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Prime Time ! Fluids during Cardiac Surgery

Prime Time ! Fluids during Cardiac Surgery . Dirk Himpe MD PhD MHE EDIC ZNA Middelheim General Hospital Antwerp Belgium. Outcome ?. Engoren et al. Ann Thorac Surg 2002; 74:1 180-6. Koch CC et al. Ann Thorac Surg 2006; 81:1650-7. Carson J, Lancet 1996, 348: 1055-60. Factors:

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Prime Time ! Fluids during Cardiac Surgery

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  1. Prime Time !Fluids during Cardiac Surgery Dirk Himpe MD PhD MHE EDIC ZNA Middelheim General Hospital Antwerp Belgium

  2. Outcome ?

  3. Engoren et al. Ann Thorac Surg 2002; 74:1 180-6

  4. Koch CC et al. Ann Thorac Surg 2006; 81:1650-7.

  5. Carson J, Lancet 1996, 348: 1055-60

  6. Factors: .preoperative anemia, .perioperative RBC transfusions .postoperative re-exploration

  7. Weight gain after cardiac surgery < 10 % 10-20 % > 20 % 0 20 40 60 80 100 Mortality % Lowell, CCM 1990 18:728, 1990

  8. Red blood cell Platelet INFLAMMATION Polymer Blood 1994; 4:3175-81

  9. phases: pre-pump-post-ICU targets: interrelated .transfusion/anemia .acid-base status .fluid balance (colloids) .inflammation (SIRS) OR

  10. The “pump”: onset of CPB = massive fluid load bloodvolume + priming solution Htc: 20-25 % 45 % start CPB (few minutes)

  11. Issue: Type of Fluid = Determinant of Outcome ?! (direct or indirect)

  12. Blood-loss

  13. Fluid-Balance

  14. James A. Russel. JCTVA 2004, 18: 429-437

  15. Himpe D, Act Anaesth Belg, 54:207-15, 2003

  16. Acid-Base

  17. Base Excess (mean ± 1.96SEM) Succinyl-linkedGEL in buffered vehicle Albumin-Hartmann Urea-linked GEL in NS Himpe D. et al. JCTVA 1991, 5:457-66

  18. Base Excess (mean ±SD) Hydroxyethyl Starch 6% 130/0.4 in a Balanced Electrolyte Solution (Volulyte) Hydroxyethyl Starch 6% 130/0.4 in NS (Voluven) Base EM. et al. JCTVA 2011, 25:407-14

  19. damage to figured blood elements (foreign surfaces, air, pericardium & pumps)

  20. free haemoglobin -> inflammation 1200 mg/L mechanical stress on blood during CPB 1000 800 electrically charged 4% MFGelatine 4% Albumin 600 6% HES 70/0.5 Normal Saline 400 200 0 120 min baseline Sumpelmann R et al. Anaesthesia 55: 976, 2000

  21. Himpe D, Act Anaesth Belg, 54:207-15, 2003

  22. Mortality

  23. Comparison of types of priming solutions used for CPB with the survival rate of coronary bypass patients. NS I. crystalloid (211 pts) II. 25 % human albumin (217 pts) III. 6% hetastarch (298 pts) IV. 6% hetastarch & 25% human albumin (161 pts) Canver C. C. & Nichols R. D. Chest 2000;118:1616-1620

  24. Himpe D, Act Anaesth Belg, 54:207-15, 2003

  25. Conclusions from the available evidence to date: • outcome after cardiac surgery: • there is more than priming fluids between heaven and earth; • but: - always colloids in the CPB prime; - electrically charged colloids may reduce blood damage (inflammation ?); - balanced solutions abolish the CPB acid-base problem; • minimizing volume of extracorporeal circuits may help;

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