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Cardiac Anesthesia Update. Charles E. Smith, MD Professor, CWRU School of Medicine Director, CT Anesthesia MetroHealth Medical Center. Objectives. ASE guidelines- IOTEE ACC/AHA guidelines- Valves Diabetes + hyperglycemia Neurocognitive dysfunction Transfusion. ASE/SCA Guidelines- TEE.

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cardiac anesthesia update
Cardiac Anesthesia Update

Charles E. Smith, MD

Professor, CWRU School of Medicine

Director, CT Anesthesia

MetroHealth Medical Center

objectives
Objectives
  • ASE guidelines- IOTEE
  • ACC/AHA guidelines- Valves
  • Diabetes + hyperglycemia
  • Neurocognitive dysfunction
  • Transfusion
ase sca guidelines tee
ASE/SCA Guidelines- TEE
  • Accelerated growth of IOTEE by anesthesia
  • Complexity of US technology
  • Conduct of exam
  • Interpretation of results

Mathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in Perioperative Echo. JASE + Anesth Analg 2006.

training credentialing
Training + Credentialing
  • 2 levels of training: basic + advanced
    • Basic: within usual practice of anesthesia
    • ventricular fct, gross valve lesions
    • Advanced: full diagnostic potential of echo
  • ASE /SCA/NBE:
    • Testamur status: exam
    • Board certified: 1 yr TEE/ CT fellowship [vs alternate training, 2-4 yr, 300 exams]
  • Credentialing: hospital-specific process

Mathews JP et al: JASE + Anesth Analg 2006.

standard tee exam guidelines
Standard TEE Exam: Guidelines
  • Comprehensive: 20 cross-sectional views
    • UE level: Asc aorta, MPA, L+R atria, AV+PV
    • ME level: L+R atria, L+R ventricles, MV+TV
    • TG: L+R ventricles
    • Thoracic Aorta: Desc + distal arch

Mathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in Perioperative Echo. JASE + Anesth Analg 2006.

acc aha guidelines
ACC/AHA Guidelines
  • Review of literature by experts
  • Grade evidence: Level A →C [RCT→opinion]
  • Recommendations:
  • Class I: beneficial
  • Class IIa: generally in favor
  • Class IIb: less well established
  • Class III: not useful, potentially harmful?

AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS

valvular heart disease
Valvular Heart Disease
  • Decision to repair/replace valve should be made before surgery
  • IOTEE should be used to confirm dx, evaluate repair + evaluate new findings (e.g., moderate AS in setting of CABG, moderate AI if ↓ EF or ↑ LVEDD, aortic root reconstruction if dilated > 5 cm)

AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS

iotee indications
IOTEE Indications
  • Class I: valve repair, valve replacement- stentless / autograft (Ross), valve surgery in setting of endocarditis
    • Level of evidence= B
  • Class IIa: all valve surgeries
    • Level of evidence =C

AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS

aortic stenosis
Aortic Stenosis
  • Check annulus size
  • Verify size of aortic root (mismatch? aneurysmal?)
  • After bypass: problems w prosthesis: immobility, leaks

AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS

severe aortic stenosis
Severe Aortic Stenosis

2.0 cm

5.7 m/s

1.3 m/s

2.0 2 1.3

AVA = 3.14 ( ------) X ------ = 0.72 cm2

2 5.7

severe aortic regurgitation
Severe Aortic Regurgitation

T 1/2 = 84 ms

Vena Contracta = 11 mm

mitral regurgitation
Mitral Regurgitation

Functional vs structural

After bypass:

Residual MR, MS, SAM

Leaks

Immobility of prosthesis

AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS

severe mitral regurgitation
Severe Mitral Regurgitation

PISA ROA

rn=1.1cm

vn=59 cm

vp=450 cm

= 2Π(1.1)2(59/450)

= 0.99 cm2

cardiac tamponade
Cardiac Tamponade

RA Diastolic Collapse

type a dissection tee
Type A Dissection: TEE

MHMC #0777095

Type A dissection with flap extending to just superior to RCA ostium

aortic dissection
Aortic Dissection:

TEE Distal Thoracic Aorta

MHMC #0777095

Demonstration of extension of dissection distally

diabetes hyperglycemia
Diabetes + Hyperglycemia
  •  neuro injury after focal + global ischemia
  •  myocardial infarct size
  •  WBC function
  • Impaired wound healing
  •  risk infection, especially gluc > 250
reasons for hyperglycemia
Reasons for Hyperglycemia
  •  insulin requirements w obesity, steroids, stress response to surgery + CPB
  • Excess glucose in pump prime, cardioplegia
  •  gluconeogenesis + glycogen breakdown (CPB + stress response)
  •  glucose utilization: hypothermia
  •  insulin production: pancreatic hypoperfusion

Smith et al: J Cardiothorac Vasc Anesth 2005;19:201

diabetes deep sternal wound infection
Diabetes + Deep Sternal Wound Infection
  • Hyperglycemia - major role in impaired wound healing + deep sternal wound infection
  • Insulin infusion + moderate control
    • Titrate infusion to gluc 125-175 mg/dl
    • Start in OR, continue to POD 3
  •  incidence to 0.3%, similar to non-diabetics

Portland Protocol: Starr Center for Cardiac Surgery. www.starwood.com/research/insulin.html

van den berge study
Van Den Berge Study
  • RCT, 1548 diabetic + non-diabetic SICU patients
    • 60% had cardiac surgery
  • Compared tight vs. conventional glucose control
    • Tight: 80-110 mg/dl
    • Conventional: insulin only if glucose > 210; endpoint 180-200
  •  mortality in tight group 4.6 v. 8%
  •  infections, dialysis dependent RF, # transfusions required, need for prolonged mechanical ventilation

N Engl J Med 2001;345:1359-67

how tight should intraop control be
How Tight Should Intraop Control Be?
  • Furnary- 99: < 200 w insulin infusion ↓ mortality
  • Van den Berghe- 01: 80-110 w insulin infusion ↓ mortality (vs 180-220)
  • Furnary- 03: < 150 w insulin infusion ↓ mortality (vs > 250)
  • Finney- 03: < 145
  • Lazar- 04: < 200 w insulin infusion (vs > 250)
  • Ouattata- 05: < 200 w insulin infusion
mhmc study
MHMC Study
  • Prospective, non-randomized, n=40
  • Diabetics received continuous infusion regular insulin, 10 u/m2/h + variable D10W, starting rate 100 ml/h or 9.4 gm gluc/h
  • Target glucose 101- 140
  • Standardized anesthetic, bypass, cardioplegia
  • POC glucose testing + multiple biochemical measurements

J Cardiothorac Vasc Anesth 2005;19:201

mhmc study results
MHMC Study- Results
  • 53% achieved adequate intraop control + 35% had control by end of surgery [total =88%]
  • 12% never had control (starting glucose 307-550)
  • 25% had hypoglycemia requiring D50 (mean gluc 57, range 33-74, mostly CRF pts)

J Cardiothorac Vasc Anesth 2005;19:201

current approach diabetics
Current Approach- Diabetics
  • Insulin infusion- mix 250 units regular insulin in 250 ml 0.9% saline
  • Flush line w 25 ml [insulin binds to tubing]
  • Starting dose: gluc/100 per hr, continue in ICU
  • Target glucose 100 - 150
  • Measure gluc q 1h
  • Bolus doses can be given IV
  • Be careful with renal failure +after CPB- accumulation of insulin + risk hypoglycemia
cognitive dysfunction
Cognitive Dysfunction
  • Inability to perform normal activities after surgery
  • 4 major domains of function
    • Verbal memory + language comprehension
    • Abstraction, visuo-spatial orientation
    • Attention, psychomotor processing speed, concentration
    • Visual memory

Newman MF: SCA Annual Meeting, 2007

cognitive decline cabg
Cognitive Decline, CABG

Newman MF: N Engl J Med 2001;344:395. Duke, n=261

social economic costs
Social + Economic Costs
  • Cognitive dysfunction
    • ↓ quality of life
    • ↓ return to work
    • Altered personality, relationships
    • ↓ sexual function
implications
Implications
  • Abrupt decline in cognitive function heralds:
    • Loss of independence
    • Withdrawal from society
    • Death

Seattle Longitudinal Study of Aging

Berlin Aging Study

potential mechanisms
Potential Mechanisms
  • High-risk patients
  • High-risk surgical procedures
  • High-risk anesthetic techniques
patient risk factors
Patient Risk Factors
  • Predictors:↓ baseline cognition, deficit at discharge, ↑ age, ↓ yrs of education
  • Not predictive: EF, HTN, DM, surgical factors: XC time, CPB time
  • Etiology: ASVD of proximal aorta, genetics, anesthetics, pre-existing brain disease

Newman MF: SCA Annual Meeting, 2007

genetic factors
Genetic Factors
  • ApolipoproteinE ε-4 hyp: APOE allele- ↓ cognitive outcome
  • Single nucleotide polymorphisms: SNPs- modulate inflammation, cell matrix adhesion/interaction, lipid metabolism, vascular reactivity, PEGASUS study:
    • minor alleles of CRP 1059G/C + SELP 1087G/A associated w POCD

Newman MF: SCA Annual Meeting, 2007

surgical factors aortic manipulation
Surgical Factors: Aortic Manipulation

Emboli detected by TEE after unclamping; Barbut D: 1996

microemboli or scads
Microemboli or SCADs
  • Small capillary + arteriolar dilations: 10-70 microns
  • “Footprint” of embolic material during CPB
    • density correlates with CPB duration
    •  after CPB, most gone by 1 wk

Moody DM: AnnThorac Surg 1995;59:1304

anesthetic factors
Anesthetic Factors
  • May interact w peptides- ↑ oligomerization, amyloid deposition + protein folding
  • Low BIS levels were associated w ↑ risk in elderly [cumulative hr BIS < 45]
  • Longitudinal studies in progress to assess POCD, delirium + effect of anesthetics

Monk TG: Anesthesiology 2004;A62

Newman MF: SCA Annual Meeting, 2007

anesthetic risk factors
Anesthetic Risk Factors
  • Anesthetic agents affect release of CNS neurotransmitters
    • acetylcholine, dopamine, norepinephrine
  • Effects of anesthetics on cholinergic neurons in the basal forebrain [memory regulation]?
  • Effects of aging on choline reserves
  • Difficult to evaluate effects of anesthesia on long term memory + cognition
blood trx blood conservation
Blood Trx + Blood Conservation
  • Cardiac surgery consumes >80% blood products transfused at operation
  • Blood products may be assoc w major morbidity + mortality: TRIM, TRALI, infection, death
  • Trx practices vary greatly
  • High risk pts: Elderly, Preop anemia / coagulation defect, Preop antiplatelet drugs, Redo or complex procedure, Emergency, co-morbidities
optimal hematocrit 1
Optimal hematocrit-1
  • Therapeutic dilemma: Anemia is bad, but so is transfusion
  • Anemia
    • ↑ mortality
    • ↓ quality of life
    • Jeopardizes organ viability, especially in presence of limited vasodilator reserve

Gravlee GP. SCA Annual Meeting, 2007

optimal hematocrit 2
Optimal hematocrit- 2
  • Therapeutic dilemma, cont’d
  • Transfusion is bad
    • ↑ mortality + morbidity
    • immediate ↑ O2 transport is limited
    • TRIM, ↑ inflammation [role of leukoreduction], TRALI
    • Viral/bacteria/parasites

Gravlee GP. SCA Annual Meeting, 2007

transfusion avoidance techniques
Transfusion Avoidance Techniques
  • High yield:
    • ↑ preop Hct
    • ↓ CPB priming volume
    • RAP: retrograde autologous priming
    • Effective intraop cell saver
    • Ultrafiltration
  • Lower yield:
    • Antifibrinolytics
    • Protamine dosing

Gravlee GP. SCA Annual Meeting, 2007

retrograde autologous priming
Retrograde Autologous Priming
  • Replace crystalloid prime w pts own blood
  • Limits degree of HD
  • Fewer pts reach critical trx trigger

Murphy GS. SCA Annual Meeting, 2007

retrograde autologous priming 2
Retrograde Autologous Priming- 2
  • How to do this?
    • Heparinize, place arterial cannula, allow pts blood to flow backwards + displace crystalloid [perfusionist: “rapping”]
    • Maintain SBP > 100 using small doses of PHE (80-400 ug). Turn off vasodilators
    • Primary risk- hypotension

Murphy GS. SCA Annual Meeting, 2007

retrograde autologous priming 3
Retrograde Autologous Priming-3
  • What is the data?
    • Rosengart, 98: ↑ Hct, ↓ RBC trx
    • Shapira, 98: ↑ Hct, ↓ RBC trx
    • Balachandran, 02: ↑ Hct, ↓ RBC trx
    • Eising, 03: ↑ COP, ↓ extravascular lung water+ earlier time to mobilization
    • Murphy, 04 + 06: ↑ Hct, trend to ↓ mortality, delirium, afib, + vent > 24 hr
cell salvage 1
Cell Salvage- 1
  • After bypass: transfer blood from prime to cell saver bowl for washing
  • Can also collect shed blood for washing
  • Hct of processed blood: 60%,  2-3 DPG but processing eliminates platelets +factors
  • Savings: ~ 1-2 units allogeneic blood
cell salvage 2
Cell Salvage- 2
  • Requirements: CPB
    • Anticoagulated blood
    • Centrifuge bowl + tubing
  • Shed Blood
    • Aspiration assembly
    • Reservoir
    • Tubing
cell salvage 3
Cell Salvage- 3
  • Few disadvantages in heart room because have:
  • Dedicated perfusionist + heparinized pump prime and
  • Wound is clean
  • Risks:
  • Air embolism w infusion under pressure
  • DIC if use “cell saver suction” for thrombogenic material
ultrafiltration
Ultrafiltration
  • Remove water + low MW substances under a hydrostatic pressure gradient
  • Induces hemoconcentration: ↓ total body water accumulation + inflammatory mediators
  • ↓ bleeding, blood trx, morbidity + mortality
  • Initially validated in peds, but also adults

Tassani 99; Kiziltepe 01; Leyh 01; Luciani 01;

reasons why trx avoidance techniques fail
Reasons Why Trx Avoidance Techniques Fail
  • Had PVCs, PACS
  • Had to start vasopressors/ inotropes
  • Looked a little oozy
  • BP a little low
  • CI was a little low
  • Pt was old
  • Pt was high risk

Gravlee GP. SCA Annual Meeting, 2007

summary
Summary
  • IOTEE: routinely use for valves, often helpful for CABG
  • Hyperglycemia: treated w insulin infusion, target glucose < 150, especially if diabetic
  • Cognitive dysfunction: high risk pts + surgery; genetics + anesthetic factors play a role
  • Multimodal blood conservation techniques work well: RAP, cell saver, ultrafiltration, amicar, protamine dosing