113-

Blood gas control during cardiopulmonary bypass

DT Pearson Freeman Hospital, Newcastle-upon-Tyne

Introduction Why control blood gases during

hypothermic CPB?
The functional replacement of the heart and lungs
by blood pump and artificial oxygenator during
a The maintenance of adequate perfusion to the
open heart surgery is now commonplace. To in- brain and other organs is essential in all patients
crease the tolerance of the heart to ischaemia supported by a pump oxygenator. Reduced cere-
during the surgery, systemic hypothermia is em- bral perfusion may result from systemic arterial
ployed ; augmenting cardioplegia and topical hypotension,~ though the level and degree of au-
myocardial cooling. toregulation of cerebral blood flow (CBF), in the
The conduct of cardiopulmonary bypass (CPB) absence of haemodynamically significant
is not only concerned with the preservation of atherosclerotic lesions, is dependent upon acid-
organ viability but also with maintenance of organ base status during hypothermia. The use of a
function. An important safety feature of hypo- pH-stat regime uncouples cerebral flow and
thermic CPB concerns the following important metabolism with resultant pressure passive CBF
considerations related to blood gas control: and loss of autoregulation below a mean arterial
pressure (MAP) of 55 mmHg.2,3 Alpha-stat
1) Why control blood gases during hypothermic management maintains autoregulation of CBF at
CPB?
a lower MAP with a more physiological relation-
2) Alpha-stat and pH-stat acid base management ship between CBF and cerebral metabolic rate. 4,5
during hypothermic CPB. High arterial P02 (Pa02) is vasoconstricting, nar-
3) Significance of the term ’temperature correc- rowing the CBF autoregulatory plateau and low
tion’ as it applies to blood gas measurement
Pa02 shifts the lower limit of autoregulation to
during hypothermic CPB. a higher level.6 6 Whilst the optimal levels of arterial
4) Measurement technique and frequency of esti- PC02 (PaC02), blood flow and MAP during
mation of blood gases.
Do current hypothermic cardiopulmonary bypass are yet to
commercially available artificial be
5) established,’ the potential exists that failure
oxygenators allow the perfusionist to control of autoregulation of CBF when Pa02, PaC02 and
blood gases to prescribed levels?
levels are abnormal may precipitate cerebral
6) Which bubble oxygenator design features in- pH damage.
fluence blood gas control?
The level of Pa02 directly influences the gaseous
microemboli emission from bubble
(GME)
Address for correspondence: Dr DT Pearson, Regional The life
Cardiothoracic Unit, Freeman Hospital, Freeman Road, High oxygenators.8~9 span and stability of these
Heaton, Newcastle-upon-Tyne NE7 7DN, UK. 100% 02 bubbles present in the arterial blood is

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114

inversely related to the partial pressure Pa02 blood total C02 content constant, maintaining
gradient between the bubble and blood.10 temperature uncorrected PaC02 at 5.3 kPa. 21
There is improved myocardial electrical stability
in patients undergoing hypothermic CPB with
alpha-stat management as compared with pH-stat of the term ’temperature
Significance
management. 11,12 correction’ it applies to blood gas
as
Systemic arterial microembolism has been measurement during hypothermic CPB
suggested as an important cause of cerebral
damage.’3,’4 It has been reported in the literature Blood gas analyser: the estimation of blood gas
that oxygenators: (a) release gaseous microem- values from samples taken from the cardio-
boli8,14,15; (b) damage formed blood elementsl6-18; pulmonary bypass circuit during hypothermia in-
I

and (c) do not allow the perfusionist to maintain volves the use of blood gas analysers (BGA) in
physiological levels of Pa02 and PaC02 during which the blood sample is heated to 37°C. The
cardiopulmonary bypass,9,19,20 all of which can values obtained may be ’temperature corrected’
theoretically produce multi-organ damage. using the BGA in-built formulae to allow for the
The current balance of clinical opinion favours difference in temperature between the patient and
alpha-stat rather than pH-stat acid-base manage- the analyser’s electrodes.
ment to optimize organ function during hypo-
pH-stat: Values corrected for actual body
thermic CPB.5,7,21 The need to control PaC02,
temperature
Pa02 and pH values during hypothermic CPB is Alpha-stat: Values not corrected for actual
therefore mandatory, based on clinical and
body temperature
physiological evidence relating to organ function.
In-line electrodes: blood gas values measured
at patient temperature during hypothermic CPB.
Alpha-stat and pH-stat acid-base The use of the term ’temperature correction’ in
management during hypothermic CPB this context is different to that applied to blood
gas values when BGAs are used involving the use
The principles associated with the use of the terms of in-built formulae to correct the values to 37°C.
alpha-stat and pH-stat in relation to acid/base pH-stat: Values not corrected to 37°C
status, are effected by alteration in C02 solubility Alpha-stat: Values corrected to 37°C
during hypothermia.
During hypothermic CPB, the perfusionist at-
Henry’s Law: Gases in solution tempts to maintain PaC02 5.3 kPa and pH 7.40.
Content =
partial pressure x solubility It may be necessary to apply ’temperature correc-
During hypothermia C02 solubility [up] tion’ of the blood gas values dependent upon the
use of either alpha-stat or pH-stat acid-base
pH-stat:
Content [up] =
partial pressure [normal] x management techniques and measurement by
solubility [up] BGA or inline electrodes. Representative values
pH [normal] . for PaC02 and pH during hypothermic CPB at
25°C are shown.
Alpha-stat:
Content [normal] =
Partial pressure [down] x
solubility [up] Blood gas machine
pH [up]
During hypothermic CPB, acid-base management Measured at 37°C
may be directed towards maintenance of tempera- pH-stat pH 7.22 PaC02 8.3 kPa
ture corrected arterial PC02 (PaC02) at 5.3 kPa Alpha-stat: pH 7.40 PaC02 5.3 kPa
and pH 7.4 (pH-stat). To compensate for the
increased solubility of C02 during hypothermia,
blood total C02 content must be raised by addition Corrected to 25°C
of C02 and/or hypoventilation. The alternative pH-stat pH 7.40 PaC02 5.3 kPa
acid-base management (alpha-stat) is to keep Alpha-stat: pH 7.57 PaC02 3. 3 kPa

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In-line electrodes
Measured at 25°C
pH-stat: pH 7.40 PaC02 5.3 kPa
Alpha-stat:
.
pH 7.57 PaC02 3.3 kPa
Corrected to 37°C
pH-stat: pH 7.22 PaC02 8.3 kPa
Alpha-stat: pH 7.40 PaC02 5.3 kPa
Measurement technique and frequency of
estimation of blood gases
Significantly better control of Pa02 can be
achieved using data from an inline electrode rather
than intermittent blood gas sample values.9 The
use of data from an inline P02 electrode22,z3 to
control Pa02 levels has many advantages over
conventional intermittent blood sampling. The
time constants of changes in Pa02 during
hypothermic cardiopulmonary bypass do not
permit intermittent sampling to determine Pa02
adequately and hence allow adjustment of the
gas/blood flow ratios needed to maintain
physiological levels of Pa02. Adequate manage-
ment of C02 clearance during CPB can be
achieved by estimation of PaC02 at 15-minute
intervals. During a clinical evaluation of the gas
transfer characteristics of 10 Bentley BIO-10
bubble oxygenators, inline Pa02 values were cor-
related with BGA PaC02 values from blood sam-
ples taken at five-minute intervals. The scatter-
grams of the five-minute and 15-minute data are
shown in Figure 1. There was no significant differ-
ence between the group Pa02 and PaC02 values
when the five-minute and 15-minute data were
compared.
A high degree of temperature-dependent error
with underestimation of P02 can result from use
of blood gas analyser results.24-26 Correlation of
the Pa02 values obtained from an inline P02
electrode (Cardiomet 1000: Biomedical Sensors)
and samples analysed by BGA (Instrumentation
Laboratories IL1302) is shown in Figure 2. The
temperature-compensated BGA tended to under-
estimate the Pa02 (mean ± sd difference between
pairs of values 7.0 ± 8.6).
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115
Do current commercially available
artificial oxygenators allow the
perfusionist to control blood gases to
prescribed levels?
Introduction
Currently available bubble oxygenators effect
gas transfer by dispersing gas (100% 02) into the
venous blood via small holes in a gas sparger.
Gas exchange occurs in the resultant foam due
to the intimate mixing of blood and oxygen (direct
blood gas interface). Once this has been achieved,
coalescence of the foam and removal of remaining
bubbles is accomplished by the use of a combin-
ation of the action of surface active substances in
the oxygenator defoamer, settling and filtration.
Total gas flow, size of bubbles generated in the
gas sparger, turbulence and gas transfer occurring
over the heat exchange area and in the defoamer
are all critical factors in bubble oxygenator per-
formance. Small bubbles produce excellent oxy-
genation but are inefficient at C02 removal and
difficult to remove by the defoamer. Large bubbles
are essential for C02 removal and easily removed
by the defoamer, but less efficient as far as oxy-
genation is concerned. There always exists a com-
promise between oxygenation and C02 elimin-
ation in bubble oxygenators (Galletti and Brecher,
1966) .
The use of low gas/blood flow ratios and
’efficient’ oxygenation may result in inadequate
C02 clearance. Typically during hypothermic car-
diopulmonary bypass, as metabolic rate and there-
fore 02 demand falls, the perfusionist controls
the Pa02 by reducing the gas to blood flow ratio.
However, if this results in inadequate C02 clear-
ance, he or she is faced with the dilemma of
raising the gas to blood flow ratio producing high
Pa02 and normal PaC02 values or accepting
normal Pa02 values with C02 retention. Control
of Pa02 to physiological levels may be associated
with C02 retention as shown in Figure 3.9 Whilst
this may be acceptable during hypothermic per-
fusion using a pH-stat technique of blood gas
management, the need to maintain C02 clearance
using an alpha-stat technique can present prob-
lems for the perfusionist.
The independent control of Pa02 and PaC02
and the ability to adjust the flow rate and 02
concentration of the ventilating gas in membrane
116

Figure 1 Scattergrams of blood gas data for Pa02 and PaC02 in Bentley BIO-1 0 bubble oxygenator group: (a) 15-minute
’

samples (Pa02 34.0 -t 5.1 kPa; PaC02 5.2 -L 0.9 kPa; n 193); (b) 5-minute samples (Pa02 30.3 -t 14.9 kPa; Pa02 5.2 ±
=
1.1
kPa; n =
67) mean ± SD. Shaded area indicates blood gas target range

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 117

Figure 2 Comparison of Pao2 measurement techniques: (a) scattergram of Pa02 data from IL1302 blood gas analyser and
Cardiomet 1000 in-line electrode with line of identity (correlation coefficient 0.79); (b) scattergram of difference between IL1302
and Cardiomet 1000 data

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 118

Figure 3 Scattergrams of blood gas data for Pa02 and PaC02 in Harvey H1500 bubble oxygenator groups: (a) intermittent P02
data (Pa02 30.9 ± 7.1 kPa; PaC02 5.9 ± 0.7 kPa); (b) continuous POz data (PaO~ 14.0 ± 2.0 kPa; PaC02 6.3 ± 0.7 kPa) mean ±
SD. Shaded area indicates blood gas target range

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oxygenators (which do not have a direct blood
gas interface) enables the perfusionist to manage
blood gas values more easily.2’ The use of nitrogen
to dilute the 02 concentration in the ventilating
gas of bubble oxygenators has been proposed as
a method of controlling the PaOb 28 but it cannot
be recommended for clinical use.29-31
Clinical oxygenator evaluation
During clinical hypothermic cardiopulmonary
bypass (CPB) in adult patients, the ability of the
perfusionist to control arterial P02 and PC02 has
been evaluated in: (a) five groups of bubble
oxygenators (Polystan venotherm, Harvey H1700,
Bentley BIO-10, Gambro 10 and Shiley S100A
HED); (b) two groups of membrane oxygenators
(Harvey HF4000 and Cobe CML) using a pH-stat
blood gas management technique; and (c) three
groups of bubble oxygenators (Bentley-10B,
Bentley-l0Plus and Harvey H1700) using alpha-
stat blood gas management technique (Table 1).
’Ten oxygenators from each manufacturer
used in each of the 10 study groups.
Table 1 Blood gas control: oxygenators evaluated
Patients: the study included 100 patients under-
going open-heart surgery for acquired valvular or
ischaemic heart disease randomly assigned to one
of the 10 oxygenator groups according to the
oxygenator used for CPB. The clinical profile of
the patients allocated to each oxygenator group
is shown in Tables 2 and 3. All patients were
anaesthetized by the same anaesthetist (DTP),
using a modified form of neuroleptanalgesia sup-
plemented by nitrous oxide and muscle relaxants.
Cardiopulmonary bypass: oxygenator evalu-
ation was undertaken during hypothermic CPB
(24-28°C) with the addition of cold cardioplegia.
The bypass circuit, consisting of the oxygenator
to be evaluated, cardiotomy reservoir (Harvey
H705F or H4700) and customized tubing circuit,
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119
Table 2 Clinical profile of oxygenator groups
was mounted on a Cobe Stockert Pump Console.
No prebypass or arterial line filters were included
were in the circuit. The oxygenator and tubing circuit
were flushed with 100% C02 prior to priming
with Plasmalyte 148 (Travenol Laboratories).
Perfusion technique: to conform with current
clinical practice, the blood flow rate (QB) was
maintained at 2.4 l.min-1.m2 body surface area
during cardiopulmonary bypass and reduced by
25% during hypothermia commensurate with ac-
ceptable oxygenator reservoir levels and surgical
technique and preference. Gas was delivered to
the oxygenator from back pressure compensated
anaesthetic rotameters.
In the bubble oxygenators (pH-stat), the flow
rates of 100% 02, with or without the addition
of small amounts of 100% C02, were manually
adjusted in an attempt to maintain predetermined
target levels of Pa02 and PaC02 (Table 4). No
C02 was added during the rewarming phase of
CPB. In the bubble oxygenators (alpha-stat), only
100% 02 was used, without the addition of any
C02. Two important restraints were placed upon
the perfusionist controlling the blood gases:
a) Total gas flow rate was not adjusted below
0.51 per minute even if the Pa02 was above
the target range.
b) Inadequate C02 clearance with associated
elevation of PaC02 was corrected by increas-
ing gas flow rate and took precedence over
maintenance of target Pa02 levels.
120
Table 3 Characteristics of oxygenator groups
Table 4 Target blood gases
Continuous Pao2 measurement using Cardiomet 1000
Intermittent PaC02 measurement using IL 1302
The Bentley-lOB is a typical bubble oxygenator
in which all of the gas (100% 02) is dispersed
into small bubbles at the sparger to mix with the
incoming venous blood and effect gas transfer.
This oxygenator has been modified in the Bentley-
lOPlus to incorporate an integral gas proportioning
valve (gas controller). When this proportioning
valve is set at maximum, all of the gas entering
the device is directed to the sparger. As the valve
is progressively adjusted from maximum to the
minimum setting, an increasingly greater propor-
tion of the total gas flow is directed, via the
original quick prime port, to the heat exchange
area of the oxygenator (Figure 5). At minimum
setting of the valve, 10% of the total gas flow
passes through the sparger and 90% is directed
to the heat exchange area. The technique of con-
trol of blood gases in the Bentley-l0Plus
oxygenator (alpha-stat) differed from the other
bubble oxygenators. A gas (Qa) to blood (QB)
flow ratio of 1:1 with a QB of 2.4 l.min-l.m-2
body surface area was used at the start of CPB.
The initial QG was maintained throughout the
bypass even when QB was reduced during
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(patient and bypass data)
hypothermia. Pa02 was controlled by alteration
of the setting of the gas controller valve on the
top of the oxygenator.
In the membrane oxygenators (pH-stat), Pa02
and PaC02 levels were adjusted by alteration of
the percentage 02 and C02 in the gas to the
device; a total gas flow rate of 10 l.min-1 (Cobe
CML) or 4.0 l.min-1 (Harvey HF4000) was main-
tained throughout the period of bypass.
Gaseous microemboli (GME): GME were
monitored in the arterial line leading from the
oxygenator using a TM8 Microbubble Activity
Monitor. Signals from the TM8 were computer
processed to generate GME.1-1 during the CPB. 32
From this data an oxygenator group mean ± SD
GME level was calculated.
Blood gas analysis: in all oxygenator groups, a
Cardiomet 1000 inline P02 electrode (Biomedical
Sensors) was used to provide continuous data for
blood temperature and to control the Pa02-
Arterial blood samples were analysed for PaC02
using an IL1302 blood gas analyser. PaC02 and
Pa02 values were blood temperature uncorrected
in the alpha-stat oxygenator groups (five-minute
samples) and blood temperature corrected in the
pH-stat oxygenator groups (15-minute samples).
PaC02 values were corrected with the inline Pa02
values at the time of blood sampling.
Blood samples: whole blood samples (25ml)
were withdrawn for haematology studies before
and after CPB. Values for plasma haemoglobin
and platelet count were corrected for haemo-

Figure 4 Schematic diagram of Bentley
pattern engendered by manipulation of the gas controller
dilution. Nopatient was taking antiplatelet drugs
(aspirin dipyridamole) prior to surgery and no
or
donor blood was transfused before or during the
time of blood sampling. Anticoagulation was
maintained using heparin; the accelerated clotting
time being monitored using a Haemochron and
maintained >400 seconds throughout bypass.
Results
Scattergrams of the blood gas data for all 10
oxygenators in each evaluation group are dis-
played in Figures 5, 6 and 7, together with the
target range for PaC02 and Pa02. The oxygenator
group blood gas values (mean ± SD) and the
percentage of values when both PaC02 and Pa02
are in the target range are shown in Table 5. In
all oxygenator groups, it was possible to control
the PaC02 to within the target range, confirming
the ability of the perfusionist to adhere to the
prescribed protocol of giving priority to C02
clearance. The degree of Pa02 control is
demonstrated by the spread of data points in the
scattergrams and percentage values in the target
range.
121
10PIus showing effect of alteration of gas flow
Bubble oxygenators (pH-stat): the number of
blood gas values in each group is similar, but the
distribution of blood gas values and the percentage
of values when both PaC02 and Pa02 were within
the target range is markedly different for some
of the oxygenator groups (Figure 5 and Table 5).
Only 3% of the values obtained in the Bentley
BIO-10 group fell within the defined normal
range, compared with 17% for the Gambro 10
group, 20% for the Shiley S-100A HED group,
31% for the Polystan venotherm group and 36%
for the Harvey H1700 group. The Bentley BIO-10
bubble oxygenator group mean Pa02 values were
significantly higher (p<0.05) than the other
oxygenators evaluated, though mean Pa02 values
in all groups were above the normal range (Table
5).
When the bubble oxygenator groups are
compared, the Polystan venotherm releases sig-
nificantly less GME than the other oxygenators
(p<0.02) and the Shiley S100A HED releases
significantly greater numbers of GME than the
other oxygenators (p<0.02) except for the
Gambro 10. No significant differences could be
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122

Harvey H1700

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 123

Bentley BIO-10

Gambro 10

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124

Figure 5 Scattergrams of blood gas data for Pa02 and PaC02 in five bubble oxygenator groups using a pH-stat acid base
management technique: (a) Polystan venotherm; (b) Harvey H1700; (c) Bentley BIO-1 0; (d) Gambro 10; (e) Shiley S1 OOA HED.
Shaded area indicates blood gas target range

demonstrated between the Bentley BIO-10, pore size of the bubble disperser (using data
Harvey H1700 and Gambro 10 (Table 6, Figure 8). provided by the manufacturers). The results are
In the bubble oxygenator groups (Table 6), shown in Figure 10. A statistically significant in-
there were statistically significant differences verse relationship has been established (p<0.05).

between the gas/blood flow ratios used by the
perfusionist, within the confines of the evaluation
protocol, to control the PaC02 and Pa02 within
the target range. Correlation of Pa02, GME levels
and gas/blood flow ratios in the bubble oxygenator
groups (Figures 8 and 9, Tables 5 and 6) indicates
that the use of low gas/blood flow ratios is not
The larger bubble disperser pore size in the
Polystan Venotherm necessitated the use of com-
paratively higher gas/blood flow ratios to attain
adequate gas exchange with significantly lower
GME production. The lower gas/blood flow ratio
used in the Shiley S100A HED oxygenator group
was associated with a small pore size and sig-

necessarily associated with low GME levels and
inadequate oxygenation as evidenced by the
Bentley BIO-10 data. The Bentley BIO-10,
Gambro 10 and Shiley S100A used significantly
lower gas/blood flow ratios than the two other
bubble oxygenators evaluated, but had high GME
levels in the arterial blood. The lowest levels of
GME, from the Polystan venotherm bubble
oxygenator group, were associated with a high
gas/blood flow ratio.
The mean GME levels in the five bubble
oxygenator groups have been correlated with the
nificantly higher GME levels.
Bubble oxygenators (alpha-stat): the Bentley-
lOPlus allowed significantly better control of Pao2
(p<0.05) and a smaller scatter of values than the
Bentley-lOB. Both oxygenator group PaC02
values were within the target range. The gas
controller valve permitted a considerable degree
of independent PaC02 and Pa02 control in the
Bentley-10Plus, though there was no significant
difference in GME emission between the two
oxygenators. The Bentley-10 series of oxygenators
offers an improvement in blood gas control and

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 125

Figure 6 Scattergrams of blood gas data for Pa02 and PaC02 in two membrane oxygenator groups using a pH-stat acid base
management technique: (a) Cobe CML; (b) Harvey HF 4000. Shaded area indicates blood gas target range

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126

Bentley 10PLUS

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 127

Figure 7 Scattergrams of blood gas data for Pa02 and PaC02 in three bubble oxygenator groups using an alpha-stat acid base
management technique: (a) Bentley 10B; (b) Bentley 10PIus; (c) Harvey H1700. Shaded area indicates blood gas target range

Table 5 Blood gas values for 10 oxygenator groups

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128
GME over Bentley BIO-10 (Figure 7).
The Harvey H1700 bubble oxygenator was
evaluated using an alpha-stat acid-base manage-
ment technique (Figure 7). Although only 15%
of values for Pa02 and PaC02 were within the
target range, the scatter of values is small and
Table 6 Gaseous microemboli and gas/blood flow ratio in
10 oxygenator groups
Figure 8 Oxygenator group gaseous microemboli for
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compares favourably with the Harvey H1700 (pH-
stat) and Bentley-10Plus.
Membrane oxygenators (pH-stat): in both the
membrane oxygenators evaluated, the in-
dependence of Pa02 and PaC02 control allowed
a high percentage of blood gas values to fall in
the target area with minimal scatter. GME
emission was minimal and significantly lower than
in any of the bubble oxygenators evaluated.
Haematology: although all oxygenator groups
showed a rise in plasma haemoglobin when the
pre- and post-CPB values were compared, no
individual value exceeded 120 mg.dl-1 (Table 7).
Over the period of CPB, there was a marked
difference in the mean percentage reduction in
platelet count in the different oxygenator groups
(Table 7). The post-CPB platelet count was sig-
nificantly lower than the pre-CPB (p<0.05) in all
oxygenator groups except the Cobe CML and
Gambro 10. The platelet count fall could not be
correlated with gas/blood flow ratio or GME
emission in the bubble oxygenator groups. The
use of the gas controller in the Bentley-10Plus
oxygenator group did not significantly reduce
platelet depletion as compared with the Bentley-
10B.
10 oxygenators (mean ± SD)
 129

Figure 9 Oxygenator group gas/blood flow ratio for ten oxygenators (mean ± SD)

Table 7 Oxygenator group plasma haemoglobin (mg.dl-’) and platelet count (x 109.1-1): haematocrit corrected

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130

size (correlation
Figure 10 Comparison of gaseous microemboli production of bubble oxygenators and bubble disperser pore
coefficient -0.91 ): (a) oxygenator group gaseous microemboli (mean ± SD) in five bubble oxygenators (pH-stat acid-base
management); (b) bubble disperser pore size

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Discussion
Choice of oxygenator for clinical CPB must
take into account the gas transfer characteristics
of the device and how these relate to the acid-base
management technique used during hypothermia.
Clinically significant differences have been
demonstrated in the 10 oxygenators studied.
When compared with the Bentley-lOB, the
Bentley-10Plus is a significantly improved design,
though no reduction in GME or improvement in
platelet depletion have been associated with its
use in the current study. It is possible that by
adjustment of the total QG in conjunction with
use of the gas controller, a further improvement
in control of blood gas values could have been
attained in the Bentley-10PIus oxygenator.
The bubble oxygenator using the highest gas/
blood flow ratio in the pH-stat study (Harvey
H1700) was evaluated to assess its performance
when an alpha-stat regime was used. This
oxygenator allowed superior control of blood
gases in the bubble oxygenator (pH-stat) evalu-
ation. Whilst there was interdependence of PaC02
and Pa02, satisfactory control of blood gases,
comparable to the Bentley-10Plus, was achieved
with no increase in GME or platelet depletion.
In membrane oxygenators there is considerable
flexibility in the control of blood gases. The in-
dependent control of Pa02 and PaC02 and the
ability to adjust the flow rate and 02 and C02
concentration of the ventilating gas enables the
perfusionist more easily to manage blood gas
values using either a pH-stat or alpha-stat regime.
Which bubble oxyenator design features
influence blood gas control?
Improvement in ’efficiency’ of oxygenation by the
use of low gas/blood flow ratios in bubble
oxygenators may result from an increase in gas/
blood surface area interface consequent upon
generation of smaller oxygen bubbles in the oxy-
genation column of the device.33,34 However, the
defoamer is not as efficient at removing smaller
bubbles which remain after gas transfer and
systemic arterial gaseous microembolism may
ensue. The lower gas/blood flow ratios used, whilst
allowing adequate 02 transfer, may also result in
inadequate C02 clearance. C02 should not be
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131
added to the oxygenator gas supply in bubble
oxygenators.
Diversity of design characteristics in the bubble
oxygenators evaluated may account for the differ-
ences in gas/blood flow ratios used during CPB.
It was noted that the devices achieving adequate
gas exchange at the lower gas/blood flow ratios
(Bentley BIP-10, Gambro 10 and Shiley S100A
HED) generated relatively high gaseous micro-
emboli (GME) levels in the arterial blood. The
size of bubbles generated in the bubble disperser
of bubble oxygenators is a function of the pore
size of the gas disperser.35 The inverse correlation
of mean GME levels in the five bubble oxygenator
groups (pH-stat) with the pore size of the bubble
disperser supports this concept. The larger bubble
disperser pore size in the Polystan Venotherm
necessitated the use of comparatively higher gas/
blood flow ratios to attain adequate gas exchange
with significantly lower GME production; theor-
etically consistent with the production of larger,
’more easily defoamed’ bubbles in the oxygenation
column of the device and relatively ’less efficient’
gas transfer. The lower gas/blood flow ratio used
in the Shiley S100A HED oxygenator group was
associated with a small pore size and significantly
higher GME levels.
During clinical perfusion with any individual
bubble oxygenator, there is a direct relationship
between gas/blood flow rate, arterial P02 and
GME levels in the arterial blood. GME levels are
also inversely related to arterial reservoir level.
The efficiency of defoaming in bubble oxygenators
is related to many factors, including design, size
and shape of the defoamer, flow pattern through
the defoamer and dynamic holdup (resident time).
It is directly comparable to those established
factors influencing the defoaming capacity of
cardiotomy reservoirs.36
The Bentley-10Plus bubble oxygenator allows
the level of Pa02 to be adjusted with the gas
controller valve. Maintenance of a fixed gas flow
of sufficient magnitude to ensure adequate C02
elimination can be presented from inducing over-
oxygenation and high Pa02 values during
hypothermic CPB by manipulation of the gas
controller valve. This valve proportions the gas
away from the oxygenation efficient gas sparger
to the less efficient heat exchange area. Gas
diverted to the heat exchange area of the device
no longer contributes significantly to further
132
oxygenation, but is able to continue to effect C02
elimination. A unique degree of independence of
control of Pa02 and PaC02 has been confirmed
using the oxygenator in the clinical environment.
Summary
The need to control PaC02, Pa02 and pH values
during hypothermic CPB is mandatory, based on
clinical and physiological evidence relating to
organ function. Control of blood gases contributes
to the overall safety of CPB.
Since the current balance of clinical opinion
favours alpha-stat rather than pH-stat acid-base
management during hypothermic cardio-
pulmonary bypass, a comprehensive understand-
ing of the principles involved, associated blood
gas measurement techniques and implications of
temperature correction are essential.
Adequate and accurate control of Pa02 during
CPB necessitates the use of inline P02 electrodes.
Commercially available bubble oxygenators do
not allow the perfusionist adequately to control
blood gases. Control of PaC02 and Pa02 are
interdependent.
The of bubble oxygenators results in an
use
overall to hyperoxygenation and an in-
tendency
ability to clear C02. This tendency can cause
problems in blood gas control when alpha-stat
blood gas management techniques are used during
hypothermic CPB.
Bubble oxygenators using relatively high gas/
blood flow ratios allow better control of blood
gases and lower GME emission.
The Bentley-10Plus bubble oxygenator offers a
degree of independent control of Pa02 and
PaC02-
The useof membrane oxygenators enables
superior control of blood gases with independent
control of Pa02 and PaC02 and GME free per-
fusion to be achieved by the perfusionist.
Acknowledgements
A grant from the Department of Health and
Social Security enabled this work to be under-
taken. Dr A Murray and Mr R Clayton, Regional
Department of Medical Physics, Freeman Hos-
pital, Newcastle-upon-Tyne, assisted in the pro-
duction of the data. The provision of the
oxygenators for evaluation by the manufacturers
Downloaded from prf.sagepub.com at UCSF LIBRARY & CKM on April 20, 2015
is gratefully acknowledged. The technical assist-
ance of the perfusionists in the Cardiothoracic
Unit at Freeman Hospital, Newcastle-upon-Tyne,
is appreciated.
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