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Cardiopulmonary Bypass

Cardiopulmonary bypass involves an


extracorporeal circuit that provides
oxygenated systemic blood flow when the
heart and lungs are not functional.
CPB is accompanied by normovolemic
hemodilution and nonpulsatile flow.
proinflammatory cytokines, and a systemic
inflammatory response
Contact of blood with extracorporal circuit
Activator of the coagulation system

Priming
primed with a balanced electrolyte
solution
The average priming volume is
approximately 1500 mL
A colloid, usually albumin, is
commonly added to the pump prime
to increase oncotic pressure and
reduce fluid requirements, thus
decreasing extravascular lung water.

Venous blood drains by gravity from the right


atrium or vena cavae into a cardiotomy reservoir
bag, passes through an oxygenator attached to a
heater/cooler unit, and is returned to the arterial
system through a filter using either a roller or a
centrifugal pump
Roller pumps are pressure-insensitive and can
pressurize the arterial line in the face of outflow
obstruction. Centrifugal pumps are afterloadsensitive, such that they will reduce flow if the
outflow is obstructed.

Suction lines
The benefits ofblood salvage into the pump may be
offset by the adverse effects of the aspirated blood.
blood in contact with tissue factor in the pericardium
is replete with fat and procoagulant and
proinflammatory mediators, such as complement and
cytokines
Notably, return of cardiotomy suction into the circuit
usually causes systemic hypotension, most likely
because of the high levels of inflammatory mediators
present
An additional suction line can be connected to an
intracardiac vent,

Oxygenator
adjusting the FIO2 and sweep rate
The sweep rate is generally
maintained slightly less than the
systemic flow rate to eliminate CO2
from the blood to achieve a desired
value (generally around 40 50 mm
Hg)

cardioplegia delivery
preselected ratio of pump volume to
cardioplegia solution (such as 4 : 1).
The final mixture then passes
through this heat exchanger for
delivery of cold or warm cardioplegia.
pressure that should not exceed 40
mm Hg to prevent coronary sinus
rupture.

Additional features of the CPB


Inline monitoring of arterial and venous
blood gases
direct connection to the cell-saving
device
arterial line filter (usually 40 mm),
which is essential to remove
microemboli before blood is returned
to the patient
Hemofilters

Cannulation for Bypass


Arterial cannulation
Placement of a cannula in the
ascending aorta just proximal to the
innominate artery
Cannula size is determined by the
anticipated flow rate for the patient
based on body surface area
Assess the presence of
atherosclerotic plaque and
calcification

Venous drainage

Initiation and Conduct of


Cardiopulmonary Bypass
Heparin management.
Dose 300-400 U/kg cek ACT 3-5 minutes
ACT >350 biocompatible canulation, ACT
>480 on bypass, ACT >250 off pump

Retrograde autologous priming (RAP) can


be used to reduce the hemodilutional
effects of the priming solution and
maintain a higher hematocrit on pump

Systemic pressures and flows.


nonpulsatile flow
maintained between 50 and 70mm Hg
The flow rate should exceed 2 L/min/m2
at normothermia and can be reduced to
1.51.7L/min/m2 at 30C with low flow
bypass.

Hematocrit
Both the hematocrit (HCT) on pump and the
systemic flow rate determine the amount of oxygen
delivery to the body.
Hemodilution reduces blood viscosity and improves
microcirculatory flow, but at the extremes of
hemodilution there is a significant reduction in
oncotic pressure that increases fluid requirements.
Very low hematocrits on pump have been
associated with increased mortality and an increase
in the incidence of renal dysfunction, stroke, and
prolonged mechanical ventilation.

Temperature management. The


systemic temperature may be
maintained at nor- mothermia or at
varying degrees of hypothermia
depending on the surgeons preference and the operative procedure.

Terminating Bypass
Before terminating bypass, the patient should be
warmed toward normothermia
Cardiac performance is assessed. Inotropic
support should be considered for marginal cardiac
performance.
When the patient is stable, protamine is
administered to reverse heparin effect and should
return the ACT to normal. The dosage is
commonly based on a 1 : 1 mg:mg ratio
The suction lines are turned off once the
protamine administration has started. The venous
line is usually removed first and drained into the
cardiotomy reservoir.