Cardiopulmonary bypass in infants and children
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Cardiopulmonary Bypass in Infants and Children. 세종병원 박 천 수. The Child Is Not A Small Adult. The Difference from Adults. What’s the difference?. - In the response to and the management of CPB -. Smaller circulating volume Higher oxygen consumption (metabolic) rate

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Cardiopulmonary Bypass in Infants and Children

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Cardiopulmonary bypass in infants and children

Cardiopulmonary Bypass in Infants and Children

세종병원

박 천 수


The child is not a small adult

The Child Is Not A Small Adult


The difference from adults

The Difference from Adults


What s the difference

What’s the difference?

- In the response to and the management of CPB -

  • Smaller circulating volume

  • Higher oxygen consumption (metabolic) rate

  • Reactive pulmonary vascular bed

  • Presence of intracardiac and extracardiac shunting

  • Immature organ systems

  • Altered thermoregulation

  • Poor tolerance to microemboli


Circulating volume

Circulating Volume


Discrepancy

Discrepancy

- Circulating volume vs. priming volume -


Discrepancy1

Discrepancy

- Circulating volume vs. priming volume -


Cardio pulmonary bypass

Cardiopulmonary Bypass


Schematic diagram

Schematic Diagram


Components

Components

  • Cannulae : arterial/ venous

  • Tubing : diameter/ length

  • Blood pump : roller/ centrifugal

  • Reservoir

  • Oxygenator : membrane/ bubble/ film

  • Arterial filter

  • Supplements : cardioplegic circuitry/ untrafiltration circuitry/ vent or cardiotomy sucker circuitry


Components1

Components

  • Cannulae : arterial/ venous

  • Tubing : diameter/ length

  • Blood pump : roller/ centrifugal

  • Reservoir

  • Oxygenator : membrane/ bubble/ film

  • Arterial filter

  • Supplements : cardioplegic circuitry/ untrafiltration circuitry/ vent or cardiotomy sucker circuitry

Priming


Low priming

Low Priming

- Bloodless CPB -


Low priming1

Low Priming

- Bloodless CPB -


Sejong neonatal circuitry

Sejong Neonatal Circuitry


Flow rate

Flow rate

Metabolic rate


Myocardial protection

Myocardial Protection


Immature heart

Immature Heart

Free Fatty Acid

Glucose

Ann ThoracSurg 2003;75:1668-77


Physiologic differences

Physiologic Differences


Total body oxygen consumption

Total Body Oxygen Consumption

More tolerable

Ann Surg 1950;132:531-9


Immature heart1

Immature Heart

Mature

Immature

SeminThoracCardiovascSurgPediatr Card SurgAnnu 2004;7:141-54


Immature heart2

Immature Heart

More Tolerable ?


Immature heart3

Immature Heart

More Tolerable ?

  • Yes ! in normal heart

  • No !! in diseased heart


Immature heart4

Immature Heart

  • Immature heart with CHD

    • Exposure to hypoxia

    • Exposure to volume overload

    • Exposure to pressure overload

    • Intrinsically ↓amount of ATP (~50%)

    • ↑ calcium sensitivity, ↓ antioxidant defense mechanism

       Not tolerable !!


Myocardial protection1

Myocardial Protection

  • Hypothermia

  • Cardioplegia


Myocardial protection2

Myocardial Protection

  • Hypothermia : “ Main Stay ”

    • Protective effect

      • ↓ metabolic demand

      • stopping electromechanical work

      • ↓ loss of metaboilc substrate

    • Deleterious effect

      • “cooling contracture” : release of intracellular calcium

      • Avoid cold perfusion before X-clamp or use of warm induction CPS

      • Hypocalcemic priming


Myocardial protection3

Myocardial Protection

Ann ThoracSurg 2003;75:1668-77


Myocardial protection4

Myocardial Protection

Rapid rewarming : ↑ ↑ CPB temperature

Septal temperature

Rectal temperature

J ThoracCardiovascSurg 1988;96:414-22


Myocardial protection5

Myocardial Protection

  • Maintenance of myocardial hypothermia

    • Systemic hypothermia : cold perfusion

    • Cold cardioplegic solution

    • Topical cooling

    • Cold ambient temperature in the OR : Air conditioning

  • Degree of hypothermia : needs for reduced flow and expected duration of myocardial ischemia

    • Mild : 30 ~ 34℃

    • Moderate : 25 ~ 30 ℃

    • Deep : 15 ~ 22 ℃


Myocardial protection6

Myocardial Protection


Myocardial protection7

Myocardial Protection

  • Cardioplegia

    • Therapeutic arrest of the contractile apparatus and all electrical activity of the myocytes

    • Maintenance of hypothermia

    • Cardioplegia: adressing the problems related to “Ischemia – reperfusion injury”

    • Type of cardioplegia

       Lack of consensus !!


Myocardial protection8

Myocardial Protection

* From AATS 2003 and STS 2004


Myocardial protection9

Myocardial Protection

  • General consent in CPS

    • Blood = Crystalloid

      • Blood > Crystalloid : preop stress, longer ischemic time expected

    • Hypocalcemic

    • Add Mg

    • High osmotic pressure

    • Lower infusion pressure


Myocardial protection10

Myocardial Protection

  • Modifications in CPS

    • Dosage : Single shot vs. multidose

    • Administration

      • Antegrade : indirect/ direct

      • Retrograde

    • Add substrate or oxygen

    • Warm induction/ warm shot


Sejong general hospital

Sejong General Hospital

  • Type of cardioplegic solution

    • Crystalloid

      • Del Nido

      • Bretschneider

    • Blood : mixing crystalloid + O2 blood = 4:1

  • Dosage

    • One-shot: BSA ⅹ 600 ml

    • Multidose: initial 20~30ml/kg  10ml/kg

  • Infusion pressure: ~ 40mmHg (perdiatric)

  • Plasma solution (base solution) : 1000ml

  • Potassium : 26 mEq

  • Mannitol : 3.25g

  • 1%Lidocaine : 130mg

  • Sodium bicarbonate : 13mEq

  • 50% Magnesium sulfate : 2g

  • 20% Glucose 10ml: 2g


Cerebral protection

Cerebral Protection


Brain

Brain

  • Immature brain

    • Critical period : GA 6months ~ 6month after birth

  • Neurologic injury

    • Intrinsic pathology

    • Injury related to preexsting conditions

      • Cyanosis

      • Heart failure

    • Injury during surgery

      • Adverse effect of CPB

      • Use of cirulatory discontinuation


Cerebral blood flow

Cerebral Blood Flow

  • Autoregulation : maintain blood flow

Cerebral

Blood

Flow

(ml/100gmin)

Mean arterial pressure (mmHg)


Cerebral blood flow1

Cerebral Blood Flow

- Temperature -

Moderate HCPB

Deep HCPB

Circulation 1989;80(supplI):I209-I215


Cerebral blood flow2

Cerebral Blood Flow

- Temperature -

Circulation 1989;80(supplI):I209-I215


Cerebral metabolic rate

Cerebral Metabolic Rate

- Temperature -

J ThoracCardiovascSurg 1991;101:783-94


Cerebral metabolic rate1

Cerebral Metabolic Rate

- Temperature -

10

CMRO

(ml/100g/min)

5

Temperature (℃)

0

10

20

30

40

J ThoracCardiovascSurg 1991;101:783-94


Cerebral blood flow3

Cerebral Blood Flow

- Minimal Pump Flow Rate -

Ann ThoracSurg 1993;56:1366-72


Acid base co 2 management

Acid-Base (CO2) Management

  • Temperature ↓

    • blood pH alkalotic

    • cerebral vascular resistance ↑

    • switched major buffering system

      : (NH3-, HCO3-)  alpha imidazole ring in Histidine

  • Cerebral blood flow : distribution of cold perfusate

  • intracellular pH (pHi)

    • Intracelluar enzymatic function

Cerebral blood flow ↓


Acid base co 2 management1

Acid-Base (CO2) Management


Acid base co 2 management2

Acid-Base (CO2) Management

  • During mild or moderate hypothermia

    • Alpha-stat vs. pH-stat ~ no difference

  • Combination during deep hypothermia

    pH-stat during cooling phase

  • alpha-stat just before

    circulatory discontinuation


Aortic arch surgery

Aortic Arch Surgery


Deep hypothermic bypass

Deep Hypothermic Bypass

- DHCA vs. regional perfusion -


Deep hypothermic bypass1

Deep Hypothermic Bypass

- DHCA vs. regional perfusion -

?

  • Optimal perfusion flow: ?

  • Optimal perfusion pressure: ?

  • Is it really neuroprotective?


Deep hypothermic bypass2

Deep Hypothermic Bypass

- DHCA vs. regional perfusion -

- Survey ; CHS in North America -

<

J ThoracCardiovascSurg 2009;137:803-6


Deep hypothermic bypass3

Deep Hypothermic Bypass

- DHCA vs. regional perfusion -

- Survey ; CHS in North America -

J ThoracCardiovascSurg 2009;137:803-6


Deep hypothermic bypass4

Deep Hypothermic Bypass

- Regional perfusion -

Asou T et al. Ann ThoracSurg 1996;61:1546-8.


Deep hypothermic bypass5

Deep Hypothermic Bypass

- Regional perfusion -

Imoto Y et al. Ann ThoracSurg 1999;68:559-61.


Deep hypothermic bypass6

Deep Hypothermic Bypass

- Regional perfusion -

Ishino K et al. Eur J CardiothoracSurg 2000;17:538-42.


Deep hypothermic bypass7

Deep Hypothermic Bypass

- Regional perfusion -

Tchervenkov CI et al. Ann ThoracSurg 2001;72:1615-20.


Deep hypothermic bypass8

Deep Hypothermic Bypass

- Regional perfusion -

Lim C et al. Eur J CardiothoracSurg 2003;23:149-55.


Summary

Summary

  • Remarkable improvement of surgical outcomes especially in small children

  • Recently, lack of study

  • Keep in mind for the importance of Cardiopulmonary bypass !!


Thank you

Thank You !


Cardiopulmonary bypass in infants and children

CPB


Oxygenator

Oxygenator

Capiox R05 (Terumo)

Safe Mini (Maquet)


Cannulae

Cannulae

A

V


Adverse effects of cpb

Adverse Effects of CPB


Systemic inflammatory response

Systemic Inflammatory Response

  • The complex interaction

    • with regulatory and counterregulatory effects

  • The initiating event

     contact activation of the blood elements

  • Other factors : Ischemia and reperfusion/ Hypotension with nonpulsatile perfusion/ Anemia/ Transfusion/ Heparin and protamine


Systemic inflammatory response1

Systemic Inflammatory Response

  • Direct tissue injury

  • Ischemia-reperfusion injury

  • Hypercoagulable state

  • Endothelial injury

    • Altered microcirculatory function

    • Vasoconstriction

    • ↑ capillary permeability  interstitial edema

Steroid

↑ vascular resistance


Endocrine system

Endocrine System

  • Factors influencing the endocrine system

    • Surgical stress

    • Peripheral vasoconstriction and acidosis

    • Lack of pulsatile flow

    • Exclusion of the lung in the circulation

    • Hemodilution

    • Hypothermia and rewarming

    • Anesthetic managements


Endocrine system1

Endocrine System

  • Catecholamines :epinephrine, norepinephrine

    • ↑ during initiation of CPB

      • Increased production

      • Receptor downregulation

    • Rapidly ↓ after discontinuation of CPB

  • Insulin (in hypothermic CPB)

    • ↓ level and ↓ peripheral response

    • gradually ↑ after CPB off

       Hyperglycemia during and after CPB


Endocrine system2

Endocrine System

  • Steroid hormones : ↑ during CPB

    • Cortisol

    • Vasopressin : ↑ for upto 48 ~ 72 hours after surgery

    • Glucagon

    • Growth hormone

  • Thyroid hormone

    • ↓ during CPB and for upto several days after surgery

    • Triiodothyronine: useful inotropes after CPB


Cardiopulmonary bypass in infants and children

Lung

  • Pulmonary dysfunction

    • Abnormal respiratory mechanics d/t cardiac defect itself

    • Many inflammatory cells in parenchyme

       source and target of IR to CPB

    • Ischemic effect : ↓ perfusion through PA

       Endothelial damage

    • Solutions : Steroid, Liquid ventilation, MUF…

  • Paranchymal effect (↑ lung water  ↓ lung compliance)

  • Vascular effect (↑ PVR  ↓ RV function)


Kidney

Kidney

  • Oliguric renal dysfunction

    • Mechanism: unclear

    • Generally improve by 24 ~ 48 hours after surgery

    • Possible mechanism

      • Surgical stress and ↑ stress hormones

         ↓ renal blood flow and GFR

      • Alteration of renal parenchymal flow pattern

        • ↓ cortical blood flow vs. ↑medullary blood flow

      • Activation of renin-angiotensin system

  • Peritoneal dialysis in high-risk infant


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