Professional Documents
Culture Documents
Cardiopulmonary Bypass:
Empiric or Scientific
Douglas F. Larson, Ph.D.,CCP
Professor of Surgery
Program Director, Circulatory Sciences
The University of Arizona
Introduction
since 1953.
In 2003 (50 years later), we are still
trying to determine the correct
parameters for conducting CPB.
As the CPB systems and anesthesia
techniques improve, we must re-evaluate
our methods.
Also, we must adapt our perfusion
techniques to meet the patients age and
pathology.
Introduction
To patient disease
To CPB
This appears to be the proper time to
re-evaluate our perfusion techniques
with the recent reports of adverse
neurological outcomes with CPB.
1 -3 weeks old
2 months
Adults
VO2
7.6 ml O2/kg/min
9.0 ml O2/kg/min
4.0 ml O2/kg/min
250 ml O2/min
100-130 ml O2/min/m2
Condition
(VO2)
37oC Unanesthetized = 4 ml/kg/min
37oC Anesthetized = 2-3 ml/kg/min
28oC Anesthetized* = 1-2 ml/kg/min
VO2 = 3 ml/kg
VO2 = 2 ml/kg
DO2
VO2:
80 kg
HCT 24%
Fick Equation
flows (Q).
Harris, Br. J. Anaesth. 43;1113:1971
oxygenation is satisfactory.
If distant capillaries are not equally perfused,
tissues may not get blood flow and as a result the
Lactate
Is serum Lactate a good
marker of adequacy of
perfusion?
Lactate
Elevated blood lactate levels associated
with metabolic acidosis are common
among critically ill patients with
systemic hypoperfusion and tissue
hypoxia.
This situation represents type A lactic
acidosis, resulting from an imbalance
between tissue oxygen supply and
demand.
Lactate
Lactate production results from cellular
metabolism of pyruvate into lactate
under anaerobic condition.
A peak blood
lactate level
of >4.0 mmol/L
during CPB
was identified as a
strong
independent
predictor of
mortality
and morbidity
and suggests that
occult tissue
hypoperfusion
occurred during
CPB.
Lactate
Problems
consumption (VO
2) is dependent on delivery
(DO2).
Comparison
of
PCO2
versus
SvO2
HGB = 9 g/dl
Art. Press = 70 mmHg
Warm
1.7 L/m2
1.9 L/m2
Comparison of PCO2
versus
Temperature and Flow Rate
1.7 L/m2
HGB = 8 g/dl
Art. Press = 60-70 mmHg
n= 50 Adult CABG
1.9 L/m2
Comparison of SvO2
versus
Temperature and Flow Rate
1.7 L/m2
HGB = 8 g/dl
Art. Press = 60-70 mmHg
n = 50 Adult CABG
1.9 L/m2
PCO2
PCO2 is a valuable parameter for determining
the adequacy of CPB to a given metabolic
condition.
PCO2 can help to detect changes in oxygen
demand (e.g., the metabolic changes that
accompany temperature changes, flow rates,
and drug administration)
PCO2, together with SvO2, can help to assess the
adequacy of DO2 to global oxygen demand and
thus may help to assess perfusion adequacy.
Adequacy of Perfusion
Flows
Hematocrit
Pressures
Oxygen carrying
capacity
Tissue perfusion
Gas exchange
Pressures
Optimal PaO2s
Viscosity
Vascular
Optimal PaCO2s
compliance
Arterial Pressures
The arterial pressures are a very
Vascular tone
Anesthetic agents
Hemodilution (Hgb/Hct)
Prime composition (viscosity)
Temperature
Pathological conditions (diabetes)
Anatomic features:
Arterial Pressures
Flow
Pressures =
Resistance
We have discussed the issues about
arterial flow and now will discuss the
factors related to vascular resistance.
Vascular Resistance
Poiseuilles Law
Q = Pr
8l
Therefore:
Vascular resistance is related to:
vascular tone,
blood viscosity (HCT)
at a given flow rate.
Vascular Resistance
Autoregulation of vascular resistance.
Different organs display varying
degrees of autoregulatory behavior.
Normal Autoregulation
Drop in
Restoration of blood flow
arterial pressure
due to institution of CPB
Autoregulation
At normothermic conditions in normal
Autoregulation
Autoregulation of blood flow for the heart,
Normal Vasorelaxation
Vascular
Smooth
Muscle
Cell
Vascular
Endothelial
Cell
PaCO2
Acetylcholine
Hypoxia
ADP
NOS
NO
Relaxation
NO is nitric oxide
Diabetic Vasorelaxation
Uncoupled
autoregulation
in diabetic
vasculature
PaCO2
Acetylcholine
Hypoxia
ADP
Vascular
Endothelial
Cell
NOS
Thickened
Basement
Membrane
NO
Vascular
Smooth
Muscle
Cell
Relaxation
Reduced NO
Synthesis
Pallas, Larson Perfusion.11;363-370:1996
Arterial Pressures
Therefore, arterial pressures are
Adequacy of Perfusion
Flows
Hematocrit
Pressures
Oxygen carrying
capacity
Tissue perfusion
Gas exchange
Pressures
Optimal PaO2s
Viscosity
Vascular
Optimal PaCO2s
compliance
VO2
3 ml/kg
2 ml/kg
1 ml/kg
Through
increasing
DO2 with
flow rate
or
hematocritthe VO2
demand
can be
achieved.
Hematocrit
Therefore, the coupling between
Adequacy of Perfusion
Flows
Hematocrit
Pressures
Oxygen carrying
capacity
Tissue perfusion
Gas exchange
Pressures
Optimal PaO2s
Viscosity
Vascular
Optimal PaCO2s
compliance
Oxygenation (PaO2)
What are optimal PaO2s
Oxygen content in the blood is mainly
PaCO2
PaCO2s have a marked effect on the pH,
HCO3-, hemoglobin saturation and most
importantly cerebral circulation.
Conclusion
Flow rates
Systems
Patient
Heart-lung Machine
Shared
Hematocrit
Anticoagulation
Adequacy of Perfusion
Flows
Hematocrit
Pressures
Oxygen carrying
capacity
Tissue perfusion
Gas exchange
Pressures
Optimal PaO2s
Viscosity
Vascular
Optimal PaCO2s
compliance
New Issues
Patient disease:
diabetes,
peripheral or carotid vascular disease
Patient age (senescent)
We have no protocols for perfusion of the
aged patient.
It is known that their physiology is as
different as infants are compared to
adults.
New Issues
Patient age (senescent)
The risk of major complications
is 14% to 24% in 80 to 90 yo.
Neurological Problems
The neurological problems associated
Neurological Problems
The most important risk factors for brain
Neurological Problems
Correspondingly, the stroke rate after
Neurological Problems
Placement of the arterial cannula into
Definitions
CaO2 =(SaO2 x Hgb x 1.34) +(PaO2 x 0.003)
CvO2 =(SvO2 x Hgb x 1.34) +(PvO2 x 0.003)
DO2 = CI x CaO2 x 10
Lactate
Tissue hypoperfusion with lactic
Lactate
Lactate
Systemic microvascular control may