial cannula immediately after
cardiopulmonary bypass +arrow," The venous cannula+s,* which are still in place in the
right atrium and5or vena cavae* are not shown for illustrative purposes
It is important that the pump sucer+s, or vent+s, not be used if fibrin glue or coagulation!
inducing drugs are being used in the operative field +#$#*#$-," Aspiration of blood
containing this material* even if in a li&uid state* can cause coagulation in the cardiotomy
reservoir* venous reservoir* or oxygenator with stasis* thus compromising use of the
circuit in the event C() must be restarted" Similarly* the pump sucer+s, should be
turned off after protamine administration is observed to be effective to avoid similar
problems" A guideline is for the anesthesiologist to announce when one!fourth to one!
half the anticipated protamine dose has been administered as a signal to discontinue
use of the pump sucers"
After the arterial cannula has been removed* residual perfusate in the C() circuit can be
salvaged by transfer into a completely de!aired sterile intravenous bag for possible
transfusion by anesthesia personnel" )ags containing residual perfusate should be
labeled with the patient9s name* hospital identification number* and time and date of
collection" In practice* residual perfusate is most often administered in the immediate
post!bypass period" Alternatively* a cell!salvage device may be used to process blood
whereby it is washed before transfusion" A hemoconcentrator can also be used to
process residual perfusate before collection" It is important that supplemental protamine
sulfate is given after any such transfusion of unwashed residual perfusate to counteract
heparin contained in the salvaged perfusate"
The time of administration of protamine sulfate has been temporally related to
hemodynamic deterioration in some patients +see Chapter -'," The perfusionist should
continue to observe patient hemodynamics at this time and maintain the C() circuit in a
functionally usable state if it is necessary to urgently restart bypass" If the patient must
be placed bac on C()* then the protamine must be stopped and a full loading dose of
heparin +'$$ to 8$$ units5g, should be given before restarting bypass to ade&uately
anticoagulate the patient" Sometimes the readministration of heparin will neutrali/e the
heparin>protamine complex and the previously observed hemodynamic deterioration will
resolve +#$'*#$8," Circuit disassembly and recovery or processing of residual perfusate
should not be undertaen until it is reasonably certain that the patient will maintain
ade&uate hemodynamics"
(1RCUSIOE (ROTOCO:S* AUI?1:IE1S* AE? STAE?AR?S
)ac to Fuic :ins
(rotocols* guidelines* and standards are no substitute for common sense and
experience" 4owever* they have been useful in promoting safe conduct of C()" (erhaps
in its simplest form* an institutional protocol outlines the selection of circuit components
and re&uired priming volumes +with constituents, according to patient si/e or diagnosis"
These protocols are often determined after review of manufacturer product data and
then further developed and updated after a period of use" Such protocols provide some
consistency on a case by case basis regardless of perfusion personnel involved" )asic
institutional protocols may be customi/ed to a specific surgeon or for specific procedures
or patient conditions"
A second type of protocol* which is particularly applicable for pediatric cases or specialty
situations* outlines recommended or preferred cannula si/e and type" Clow charts can
be created by performing benchtop measurements or can be provided by manufacturers*
showing pressure drops at different flows for arterial cannulas" Similarly* venous
cannulas most often are classified by a range of flows with height differentials typically
used for gravity siphon drainage"
Gore detailed protocols may be used to describe various aspects of conduct of C() and
ancillary or more rarely performed procedures such as performing hemodialysis during
bypass" Such protocols are usually uni&ue to the institution and sometimes contain
specific protocols according to surgeon preference" An example might be desired range
of arterial blood pressure while on bypass or treatment regimens for abnormal laboratory
results"
?etailed protocols also may list in outline form specific steps for circuit assembly*
priming* and management during certain less fre&uently performed procedures such as
cardiac transplantation* left heart bypass for repair of the descending thoracic aorta* or
retrograde cerebral perfusion" (rotocols should be developed with input from all team
members and should be periodically reviewed and updated so that they remain
contemporary with current clinical practice" (rotocols are especially useful when
orienting new personnel who may bring preconceived methods of C() conduct learned
during training or previous 0ob experience" Although it is generally agreed that C() can
be conducted in many ways with acceptable patient outcome* safe conduct on a case by
case basis can be facilitated by use of mutually agreed on protocols that clarify
personnel roles and expectations and specific patient management issues"
The first national standard of perfusion practice formulated by a professional society
appeared in #B@6 +#$., and contained basic items that were considered important for
inclusion on a perfusion record such as names of the surgeon* perfusionist* and
anesthesiologist" Also to be recorded were timed entries for specific parameters such as
C() systemic blood flow* patient temperatures and pressures* and blood gas results"
In #B6@* a second standard of practice document was published by the American
Academy of Cardiovascular (erfusion +#$7," It acnowledged that although the primary
responsibility for care of the patient undergoing C() rested with the surgeon or
physician in charge* it was the responsibility of the perfusionist to assist the surgeon in
any way possible in care of the patient and particularly within the defined area of
expertise of the perfusionist" It further emphasi/ed the necessity for a written perfusion
record* choice of e&uipment including cost containment and use of available safety
devices* personnel +two &ualified perfusionists or a &ualified assistant for the primary
perfusionist per case was deemed preferable,* mandatory use of a pre!bypass checlist*
and conduct of perfusion"
The standard addressed issues such as maintenance of a safe volume at all times in the
C() reservoir* the volume of which would allow #. seconds for reaction time in the
event of interrupted venous drainage" It specified that systemic blood flow rates should
be maintained at such a level that inade&uate tissue perfusion not develop* examples of
which were development of increasing metabolic acidosis* mixed venous oxygen
desaturation* or 11A changes" Specific pressure ranges were not defined in the
standard* but the standard did state that the systemic blood pressure 3must be
maintained at an ade&uate level so that organ preservation and function are not
compromised or impaired function detected"3 Anticoagulation assessment should be
performed on a routine basis and should be ade&uate to prevent clotting in the
extracorporeal circuit and consumption of blood clotting factors" This document was
updated in #BB8 +#$@,"
AmS1CT then developed essentials for perfusion practice that was endorsed by their
membership in #BB- +#$6," In the preamble* the standard reiterated a statement that
appeared in an earlier scope of practice +#$B,= 31xtracorporeal circulation shall be
conducted according to established procedures and protocols in accordance with
hospital policy and upon prescription by a physician"3 Tenets of the standard included= an
accurate perfusion record must be maintained2 the perfusionist should use a checlist+s,2
extracorporeal circulation should be conducted by a nowledgeable and competent
perfusionist2 anticoagulation should be monitored2 appropriate gas exchange* blood flow*
pressures* and volumes should be maintained2 appropriate safety and monitoring
devices should be used2 the perfusionist should mae a reasonable effort to contain
costs2 and the perfusionist must ensure proper maintenance of e&uipment" Those
essential statements dealing with actual conduct of perfusion were &ualified by the
phrase 3according to the established protocol3 to permit variations in individual team
practice" The intent of these standards was to provide guidance for safe perfusion
practice rather than mandating specific practice"
In #BB.* AmS1CT published guidelines for perfusion practice +##$, to augment the
earlier essentials document +#$6," The basis for this document was a national survey on
perfusion practice conducted by the organi/ation in #BB' +###," The guidelines are &uite
specific to each essential" As guidelines* most of the recommendations are phrased in
statements using the words 3should3 or 3may*3 indicating* once again* institutional or
surgeon variability in the conduct of perfusion"
COEC:USIOES
)ac to Fuic :ins
C()* as noted by Hirlin and )arratt!)oyes +##-,* is conceptually simple and e&uipment
is now available to accomplish it with ease" In the #B7$s* when C() was 0ust beginning
to be practiced routinely in ma0or medical centers* Aalletti and )recher +', made a plea
that it be ept simple* particularly considering the multitude of parameters that could be
monitored" Although C() was not ideal in #B7-* nor is it at the current time* it is an
established procedure that is well tolerated in most patients who mae uneventful
recoveries after their cardiac surgery" Until an alternative method is developed to provide
the surgeon a motionless blood!free operative field and safely protect vital organs* C()
will liely continue to be used at current levels of a million procedures annually
worldwide"
As stated previously* the actual conduct of perfusion practice may vary according to
surgeon5perfusionist preference and institutional or even regional practice" 4owever*
national consensus on what constitutes ade&uate and safe conduct of C() has been
delineated and promulgated by professional organi/ations in the last two decades" Such
guidelines and protocols are important to consider in the context of individual practice*
but they must be used in perspective" Auidelines and protocols cannot anticipate every
contingency or emergency that might arise during C()" Auidelines and protocols cannot
govern all activities of all team members" All personnel involved in the conduct of C()
must rely on experience and deductive reasoning to solve problems or avoid a perfusion
crisis" Auidelines and protocols are derived from experience" 1xperience includes
mistaes* accidents* and failures" Auidelines and protocols are meant to eliminate these
life!threatening events but should not be totally relied on without constant awareness of
the individual patient being supported by C() and constant vigilance to detect early any
abnormal behavior on bypass that could compromise patient safety"
ACHEO;:1?AG1ET
)ac to Fuic :ins
The authors acnowledge the artwor of :ee Rose and Steve Schuene" Terry Crane*
Aaron 4ill* and Pohn Toomasian criti&ued the manuscript in draft form"
H1< (OIETS
)ac to Fuic :ins
The patient9s chart should be reviewed before C() to obtain information regarding the
proposed surgical procedure and patient history"
Assembly of the C() circuit should be performed in a consistent manner on a day!to!
day basis"
Roller pump occlusion on all pumps should be set before use for each case"
Centrifugal pump flow probes must be calibrated and /eroed before use for accurate
C() systemic flow measurement"
Completion of a pre!bypass checlist will greatly ensure the odds of proper C()
assembly and function"
Ginimi/ing circuit prime volume will result in a higher mixed patient5circuit hematocrit
and possibly reduce the need for homologous blood transfusion"
C() should be established by activating the systemic pump first +before release of the
venous line clamp, to avoid exsanguination in the event of a malfunction of the C()
systemic pump"
Dents should be tested before use to verify proper suctioning effect"
The C() reservoir volume should be continuously monitored so that appropriate
changes in systemic blood flow can be made in the event of decreased venous
drainage"
Cooling and warming rates should not exceed an approximate #$KC gradient +arterial
blood and patient temperature when cooling2 venous blood and heat exchanger water
source when rewarming,"
Geasuring SvO- does not ensure that C() systemic flow is meeting regional ?O-
re&uirements2 however* a low SvO- does indicate a problem with systemic ?O-"
A C() systemic flow index of -"- :5min5m- is recommended when normothermic for
ade&uate perfusion2 in children* the flow index should be -". :5min5m-"
4ypothermia allows proportionate reductions in C() systemic flow guided by
nomograms that rely on plateauing of O-"
Discosity +and resistance to blood flow, increases substantially with hypothermia*
indicating the importance of hemodilution with C()"
(ressure measurement artifacts are fre&uently seen during C() and result from
effects of hypothermia* uneven vasodilation with rewarming* mechanical tissue5vessel
compression* or aortic cannula tip malposition"
Central venous* (A* and :A pressures should be at or near /ero during C()2 an
increase in any one is a matter for concern re&uiring assessment of venous cannula+s,
position and confirmation of an unrestricted venous drainage line"
An elevated CD( will reduce the effective perfusion pressure to organs +e"g"* brain*
idney* liver, and tissue beds +e"g"* gut,"
Changes in the 11A may be induced by hemodilution* hypothermia* anesthetics* C()
systemic flow changes and pulsatility changes* and hypoxia* maing interpretation and
diagnosis of CES insult difficult"
3Core temperature3 is conceptually simple* but in reality brain temperature during C()
is best approximated by measuring the nasopharyngeal* tympanic* or esophageal
temperature"
Use of continuous reading in!line blood gas sensors allows precise management of
(aO- and (aCO- in the perfusate and provides a margin of safety during C()"
The flow* pressure* and temperature of cardioplegic solution and temperature of the
myocardium should be monitored to reasonably ensure ade&uate cardioplegia"
Use of circuit alarms +e"g"* level sensor* air bubble detector, can decrease the ris of
air embolism during C()"
References