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Principles of Cardiopulmonary Bypass David Machin Bsc ACP Chris Allsager MB Chb FRCA

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Principles of Cardiopulmonary Bypass David Machin Bsc ACP Chris Allsager MB Chb FRCA Principles of cardiopulmonary bypass David Machin BSc ACP Chris Allsager MB ChB FRCA Key points The use of cardiopulmonary bypass (CPB) during gas exchange in the natural lung technology allows cardiac surgical procedures also apply to the artificial lung. However, Membrane oxygenators are to be performed in a motionless, bloodless gas exchange is less efficient. Diffusional commonly used for gas exchange during surgical field. It incorporates an extracorpor- distances are greater (approximately 200 mm cardiopulmonary eal circuit to provide physiological support. in comparison with 10 mm in the human bypass (CPB). Typically, blood is gravity drained from alveolus) and surface area for gas exchange is Downloaded from the heart and lungs to a reservoir via venous 1.7–3.5 m2 compared with 70–100 m2 in the Roller or centrifugal pumps are utilized in CPB. cannulation and tubing, and returned oxy- human lung. Gas exchange obeys Fick’s law genated to the cannulated arterial system by of diffusion: Confirm adequate patient utilizing a pump and artificial lung (oxy- ADdP anticoagulation before http://ceaccp.oxfordjournals.org/ genator or gas-exchanger). The tubing and V gasa initiation of CPB. T cannulae are manufactured of clear polyvinyl Sol CPB is performed over a chloride, while the oxygenator casing and Da pffiffiffiffiffiffiffiffiffiffi MW range of temperatures connectors consist of polycarbonate (Fig. 1). (37–15C). where the amount of gas transferred (Vgas) Cardiac surgery with CPB can is proportional to the area (A), a diffusion promote a systemic Gas exchange constant (D) and the partial pressure differ- inflammatory response Three basic types of blood oxygenators for ence (dP) and is inversely proportional to the syndrome. CPB have been developed. Historically, oxy- membrane thickness (T). D is proportional to at University of Southampton on November 19, 2014 genators provided gas exchange by contact of the specific gas solubility (Sol) and inversely a blood film to an oxygen rich atmosphere proportional to the square root of its mole- (e.g. disc oxygenators) or by bubbling oxygen cular weight (MW). through blood (e.g. bubble oxygenators). Applying Fick’s law to the artificial lung, Modern day oxygenators provide gas a higher partial pressure difference of oxygen exchange to blood through a membrane (maximum pressure gradient of 760 mm Hg (e.g. sheet and hollow-fibre oxygenators). minus oxygen tension in blood) and to some Sheet membrane oxygenators can either be extent carbon dioxide (maximum gradient is configured as a flat plate microporous equal to carbon dioxide tension in blood polypropylene membrane or spiral wound phase) is required to compensate for an silicone membrane. Microporous membranes increased diffusional distance and fixed, consist of 0.05–0.3 mm pores that initially reduced surface area. Despite the pressure create a direct blood gas interface until a thin gradient for carbon dioxide (CO2) being protein film quickly forms, producing considerably lower than oxygen (O2), the molecular membranes. Silicone membranes artificial lung material is more gas perme- are considered ‘true membranes’ and prevent able to CO2 than (O2); silicone membranes David Machin BSc ACP ‘plasma leakage’ into the gas phase, which is have a CO2 :O2 transmission ratio of about Perfusionist characteristic of microporous membranes 5:1.2 Theatres Glenfield Hospital after long periods of CPB. Plasma leakage is Oxygen transfer in modern blood oxy- Groby Road thought to occur when the micropores lose genators is described by the advancing front Leicester their hydrophobicity by the adsorption of theory. Demonstrated by studies of oxygen LE3 9Q UK protein, which leaks through the micropores transport through constantly moving Tel: 0116 256 3604 and reduces gas exchange performance.1 blood films, the large binding capacity of E-mail: [email protected] Hollow-fibre oxygenators allow high surface haemoglobin for oxygen and rapid oxygen– (for correspondence) area-to-blood volume ratios and mainly con- haemoglobin kinetics are thought to create Chris Allsager MB ChB FRCA sist of microporous polypropylene or poly- two distinct zones in the blood film. Oxygen Consultant Anaesthetist methylpentene material. diffuses through a fully oxygen saturated Glenfield Hospital Leicester The physical process of convection, dif- zone to an unsaturated front where the 3 UK fusion and chemical reactions that occur oxygen binds with unsaturated haemoglobin. Advance Access publication August 24, 2006 doi:10.1093/bjaceaccp/mkl043 176 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 5 2006 ª The Board of Management and Trustees of the British Journal of Anaesthesia [2006]. All rights reserved. For Permissions, please email: [email protected] Principles of CPB Aortic Cross Clamp Arterial Filter Cardioplegia Solution Gas Downloaded from In Gas Exchanger Gas Out Cardiotomy Reservoir http://ceaccp.oxfordjournals.org/ Sucker Vent Cardioplegia Pump Pump Pump Water In Heat Exchanger Water out Venous Reservoir at University of Southampton on November 19, 2014 Systemic Blood Pump Fig. 1 Diagrammatic representation of a ‘closed’ extracorporeal circuit for cardiopulmonary bypass. Carbon dioxide transfer in modern oxygenators is more difficult haemolysis (plasma haemoglobin per 100 ml of pumped blood). to predict, because of factors such as dissolved CO2, plasma Roller pumps (RPs) and centrifugal pumps (CPs) are routinely bicarbonate ions and varying partial pressure of CO2 in the gas used and can accurately deliver blood over wide range of flow phase. The latter can be decreased by increasing the ventilating rates against a variable resistance. gas flow rate (sweep gas) entering the oxygenator gas phase. The RP comprises a length of PVC or silicone tubing situated against a curved metal backing plate (raceway) which is com- pressed by two rollers located on the ends of rotating arms at Blood pumps 180 to each other. The direction of compression of the tubing During CPB, constant blood flow is delivered to the patient by a by the rotating arm containing the roller permits forward blood mechanical pump. The characteristics of an ideal blood pump flow. Hence, this type of pump is described as a positive dis- should consider properties that effect blood flow, as described placement device, allowing constant delivery of blood volume by the Hagen–Poiseuille equation: despite minor variations in the outlet afterload. Blood flow depends upon the pump tubing internal diameter (see Hagen– ðPressure gradientÞ · ðTube radiusÞ4 · p Blood flow rate ¼ Poiseulle equation), rotation rate of the rollers and diameter of ðFluid viscosityÞ · ðTube lengthÞ · 8 the pump head. Put simply, CPs consist of a vaned impeller or a nest of smooth plastic cones within a plastic casing. These impellers or cones are Pressure Blood flow rate ¼ magnetically coupled (at the base) with an electric motor and, Resistance when rotated rapidly, generate a centrifugal force to the blood, Thus, the pump should be able to generate blood flow and which is received by the pump body. Centrifugal force is pressure against a degree of resistance. It should be made converted into kinetic energy, which gives flow, or potential of biocompatible materials, create no areas of blood stasis or energy, which gives pressure. An object that produces centrifu- turbulence and be able to adjust for different sizes of extra- gal force (CF) can be defined as corporeal tubing. These mechanical pumps have low priming volumes, are easily controlled and produce a low index of CF ¼ mass · radius · angular velocity Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 5 2006 177 Principles of CPB In a clinical setting, oxygen consumption. The potassium channel opener, nicorandil, may offer advantages over potassium-based cardioplegia by CF ¼ Mass of blood · radius of pump head providing cardiac arrest near its resting membrane potential, · speed of revolutions ðRPMÞ allowing balanced trans-membrane ion gradients and minimal Unlike RPs, CPs are totally non-occlusive and are afterload energy requirements.5 dependant. Any significant change in resistance/pressure at the Non-cardioplegic techniques include the use of moderate outlet or inlet of the pump will alter blood flow rate. The non- systemic hypothermia (i.e. core temperature of 30–32C) with occlusive feature of the CP prevents generation of excessive short periods of aortic cross-clamping and ventricular fibril- pressure in the extracorporeal circuit, thus preventing circuit lation (VF). A variation of this technique involves hypo- rupture. thermic systemic perfusion combined with prolonged VF, enabling continuous coronary perfusion. Unfortunately, this Downloaded from Myocardial protection greatly increases myocardial oxygen consumption compared with the empty beating heart; it also reduces subendocardial To provide a dry, motionless, operative area, a cross-clamp is perfusion.6 Ischaemic preconditioning for myocardial protec- placed across the ascending aorta above the coronary ostia tion is also practiced by introducing brief periods and proximal to the aortic cannula, thus isolating the coronary of myocardial ischaemia to tolerate a longer ischaemic http://ceaccp.oxfordjournals.org/ circulation and preventing blood entering the chambers of challenge. the heart. Therefore, techniques of myocardial protection are used to preserve myocardial function and prevent cell death. Cardioplegic techniques for myocardial protection involve
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