CARDIAC ANAESTHESIA

Cardiopulmonary bypass

Learning objectives

Saran Woods
After reading this article, you should:

Stephen J Gray

Abstract
The success of cardiac surgery is the result of revolutionary thinking by
those who were unafraid to take risks in the 1950s, when cardiopulmonary
bypass was in its infancy. The development of the heartelung machine has
moved a long way from the cumbersome screen oxygenator to todays
modern disposable hollow-fibre units. Perfusionists are one part of
a team of highly skilled professionals dedicated to delivering the best
quality care. Perfusion science is going through a number of changes,
many of which are focused on receiving recognition from the Health Professions Council. Hospitals can enact local policies enabling perfusionists
under the supervision of consultants to administer drugs on bypass. Regulation of parameters on cardiopulmonary bypass remains controversial.
Best practice is still evolving with regard to perfusion pressure, pump
flow, temperature management and central nervous system monitoring.
Most coronary artery bypass surgery is now performed at normothermia
or mild hypothermia, making the argument for a-stat or pH-stat blood
gas management less critical. Indeed, if the patient has intact cerebral
autoregulation (not routinely tested preoperatively), neither pump flow
nor pressure influences cerebral blood flow over that autoregulatory range.

understand the historical development of cardiopulmonary

bypass and the key components in the bypass circuit
know the primary considerations in the way cardiopulmonary
bypass is conducted
understand the importance of, and the controversy
surrounding, the parameters used to control bypass.

Roller pumps
These are the most widely used type of pump. These pumps
consist of rollers (usually two, 180 apart) positioned on the end
of a rotating arm. Forward flow is induced by the rollers compressing tubing mounted in a U-shaped raceway. The flow rate is
dependent on the diameter of the tubing, the diameter of the
raceway and the rotation rate of the rollers. Roller pumps have
the advantage of being simple to set up and prime; however, they
are traumatic to blood.
Centrifugal pumps
Two types predominate: the first uses a nest of smooth plastic
cones contained within plastic housing; the second makes use of
a vaned impeller. The cones or impellers are magnetically
coupled to an electric motor and, when rotated rapidly, impart
kinetic energy to the blood, inducing forward flow. These devices
are completely non-occlusive, and are dependent on preload and
afterload. An electromagnetic flow probe must be attached to the
arterial line to determine pump flow. These pumps are more
complex, yet less traumatic to the blood elements (reduced
haemolysis). Massive air embolism is less likely.

Keywords a-stat; central nervous system monitoring; drug administration;

flow; normothermic; oxygenator; perfusionist; pH-stat; pressure; systemic
vasculature resistance

History

The bubble oxygenator

The time line for the development of cardiac surgery is shown in

Table 1. The history from the concept of extracorporeal circulation
in 1813 by Le Gallois to the current trend of so-called mini-bypass
is charted. This claims to reduce the deleterious effects of cardiopulmonary bypass (CPB) by minimizing the bloodeair interface.

Lillehei, in collaboration with Dewall, developed the first bubble

oxygenator (Figure 1a). These oxygenators are highly efficient,
inexpensive and disposable. Venous blood is passed upwards in
a vertical column through which oxygen is simultaneously
bubbled. Eddies and vortexes are created whereby oxygen enters
the blood and carbon dioxide is released. The column consists of
either multiple vertical tubes or a fine mesh that acts as a spoiler
to promote mixing of the gas and blood. At the top of the column,
the gases and blood form a foam. Defoaming agents cause coalescence of the bubbles. On exiting the column, the arterialized
blood passes through a filter and bubble trap (Figure 1b).

Blood pumps
CPB diverts blood away from the heart (and lungs) and returns it
to the systemic arterial system. Therefore, CPB must replace the
function of the lungs (gas exchange) and heart (circulation).
Advances in efficient atraumatic blood-pumping devices have
been slow compared with those in oxygenator technology. Roller
and centrifugal pumps are the most commonly used devices.

The membrane oxygenator

Membrane oxygenators are more physiological and extensively
used. They mimic the pulmonary capillary by interposing a thin
membrane between the blood and the gas. There are different
types of membrane, including a flat sheet usually arranged as
a fan-fold and hollow fibres. These fibres have an internal
diameter of 100e200 mm. The total number of fibres ultimately
determines the efficiency of the gas exchange. Gas flows on the
inside of the fibre and blood flows to the outside, thus maximizing the surface area available for gas exchange. Membrane
oxygenators have several advantages: they separate the blood

Saran Woods ACPS LCCP BSc(Hons) is Senior Clinical Perfusionist at

Cambridge Perfusion Services, UK, with special interests in Ventricular
Assist Devices and key educational issues for perfusionists. Conflicts of
interest: none declared.
Stephen J Gray MBBS BSc FRCA is a Consultant Anaesthetist at Papworth
Hospital NHS Trust, UK. His main interest is perioperative transoesophageal echocardiography. Conflicts of interest: none declared.

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CARDIAC ANAESTHESIA

and gas phases, create far fewer bubbles, give greater accuracy in
blood gas control and make massive gas embolism almost
impossible. On the downside, they are more expensive and
technically more difficult to set up.

Key developments in extracorporeal support

Date

Activity

1813

Le Gallois first proposed the principle of extracorporeal

circulation
McLean discovered heparin
De Bakey developed the roller pump
Gibbon performed the worlds first cardiopulmonary
bypass e on a cat
Gibbon used a film oxygenator with his heartelung
machine to perform the first clinical cardiopulmonary
bypass on a patient with an atrioseptal defect
Lillehei successfully utilized cross-circulation
Dewall developed the bubble oxygenator
Bodell developed the membrane oxygenator
Concept of the mini-bypass

1916
1934
1937
1953

1955
1956
1965
2003

Key considerations on the conduct of cardiopulmonary bypass

Anticoagulation
Adequate systemic anticoagulation is an absolute requirement
for CPB. Unfractionated heparin at a dose of 300 iu/kg is used.
Activated clotting time (ACT), measured using a portable device,
determines the adequacy of heparinization. An ACT >400
seconds is required before going onto bypass.
Cannulation strategy
The ascending aorta (occasionally femoral artery) is cannulated
first. At this stage, avoidance of hypertension (mean arterial
pressure (MAP) <60 mmHg) reduces the risk of arterial dissection.
Venous cannulation (right atrium or cavae) then follows.

Table 1

a DeWall with the original bubble oxygenator. b A modern hollow-fibre membrane counterpart.
Courtesy of University Archives, University of Minnesota, Minneapolis.

Figure 1

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CARDIAC ANAESTHESIA

CPB is initiated by the perfusionist releasing the clamp on the

venous line, thereby diverting blood into the venous reservoir.
Concurrently, the speed of the pump is increased to generate
a flow of 2.2e2.4 l/min/m2. When CPB is established, ventilation
of the lungs is discontinued.

ventricular fibrillation. Defibrillation is achieved using internal

paddles with a biphasic energy of 4e10 J.
Pacing
Temporary pacing is instigated by suturing the pacing wires onto
the epicardium. These wires are connected to either a singlechamber or a dual-chamber pacing device. Whilst in the operating
theatre, fixed rate, dual-chamber pacing (DOO, rate 80e100, AV
delay 120e150 ms) is desirable because it is insensitive to
radiofrequency interference and cardiac manipulation. Once on
the critical care unit, the DDD mode is selected to obviate the risk
of pacing-induced ventricular fibrillation.

Adequacy of cardiopulmonary bypass

This remains an area of controversy. The exact parameters
defining optimal CPB are yet to be determined. The perfusionist
maintains a MAP between 50 and 70 mmHg, central venous
pressure (CVP) between 0 and 5 mmHg, mixed venous oxygenation >65% and a haematocrit >20e25%. Arterial blood is
sampled every 20 minutes for blood gas analysis, K, haematocrit and glucose.

Decannulation
The mnemonic TRAVVEL acts as a useful checklist before
terminating CPB (Table 2). Calculation of the systemic vasculature resistance (SVR) may be useful, particularly if significant
amounts of vasoconstrictor has been used to maintain MAP
throughout bypass (see section on calculation of SVR).
On reinstituting mechanical ventilation, separation from CPB
occurs with the perfusionist gradually occluding venous return to
the pump together with incrementally reduced pump flows. With
the return of stable heart rate and MAP, the venous cannula is
removed. Protamine (1 mg for every 100 iu of heparin) is
administered over 2e5 min. Any hypotension accompanying the
protamine infusion is treated with transfusion from the venous
reservoir. After removal of the aortic cannula, blood within the
CPB system is drained and returned to the patient.

Anaesthesia
Total intravenous anaesthesia with propofol (4 mg/kg/h) is the
most commonly used method. If inhalational agents are used,
they must be recommenced by the perfusionist on initiation of
bypass, so as to minimize the likelihood of awareness.
Cardioplegia
This is one of the prime constituents in myocardial protection.
Arrest of the heart is achieved by means of potassium-based
solutions. Blood cardioplegia is becoming the norm. This is
prepared on bypass with heparinized blood added to a crystalloid
base solution.
Rewarming
Extremely efficient integrated heat exchangers warm the blood
returning to the patient. Rewarming should not be too rapid
because this can lead to bubble formation, denaturing of plasma
proteins and worsening of any cerebral injury. In practice, the
difference between arterial inflow and nasopharyngeal temperatures should be less than 4.0 C.

Calculation of systemic vasculature resistance on

cardiopulmonary bypass
The SVR increases during the course of CPB. This is related to
a gradually reducing vascular cross-sectional area, vasoconstriction accompanying hypothermia, increasing catecholamines
(angiotensin II, vasopressin, endothelin) and increasing viscosity:

Defibrillation
Removal of the aortic cross-clamp and accompanying coronary
reperfusion can be associated with arrhythmias, in particular

where the units for MAP are mmHg, those for CVP are mmHg
and those for pump flow are l/min; Wood units can be converted
to dyne/s/cm5 by multiplying by 80.

SVRWood units MAP  CVP=pump flow

TRAVVEL checklist for termination of CPB

Mnemonic

Stands for

Check

T
R

Temperature
Rate

Air

V
V

Venting
Ventilation

Electrolytes

Level

Nasopharyngeal 36e37  C
Stable cardiac rate and rhythm
Epicardial pacing might be required
Techniques to remove intracardiac air
Transoesophageal echocardiography can be used to confirm adequacy
Venting lines either clamped or removed before coming off bypass
Mechanical ventilation restarted
Left lower lobe expansion visually confirmed (if pleura open)
Normalize metabolic indices
Base excess <5 mmol/l, PO2 > 10 kPa, PCO2 w5 kPa
Haematocrit >20%, K > 4.5 mmol/l
Operating table

Table 2

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CARDIAC ANAESTHESIA

Key points for statutory regulation of perfusionists

Case for regulation
Invasive procedures

Clinical perfusion scientists control, manage and are responsible for one of
the most invasive tools used in routine surgery

Clinical intervention with the potential for harm

Potential for harm in a perfusionists routine clinical practice is ever present.

Supported by coroners correspondence. Detailed in full application

Exercise of judgement by unsupervised professionals,

which can substantially affect patients health or welfare

Evidence used in applying to Health Professions Council confirms that routine

judgement of the clinical perfusion scientist can affect patients mortality
and morbidity

Table 3

Regulation of perfusionists

constancy of this charge state is important in the regulation of

pH-dependent cellular processes and enzyme function.
With a-stat, the uncorrected (37 C) pH is kept at 40 nmol/l
and the PCO2 at 5.3 kPa, so creating a relative alkalosis with
cooling. a-Stat is credited with preserving cerebral autoregulation, thereby reducing microembolization.
With pH-stat (corrected) a pH of 40 nmol/l and a PCO2 of 5.3 kPa
is established for that particular temperature. This invariably
requires carbon dioxide to be added to the circuit. pH-stat was
extensively used in the 1980s in the belief that the potent vasodilatory effects of carbon dioxide would improve cerebral blood
flow, thereby decreasing ischaemia on CPB.
So which is the preferred strategy? In adults with moderate
hypothermia (28e30 C), a-stat is recommended. In a landmark
study, Murkin et al.1 clearly showed the benefits of this approach.
However, if deep hypothermic cardiac arrest (DHCA) is used,
a cross-over strategy is advocated. Here, pH-stat is used in the
initial 10 minutes of cooling, followed by a switch to a-stat. This
maximizes cerebral cooling yet avoids the severe acidosis associated with prolonged pH-stat management. In infants, in whom
brain injury is more associated with hypoperfusion or the initiation of excitotoxic pathways, pH-stat seems to be advantageous.

Safety of the patient is paramount. Effective communication

between the various teams (surgical, anaesthetic, perfusion and
nursing) is vital.
Recently, a number of cases in which this communication has
broken down have received media attention. This has highlighted the issue of regulation of perfusionists. Perfusion is still
not a government-regulated profession. The current governing
body is the College of Clinical Perfusion Scientists of Great
Britain and Ireland. Application for recognition is currently
ongoing with the Health Professions Council (Table 3).

Drug administration by perfusionists

The Gritten Report, published in 2008, focuses on the issue of
drug administration by perfusionists. As a profession, perfusionists routinely give fluids and drugs without prescription (e.g.
Hartmanns solution, mannitol, heparin and metaraminol). The
perfusionist has no authority to give drugs without a doctors
prescription, as detailed in the 1968 Medicine Act.
Some hospitals, after broad consultation, have devised a set of
drug administration protocols. Every drug in the perfusionists
armamentarium is detailed in these protocols. If the guidelines are
adhered to, the perfusionist can administer drugs on bypass. The
consultant anaesthetist must sign the perfusion record sheet at the
start of each case. The record sheet contains a declaration stating:

Pressure versus flow

If MAP is kept within the autoregulatory range (50e150 mmHg),
cerebral blood flow (CBF) is essentially independent of pressure.
This has implications for patients with hypertension, in whom
the autoregulatory curve is shifted to the right.
Gold et al.2 provided some direction in a contentious study.
Patients were randomized either to lower (50e60 mmHg) or to
higher (80e100 mmHg) CPB pressure groups. Using the
composite end-point of combined adverse cardiac and neurological outcomes, the higher CPB pressure group had significantly better outcomes 6 months after surgery. Further analysis
showed that patients at high risk of stroke (severely atheromatous aorta) were more likely to have a stroke if the MAP was kept
in the lower pressure range.
The inter-relationship between pump flow and pressure is
complex, and is dependent on arterial impedance, temperature,
haemodilution and arterial cross-sectional area. Again, it seems
that, if cerebral autoregulation remains intact, CBF is unaltered
by changes in pump flow. At low-flow states, CBF is likely to be
dependent on perfusion pressure.

I hereby authorize the clinical perfusion scientist to administer medications and fluids in line with the Trusts clinical
guidance for drug administration through the bypass machine
under my supervision.
This is an interim measure until national guidelines are produced.

Control of parameters on cardiopulmonary bypass

a-Stat versus pH-stat
Management of arterial blood gases (ABG) during hypothermic CPB
remains controversial. Two strategies have evolved: a-stat and pHstat. Hypothermia causes alkalosis. With cooling, carbon dioxide
becomes more soluble (partial pressure decreases) and the ionization of water decreases. The net effect is a reduction in hydrogen ions.
The term a-stat relates to how acidebase regulatory mechanisms function to maintain a constant ratio (a) of dissociated to
undissociated forms of the imidazole ring of histidine. The

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CARDIAC ANAESTHESIA

Normothermic versus hypothermic cardiopulmonary bypass

In the 1990s, a number of studies were carried out to investigate
whether hypothermia was a requirement for CPB.
The Toronto Warm Heart Investigators (1994) showed no
increase in neurological complications with the use of normothermic
CPB. Conversely, the Atlanta Group demonstrated marked increases
in central nervous system CNS problems. Because the study designs
were so different, it is not surprising that the results were conflicting.
Accumulated evidence indicates that normothermic CPB does
not increase the risk of adverse neurological outcomes and that
mild hypothermia (34 C) confers additional cerebral protection
compared with mild hyperthermia (>37 C), which exacerbates
any ischaemic injury.

e Near infra-red spectrometry (NIRS): a non-invasive

method of determining intravascular regional haemoglobin oxygen saturation. Based on the premise that the
skull is translucent to infrared light. The data are displayed as a continuous trend. Remains controversial
but gaining acceptance.
 CNS haemodynamics
e Transcranial Doppler ultrasonography: ultrasound
probes are placed over the thinnest portion of the
temporal bone (acoustic window) and aligned to the
middle cerebral artery (MCA). At any one time, the
MCA carries 40% of the hemispheric blood. Interpretation of the information is usually operator dependent,
and securing the probes is difficult. This technique is
sensitive at detecting intracranial blood flow and
emboli (particulate and gaseous).

Central nervous system monitoring

Adverse cerebral events are the most devastating outcomes
associated with cardiac surgery. Factors contributing to brain
injury include atheromatous emboli from aortic cannulation, lipid
microemboli, gaseous microemboli (air leaks and cavitation),
hypoperfusion, hyperperfusion and hyperthermia. Roach et al.,3
studying 2400 patients undergoing elective coronary artery bypass
graft in 24 US centres, reported a 6.1% incidence of neurological
or neuropsychiatric adverse outcomes. These patients required
prolonged hospitalization, with only one in three returning home,
and most needed long-term care and rehabilitation.

Adequately powered prospective studies indicating improved

outcomes and economic benefits are sparse. The results of a few
outcome studies using multimodal neuromonitoring (EEG,
transcranial Doppler, cerebral oximetry) have shown substantial
reductions in length of stay and hospital expense compared with
other types of monitoring. Interestingly, and perhaps not unexpected, these studies also indicate a benefit to other vital organ
systems.
A

Monitoring neurological function falls into three areas.

 CNS electrical activity
e Electroencephalogram (EEG): measures postsynaptic
potentials in cerebral cortical neurones. Exquisitely
sensitive but too cumbersome for intraoperative use.
e Processed EEG: compressed spectral array, bispectral
index (BIS). EEG data are further analysed using fast
Fourier transforms, generating a power versus time
spectral array. Trends are formed and displayed.
Overall, more applicable to the operating theatre.
e Evoked potentials (somatosensory, auditory, motor): of
some use in thoracic aneurysmal surgery in which
there is a threat to the spinal cord.
 CNS metabolic activity
e Jugular bulb venous oximetry: a suitably placed
fibreoptic catheter gives a continual global measure of
cerebral venous oxygen saturation. Unreliable in
profound hypoperfusion and low-flow states.

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REFERENCES
1 Murkin JM, Martzke JS, Buchan AM, et al. A randomized study of the
influence of perfusion technique and pH management strategy in 316
patients undergoing coronary artery bypass surgery. J Thorac
Cardiovasc Surg 1995; 110: 349e62.
2 Gold JP, Charlson ME, Williams-Russo P, et al. Improvement of
outcomes after coronary artery bypass: a randomized trial comparing
intraoperative high versus low mean arterial pressure. J Thorac
Cardiovasc Surg 1995; 110: 1302e14.
3 Roach GW, Kanchuger M, Mora Mangano CT, et al. Adverse
cerebral outcomes after coronary bypass surgery. N Engl J Med 1996;
335: 1857.
FURTHER READING
Kaplan JA, Reich DL, Lake CL, Konstadt SN. Kaplans cardiac anesthesia.
5th edn. Philadelphia: Saunders Elsevier; 2006.

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