529607
research-article2014
SCVXXX10.1177/1089253214529607Seminars in Cardiothoracic and Vascular AnesthesiaBechtel and Huffmyer
Review
Anesthetic Management for
Cardiopulmonary Bypass: Update for 2014
Allison Bechtel, MD1 and Julie Huffmyer, MD2
Abstract
Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly
complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the
anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory
response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.
Keywords
cardiac anesthesia, cardiopulmonary bypass, coronary artery bypass surgery, inflammation, ischemic-reperfusion injury
Introduction
Cardiopulmonary Bypass
While a review of the mechanistic components of cardio-
pulmonary bypass (CPB) is beyond the scope of this spe-
cific review and is further discussed in another review of
this current journal issue, it is important to have some
basic understanding of the process of CPB.
The CPB circuit is designed to take on the work of the
human heart and lungs to accomplish the following func-
tions: divert blood from the patient in order to provide
optimal surgical conditions, oxygenate and remove carbon
dioxide from the blood, cool and rewarm the patient’s
blood and body where appropriate, and return blood to the
patient. Venous blood is drained from the right side of the
patient’s heart to the venous reservoir, which is a large
container that serves as the “mixing chamber” for blood,
fluids, and drugs that are added to the circuit. Blood is
drained from the patient mainly as a result of gravity or a
siphon effect where the difference in central venous pres-
sure, height from patient on the operation room table to the
venous reservoir (which is conventionally very low to the
ground), and any resistance in the venous circuit deter-
mines the efficiency of drainage. From the venous reser-
voir the blood travels directly to the oxygenator and heat
exchanger where oxygenation, removal of carbon dioxide,
and warming or cooling of the blood occurs. Blood is then
passed through the arterial filter and returned to the patient
via the arterial side of the circuit. Additional vents decom-
press the left ventricle and in-line filters remove air and
debris. Cannulae in the aortic root and coronary sinus sup-
ply cardioplegia solution to arrest the heart during surgery.
There are safety mechanisms built into the CPB circuit
such as bubble detectors, pressure monitors, and oxygen
Seminars in Cardiothoracic and
Vascular Anesthesia
2014, Vol. 18(2) 101­–116
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DOI: 10.1177/1089253214529607
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fail safe monitors. None of these supplant the vital need for
qualified expert perfusionists to manage the bypass circuit
in addition to anesthesiologists skilled and trained in the
management of patients with cardiac disease undergoing
cardiac surgery.
Anesthetic Management
Despite the support from CPB, the anesthesiologist plays a
central role in bringing the entire cardiac surgical team
together. Anesthesiologists trained in the care of patients
undergoing cardiac surgery help individualize the anes-
thetic management while on bypass, and importantly direct
and facilitate weaning from bypass. This article will review
conduct and anesthetic implications of CPB organized into
the prebypass and bypass periods and then provide a more
in-depth review and update of some anesthetic manage-
ment decisions including modulation of the stress response
and acute lung injury as a complication related to CPB.
Postbypass anesthetic management and considerations
will not be reviewed.
Prebypass Period
General Concerns. Preoperative preparation and evalua-
tion, monitoring, induction, and maintenance of anesthesia
for patients requiring CPB for heart surgery remains a vital
1
Emory University, Atlanta, GA, USA
2
University of Virginia, Charlottesville, VA, USA
Corresponding Author:
Julie Huffmyer, University of Virginia, PO Box 800710, Charlottesville,
VA 22908-0710, USA.
Email: jh3wd@virginia.edu
102
Table 1. Prebypass Checklist.
Anesthesia medications
•• Volatile anesthetics, IV anesthetics, analgesia, paralysis
Monitoring
•• TEE
•• Arterial blood pressure
Anticoagulation
•• Heparin or other agent
•• Assure adequate anticoagulation: ACT 250 with heparin
coated circuit (Ovrum E), otherwise 350 to 400 seconds of
heparin concentration monitoring >2 units/mL41-44
Arterial cannulation
•• Blood pressure management during placement
•• Test the line, evidence of dissection
Venous cannulation
•• SVC/IVC obstruction
•• Inspect head and neck
•• Venous drainage
and incredibly important aspect of anesthetic management
but will not be reviewed in this article. Planning for main-
tenance of anesthetic depth, neuromuscular relaxation, and
prevention of awareness during CPB is important during
the prebypass period (Table 1). Paralysis is vital to prevent
shivering during cooling and rewarming, which will
increase myocardial oxygen consumption. Movement by
the patient if not adequately paralyzed can cause disrup-
tion or dislodgement of life-sustaining cannulae for CPB.
In the time prior to initiation of bypass as well as the main-
tenance of bypass and separation periods, episodes of tran-
sient or prolonged hypotension due to either surgical
necessity or patient hemodynamic instability may place
patients at risk for awareness. Processed EEG as in use of
the bispectral index (BIS) during anesthesia for cardiac
surgery has been shown to help prevent awareness and
guide use of anesthetic medications and agents.1,2 Hypo-
thermia in addition to related changes in physiologic func-
tion such as protein binding, liver and kidney perfusion,
and metabolic rate may decrease anesthetic requirements;
hence, BIS levels have been shown to be lower in patients
during hypothermia during CPB.3 Puri and colleagues
studied 30 patients monitored with BIS during cardiac sur-
gery and those whose BIS values were known and used to
titrate anesthetic medications had significantly less hyper-
tension and tachycardia and had a nonsignificant reduction
in time to recovery of consciousness.4 BIS values also
were significantly higher in the blinded group at times that
are prone to awareness: the commencement and termina-
tion of CPB.4 Another group evaluated 40 patients under-
going coronary artery bypass graft (CABG) with CPB who
were anesthetized with propofol and remifentanil infu-
sions, one group targeting the propofol infusion to BIS
levels of 40 to 50.5 The BIS targeted group allowed a 30%
Seminars in Cardiothoracic and Vascular Anesthesia 18(2)
reduction in propofol infusion rates without affecting the
stress response to surgery.5 A very recent substudy of car-
diothoracic patients in the BAG-RECALL trial found that
significantly fewer patients in the BIS-guided group devel-
oped postoperative delirium as compared to standard end
tidal volatile anesthetic monitoring.6 Thus, evidence sug-
gests use of the BIS to help not only reduce awareness in
an at-risk population but also to possible decrease delirium
and attenuate rapid changes in hemodynamics through
providing a stable anesthetic course.
Use of near-infrared spectroscopy (NIRS) as a noninva-
sive monitor for cerebral oxygenation during cardiac sur-
gery and CPB has been suggested in addition to an
algorithm to treat cerebral oxygen desaturation and reduce
neurologic complications.7,8 Harilall and colleagues ran-
domized 40 patients for CABG surgery with CPB to NIRS
with protocol versus no NIRS.9 They found significantly
higher levels of S100β, a marker of neurological injury as
well as significantly increased desaturation time in the
control group.9 Interventions undertaken in response to
cerebral oxygen desaturation by NIRS include increasing
blood pressure, assuring adequate hemoglobin levels,
increasing oxygen content of the blood, and increasing
carbon dioxide tension to increase cerebral blood flow. A
recent study evaluated the use of norepinephrine and phen-
ylephrine as vasoconstrictors to treat hypotension on
CPB.10 These investigators found significant reduction in
frontal lobe oxygenation in diabetic patients with the use
of norepinephrine and a nonsignificant trend toward reduc-
tion in oxygenation with phenylephrine in the same group
of patients.10
A major goal of anesthesia for cardiac surgery aims at
reducing the normal neurohumoral response to surgical
stress. There are several options for induction and mainte-
nance of general anesthesia in the cardiac surgery patient
that are able to accomplish this goal.
Opiates. Historically high-dose opiate techniques com-
bined with amnestic agents such as benzodiazepines were
chosen to provide stable anesthetic and analgesic effects
and the least deleterious effects on hemodynamics.
Another technique involves the combination of low-dose
opioids and short-acting hypnotic drugs for “fast-track”
cardiac anesthesia care with a goal for extubation within a
specific time period and decreased length of stay in the
intensive care unit (ICU) and hospital. A recent Cochrane
review11 found that a low-dose opioid technique combined
with time-directed extubation protocols for fast-track car-
diac surgery patients has a comparable risk of complica-
tions including myocardial infarction, stroke, acute renal
injury, sepsis, and major bleeding and mortality as com-
pared to high-dose opioid-based general anesthesia. The
authors concluded that in low and moderate risk patients,
fast track interventions are safe and effective for earlier
Bechtel and Huffmyer
extubation and decreased ICU length of stay.11 Remifent-
anil may be an ideal drug for fast-track cardiac anesthesia
given that it preserves hemodynamic stability, has rapid
onset and offset times despite extended infusion times due
to its low context sensitive half-time, and is able to suc-
cessfully attenuate the stress response to surgical stimuli as
a strong analgesic. The benefits from remifentanil anesthe-
sia include decreased cardiac troponin release, earlier time
to extubation, decreased hospital length of stay.12 Remi-
fentanil appears to be useful for cardiac preconditioning
with high doses of remifentanil prior to sternotomy lead-
ing to decreased cardiac injury in patients undergoing on-
pump CABG surgery.13 An earlier study of fentanyl and
remifentanil demonstrated no difference in time to extuba-
tion but an improved blunting of hypertensive responses
and cortisol excretion in the remifentanil group but more
episodes of hypotension.14 In a more recent study, patients
administered remifentanil as compared to fentanyl for
CABG surgery had attenuation of the exaggerated inflam-
matory response and a decreased ICU length of stay.15 One
noted side effect of high-dose remifentanil infusion or
bolus doses is hypotension and increased use of inotropes,
but this is an acknowledged side effect and the dose can be
adjusted accordingly since low-dose remifentanil infusion
without bolus administration appears to preserve hemody-
namics even in patients with poor cardiovascular func-
tion.12 Postoperative analgesia must be addressed if
remifentanil is chosen for maintenance.
Anesthetic Induction Agents/Adjuncts: Propofol, Etomidate, and
Ketamine. Propofol is a common anesthetic agent used for
induction and maintenance in cardiac surgery. Hemody-
namic consequences associated with use of propofol for
anesthetic induction include transient vasodilation, myo-
cardial depression, and a reflex tachycardia, but these
effects can be ameliorated or even abolished with careful
titration, use of smaller total induction doses, and a bal-
anced technique. In an early study evaluating the effects of
propofol for patients undergoing CPB, high-dose propofol
infusion (200 µg/kg/min) decreased mean arterial pressure
and cardiac index while causing an increase in heart rate.16
Myocardial blood flow and myocardial oxygen consump-
tion were decreased by 26% and 31%, respectively.16
Myocardial lactate production was seen in one patient
reflecting production of myocardial ischemia.16 High-dose
propofol infusion during cardiac surgery resulted in lower
levels of plasma markers for cerebral injury compared to
low-dose propofol regimen.17 This appears to be a dose-
dependent brain protective effect of propofol due its anti-
inflammatory and antioxidant properties.17 Other evidence
indicates that propofol has beneficial effects such as anti-
oxidant, antianxiolytic, and immune system modulating
effects.18
Etomidate is a commonly used anesthetic induction
medication in patients with poor cardiovascular reserve
103
but it has been shown to cause suppression of adrenal
function even after a single dose.19,20 In cardiac surgery
patients etomidate has also been associated with reduction
in adrenal function for 24 hours but this has not translated
into an increase in vasoconstrictor requirements.21
Ketamine may possess beneficial anti-inflammatory
effects for patients undergoing cardiac surgery with CPB.
Patients randomized to ketamine-propofol-midazolam as
compared to sufentanil-propofol-midazolam for cardiac
surgery had significantly lower levels of pro-inflammatory
cytokines interleukin (IL)-6 and IL-8 and significantly
higher levels of the anti-inflammatory cytokine IL-10 after
aortic unclamping.22 A 2012 meta-analysis of 684 patients,
including 8 studies using CPB as well as noncardiac sur-
gery studies, demonstrated that administration of ketamine
significantly inhibits the early postoperative IL-6 inflam-
matory response.23
Volatile Anesthetics. In general, volatile anesthetic agents
used via vaporizer on the bypass circuit provide reduction
in systemic vascular resistance and blood pressure as well
as anesthetic to the patient. The decrease in blood pressure
associated with all the currently used volatile anesthetics is
a result of vasodilation and depression of myocardial con-
tractility. One recent study evaluated with microcircula-
tory changes associated with sevoflurane, isoflurane, and
desflurane for patients undergoing cardiac surgery with
CPB and found that sevoflurane had a negative effect on
the microcirculation, isoflurane decreased vascular density
but increased flow and desflurane produced the most sta-
ble effects on the microcirculation.24 These changes only
persisted at most for the first 24 hours after surgery and
were not associated with changes in ICU length of stay.24
Volatile anesthetics possess some cardioprotective proper-
ties such as preconditioning and postconditioning effects
that attenuate apoptosis and necrosis and help decrease
myocardial dysfunction after ischemia and reperfusion.25,26
In addition there may be activation of protective enzymes
that also protect the heart.25,26 Vasodilatory, anti-inflamma-
tory, and antioxidant effects have also been ascribed to the
use of volatile anesthetics and may play a role in the pro-
tection of the myocardium.27-29 Sevoflurane at 4 volume %
(or 2 MAC) significantly decreased the postoperative
release of brain natriuretic peptide, a marker of myocardial
contractile dysfunction and showed pronounced transloca-
tion of protein kinase C δ and ε (a measure of the occur-
rence of effective preconditioning at the cellular level).30 A
meta-analysis of 38 randomized trials from 1991 to 2012,
with studies mainly done in CABG surgery utilizing CPB
showed that volatile anesthetic agents were associated
with reduction in mortality as compared to total intrave-
nous anesthetic (TIVA), which was defined as being “not
volatile” with mortality of 1.3% in volatile anesthetic
group as compared to 2.6% in the TIVA group, yielding an
odds ratio of 0.51, confidence interval of 0.33 to 0.81. In
104
this same meta-analysis use of sevoflurane or desflurane
alone were individually associated with reduced mortality
as compared to TIVA.31
Neuraxial Anesthesia. Benefits of thoracic epidural anes-
thesia (TEA) for pain control during and after cardiac sur-
gery include a sympathetic block with stable heart rate and
decreased myocardial consumption, coronary artery dila-
tion, and increased arrhythmia threshold. In this age of
minimally invasive surgery, TEA may become a beneficial
technique for stable hemodynamics and fast-track extuba-
tion and hospital discharge.32,33 The combination of TEA
with general anesthesia may lead to a decrease in acute
renal injury, postoperative ventilation, and the composite
endpoints of myocardial infarction and death.34 Spinal
anesthesia has also been evaluated and considered in car-
diac surgery patients. High-dose intrathecal bupivicaine
(37.5 mg) was combined with general anesthesia as com-
pared to sham spinal anesthesia with skin local anesthetic
and general anesthesia resulted in less beta adrenergic
receptor dysfunction and lower stress response during
CABG surgery.35 In a meta-analysis from 2011,36 use of
TEA was shown to significantly reduce supraventricular
tachyarrhythmias and respiratory complications, but the
authors report this based on a fairly large number of stud-
ies spanning 30 years during which anesthetic agents and
technical considerations advanced dramatically. In addi-
tion, one of the main concerns in providing TEA is the risk
of epidural hematoma, given that full anticoagulation must
be achieved in order to maintain CPB. In this same meta-
analysis,36 no cases of epidural hematoma were reported.
More recently, a 2012 risk assessment of TEA for cardiac
surgery37 revealed very low risk for epidural hematoma.
The authors conclude that risk of an epidural hematoma is
similar in a patient undergoing cardiac surgery and general
surgery. Another 2012 study revealed no complications
related to neuraxial anesthesia in a series of 714 pediatric
and adult patients undergoing cardiac surgery with CPB
requiring full heparinization for congenital heart disease.38
Therefore, the updated risk calculation reveals that it is not
unreasonable to provide TEA for cardiac surgery patients
provided that an appropriate protocol is in place to safely
manage these patients with particular attention to their
coagulation profiles and preoperative and postoperative
antiplatelet therapies.37
Cannulation Sites and Options. Choice of cannulation sites
for both the venous and arterial systems is largely deter-
mined by the surgical plan and whether the patient has had
previous heart surgery that may make it difficult techni-
cally to gain access to the heart and great vessels for can-
nulation. Central cannulation consists of one aortic cannula
in the ascending aorta for the arterial line and venous
drainage from the right atrium. Axillary arterial cannula-
tion or femoral arterial and venous cannulation may be
Seminars in Cardiothoracic and Vascular Anesthesia 18(2)
employed in emergency situations, in case of repeat ster-
notomy, or in procedures that involve the ascending aorta
and arch.39 TEE can be used to help visualize vessels,
guidewires, and cannulae and help guide successful place-
ment especially in the setting of peripheral cannulation for
minimally invasive cardiac surgeries.40
Arterial Cannulation. Arterial cannulation is completed first
as a safety mechanism. If a vascular disaster occurs after
arterial cannulation, volume resuscitation can proceed
through the arterial cannula or in extreme situations,
“sucker bypass” may be employed whereby a drop-in suc-
tion catheter in the chest becomes the venous line that
diverts blood to the reservoir and arterial return can begin
via the aortic cannula. Heparin is given for anticoagulation
prior to aortic cannulation (see Table 1). During aortic can-
nula insertion, systolic blood pressure is reduced tempo-
rarily to 80 to 90 mm Hg in order to reduce sheer stress on
the aorta and prevent aortic dissection. Other complica-
tions associated with aortic cannula placement and posi-
tioning include embolization of air and atheromatous/
calcific material, accidental/inadvertent aortic arch vessel
cannulation, and vascular injury. In cases of highly calci-
fied, porcelain aortas or high atheroma burden, prior to
placement of the aortic cannula or to plan alternative meth-
ods of cannulation, epiaortic ultrasound scanning may be
employed and has been found to be helpful in identifica-
tion of potential cannulation sites/avoidance of disruption
of atheromatous plaques.45,46
Venous Cannulation. Venous cannulation of the right side of
the heart for drainage to the bypass circuit can be accom-
plished in a variety of ways. A single “multi-stage” venous
cannula inserted into the right atrial appendage via a single
atriotomy incision is useful for procedures on a closed
heart such as coronary artery bypass grafting or aortic
valve replacement. Bicaval cannulation is accomplished
with 2 separate cannulae placed into the superior vena
cava and inferior vena cava. Bicaval cannulation provides
complete isolation of the right side of the heart such that it
can be operated on or through such as in mitral and tricus-
pid valve surgery. Return of blood to the venous reservoir
may be impaired by impingement of the venous cannulae;
thus, it is important for the anesthesiologist to check the
level of blood in the venous reservoir at the start of CPB
and intermittently throughout bypass. It is also important
to do a brief physical exam to assure adequate venous
drainage of the head, by looking for signs of venous
engorgement such as swelling of the head, neck, and
tongue, conjunctival and facial edema. IVC engorgement
is more difficult to evaluate and may only be noticed by a
fall in venous reservoir volume.
If femoral venous cannulation is used, it may not pro-
vide enough drainage of blood from the heart in order to
empty the right ventricle and thus partial bypass may only
Bechtel and Huffmyer
be undertaken. This causes blood to remain circulating
through the right heart and the pulmonary vasculature,
necessitating continuation of mechanical ventilation and
oxygenation. If ventilation is discontinued, shunt physiol-
ogy may occur. Thus, if femoral venous cannulation is
planned, an alternative method of venous drainage may be
required once full mediastinal access is achieved or partial
bypass may be used with continued mechanical ventilation
and oxygenation. Making certain that the femoral venous
cannula is inserted into the right atrium, with the tip near
the SVC under TEE guidance as well as providing low-
vacuum-assisted drainage on CPB can help improve the
venous drainage.
Other Cannulae in the Heart. The bronchial, thebesian, and
systemic to pulmonary collateral networks drain into the
left side of the heart. This can cause the left ventricle to be
injured due to distention and increased wall tension during
the period of bypass. Venting is required to remove this
blood and avoid distention. A left ventricular vent is placed
via the left superior pulmonary vein, in addition to the
dual-functioning aortic root vent/antegrade cardioplegia
cannula. Antegrade cardioplegia is delivered into the aor-
tic root through a small cannula and retrograde cardiople-
gia is delivered into a coronary sinus catheter for areas of
the heart that are silently ischemic or unable to be reached
by antegrade cardioplegia.
Initiation of Bypass
Once the patient has been adequately prepared for the
onset of CPB and the prebypass checklist conditions are
met, the perfusionist unclamps the venous line, allowing
blood to fill the venous reservoir while returning oxygen-
ated blood from the arterial line to the patient’s aortic can-
nula. This process occurs fairly quickly, and full bypass
flow is said to occur once all systemic venous blood is
drained from the patient to the venous reservoir. The heart
is still contracting, but with full CPB flow, there is a mean
arterial blood pressure visible on the arterial line, and pul-
satility decreases significantly. Once full flow is assured,
mechanical ventilation and oxygenation may be discontin-
ued (Table 2). Other methods of ventilation will be
reviewed in relation to prevention of respiratory dysfunc-
tion later in this article.
Bypass Period
What is the ideal flow on CPB? What is the ideal blood
pressure on CPB? These represent age-old questions, and
the debate continues as to which is more important. CPB
flow is effectively the output of the pump and is akin to
cardiac output, which is then divided by body surface area
and cardiac index is calculated. Flow during CPB is a
105
Table 2. Bypass Period Checklist.
Venous outflow
•• What is blood level in venous reservoir?
•• Evidence of SVC obstruction
Arterial return
•• Appropriate oxygenation of arterial return blood
•• Signs of arterial dissection
•• Hypotension on bypass? Hemodilution?
•• Signs of unilateral overperfusion?
Full bypass
•• Assessment of pressure and flow on CPB
Discontinue mechanical ventilation
•• Consider continuation of low tidal volume ventilation
Discontinue fluids and drugs from anesthesia
•• Any medications required to CPB
•• Continued need for anesthetic and neuromuscular paralysis
balance between providing oxygen delivery to the tissues
and assuring surgical visualization by providing as blood-
less field as possible. The most common goal is to flow at
the lowest level that provides good surgical conditions yet
does not result in end organ oxygen delivery impairment.
Pump flow and pressure are related through arterial imped-
ance, which refers to a combination of hemodilution, tem-
perature, and cross-sectional area of the arterial bed.
Mean Arterial Pressure. Clinicians who advocate for lower
MAPs on bypass (50-60 mm Hg) suggest that there is less
trauma to blood elements, reduction of blood in the surgi-
cal field, improved myocardial protection through reduced
collateral coronary blood flow, and reduced embolic load
to the brain.47 In patients who are chronically hyperten-
sive, data indicate that the lower limit of autoregulation
and thus the safe lower limit for MAP during CPB may be
higher than the conventional 50 to 60 mm Hg.48,49 Poten-
tial advantages of using higher MAP on bypass include
enhanced tissue perfusion in patient with history of hyper-
tension and diabetes, improved collateral blood flow to tis-
sue beds at risk for ischemia, and higher MAP allows for
higher pump flow rates on CPB.47
CPB Pump Flow. Pump flow is determined by several vari-
ables including the patient’s body surface area, degree of
hypothermia, acid–base balance, oxygen consumption,
oxygen content of the blood, and depth of anesthesia. The
flow rate most commonly used during CPB is that approxi-
mating a normal cardiac index for an anesthetized normo-
thermic patient with a normal hematocrit level, 2.2 to 2.5
L/min/m2.50 When patients are perfused with hypothermic
bypass and lower hematocrit in the range of 22%, lower
pump flows are possible, in the range of a cardiac index of
1.2 L/min/m2.51 Perfusionists and anesthesiologists moni-
tor mixed venous oxygen saturation (SvO2) as a guide to
106
trend perfusion of end organ tissue beds. SvO2 of 70% is
the target but does not guarantee optimal tissue perfusion
to some beds such as muscle and fat, which are effectively
removed from the circulation when on bypass.52 Osawa
and colleagues performed an animal study to evaluate the
safe levels for hematocrit and mixed venous oxygen satu-
ration on CPB and found hematocrit level >12% and SvO2
>46% to be “safe” for CPB.53 In a study of patients under-
going CPB, Ranucci and colleagues identified the lowest
hematocrit of 26% associated with increased renal impair-
ment outcomes that allows an oxygen delivery of 262 mL/
min/m2.54
Preparation for Separation From Bypass
Once the cardiac surgical procedure is complete, prepara-
tion for the process of separation from bypass begins. This
is a multistep process and is a reverse of the prebypass
phase, beginning with rewarming of the patient and culmi-
nating in separation from bypass, reversal of anticoagula-
tion, and removal of bypass cannulae. There is potential
for awareness under anesthesia and shivering as well as
diaphoresis during this phase of bypass and measures such
as recommended in the prebypass phase should be under-
taken here to prevent awareness. Table 3 provides a check-
list of events that should occur in order to prepare for
separation from CPB.
Rewarming. During the rewarming phase, the patient is
gradually warmed by increasing the temperature of the
arterial return blood via the heat exchanger of the bypass
machine. Rewarming represents a potentially problematic
phase of the bypass period as there is temptation to rewarm
quickly, which requires high temperatures of the return
blood or perfusate. Cerebral hyperthermia may cause
increased free radical production, enlargement of any new
cerebral ischemic penumbral zones, oxygen supply and
demand mismatch in the brain, intracellular acidosis, and
increased excitatory amino acid neurotransmitters, which
can lead to neurologic injury and cognitive dysfunction in
the postoperative period.55 The brain is predisposed to
developing hyperthermia given that it receives a greater
amount of overly warmed blood and is located near the
inflow cannula in the proximal aorta. In addition, the nasal
temperature may underestimate the actual cerebral tem-
perature by 1°C to 2°C.56 An appropriate strategy to man-
age temperature prior to coming off bypass involves
monitoring temperature in the nasopharynx, tympanic
membrane, and arterial inflow line. In patients who are at
increased risk for neurological injury or cognitive dys-
function, the goal should be mild hypothermia (34 to
35°C), followed by slowly rewarming the patient to no
more than 37°C in order to prevent cerebral hyperther-
mia.56 A goal temperature for separation from bypass is
35.5°C to 36°C so as to prevent overwarming of the brain.
Seminars in Cardiothoracic and Vascular Anesthesia 18(2)
Table 3. Separation From Bypass Checklist.
Rewarming
•• What is patient temperature?
•• Readminister anesthetic drugs and paralytics
Electrolytes/acid–base balance
•• Potassium, calcium
•• Hematocrit
•• pH, metabolic or respiratory acidosis
•• SVO2
Heart rhythm
•• Defibrillation
•• Pacing necessary?
•• Arterial blood pressure
•• Is vasoplegia present?
Deairing
•• Look for air on TEE
•• Be wary of air-induced right ventricular dysfunction
•• Mechanical ventilation
•• Recruitment of lungs
•• Treat atelectasis
•• Resume ventilation and oxygenation prior to working the
heart
Vasoactive medications and inotropes
•• Evaluate need for medications prior to working the heart
•• Make sure medications are reaching the patient, via central
access
•• Work the heart
•• Reduce support from CPB, allow more blood flow through
the heart
•• Remember to ventilate first
TEE/hemodynamic evaluation
•• As CPB is weaned, evaluate TEE for heart function, regional
wall motion
•• Valvular function
Potential need for mechanical support
•• Will patient sustain self off CPB?
•• Possible options to consider: IABP, VAD, ECMO
Arterial Blood Pressure. Once aortic cross clamp is removed,
the coronary arteries are once again perfused in an ante-
grade fashion with blood from the aortic cannula. Conse-
quent to rewarming and removal of the cross-clamp, some
patients have a significant reduction in MAP as measured
by a radial artery blood pressure monitor. This reduction in
peripheral arterial pressure is a result of presumed vasodi-
lation and often there is a radial-central aortic blood pres-
sure discrepancy, such that monitors of central blood
pressure reveal a significantly higher MAP than the radial
catheter.57 Vasodilation is usually a transient problem dur-
ing separation from bypass and the early postbypass
period, but a measure of central aortic blood pressure
(either palpation of the ascending aorta, aortic blood pres-
sure monitoring via the aortic root cannula, or femoral
arterial line) may be needed to help guide therapeutic
decisions.58
Bechtel and Huffmyer
Heart Rhythm. Ventricular fibrillation after removal of the
cross-clamp and rewarming is common and it may sponta-
neously convert, but prolonged ventricular fibrillation
should be treated aggressively as subendocardial perfusion
suffers, myocardial oxygen consumption increases and the
left ventricle may become distended, which risks injury in
the face of reduction in oxygen supply. Biphasic waveform
defibrillation is accomplished with internal paddles at
energies of 10 Joules with increases of 5 Joules for each
cumulative defibrillation attempt.59 Acid–base balance and
electrolytes should be evaluated and abnormalities treated.
Lidocaine and amiodarone also aid with successful defi-
brillation. Junctional bradycardia is a common first rhythm
after the cross-clamp is removed and is usually inadequate
to maintain perfusion and cardiac output in the face of
weaning from CPB. Current methods of pacing include
atrial pacing, ventricular pacing, atrioventricular pacing,
and biventricular pacing. The BiPACS trial is a random-
ized, controlled study that evaluated biventricular pacing
for patients undergoing open-heart surgery. The results of
this study revealed that BiV pacing increased cardiac out-
put by 13% versus patients without pacing while patients
who only had atrial pacing at the same heart rate did not
have an increased cardiac output immediately after discon-
tinuation from CPB.60
De-Airing. Air emboli can have significant negative effects
while weaning from CPB, after separation from bypass,
and in the postoperative period including neurological
deficits, ventricular dysfunction, and arrhythmias. There
are several methods for de-airing including Trendelenburg
position, partial ascending aortic side clamping, CO2
insufflation, left heart vents, and the Lund technique. The
Lund technique involves the following steps.61 Opening of
the pleural spaces and lung collapse takes place after ini-
tiation of CPB. Prior to weaning from CPB, the aortic root
is suctioned with complete collapse prior to removal of the
cross-clamp. LV preload is increased to allow blood to
move through the right heart and lungs and out the LV vent
until no air is seen in the left heart. The patient is ventilated
and the heart is allowed to eject with continued de-airing
maneuvers. This technique is a faster and safer method
that is easily reproducible with significantly less gas
emboli on TEE and microemboli on transcranial Dop-
pler.61 Intracardiac air, which reflects as highly echogenic
on TEE, commonly collects in the right and left superior
pulmonary veins, left ventricular apex, left atrium, left
atrial appendage, pulmonary artery, and right coronary
sinus of Valsalva. Once blood flow is restored to the lungs,
air bubbles most commonly migrate to the right coronary
artery and innominate artery. Evidence of air embolism
may include right coronary ischemia and right ventricular
dysfunction, which is treated with increased perfusion
pressures and hemodynamic support.62
107
Restoration of Mechanical Ventilation and Oxygenation. Once
the heart is ejecting and the surgical procedure is com-
pleted during the bypass period, if ventilation has been
discontinued, mechanical ventilation and oxygenation
must begin. Conventionally, the lungs are not ventilated
during the period of CPB since the CPB machine takes
over the respiratory/gas exchange function and lack of
ventilation reduces movement in the surgical field and
improves surgical visualization. There is suggestion that
this apnea not only promotes atelectasis but also activation
of enzymes in the pulmonary circulation that is correlated
with postoperative lung dysfunction.63 Methods of provid-
ing some ventilation to the lungs have been proposed
including intermittent continuous positive airway pressure
(CPAP), low frequency/low tidal volume ventilation, ven-
tilation with some pulmonary artery perfusion in order to
match perfusion and ventilation. Studies of these methods
to provide ventilation with and without perfusion have
shown some improvement in the inflammatory response
and compliance of the lungs,64,65 time to extubation and
extravascular lung water but no overall outcome differ-
ence.66 A small randomized study of isolated valve surgery
patients recently reported that the patients who were man-
aged with beating heart, on CPB surgery and low tidal vol-
ume ventilation throughout had lower levels of
inflammatory and oxidative stress markers such as malo-
ndialdehyde, lactic acid, and myeloperoxidase.67 While
some studies have looked at inflammatory markers, a more
recent meta-analysis of trials evaluated the outcomes of
different methods of ventilation management during
CPB.68 Use of continuous positive airway pressure (CPAP)
from 5 to 15 mm Hg with range of FIO2 from 0.21 to 1.0
during CPB showed an improvement in oxygenation and
decrease of shunt fraction immediately after CPB weaning
but may interfere with surgical exposure.68 Vital capacity
maneuvers 1 to 3 times with a pressure of 35 to 40 cm H2O
at the end of the CPB period also improved the oxygen-
ation in the early post-CPB period.68 Despite early
improvements in oxygenation, neither CPAP nor vital
capacity maneuvers had sustainable effects on oxygen-
ation or lung function into the ICU time period.68 In this
same meta-analysis, continuation of low tidal volume ven-
tilation during the CPB period was not associated with any
improvement in clinically relevant respiratory or oxygen-
ation parameters.68 In 2 other trials,69,70 investigators
reported earlier extubation in patients treated with CPAP
on CPB and earlier extubation in patients receiving vital
capacity maneuvers possibly due to increased surfactant
release. Finally, the studies that looked at ventilation dur-
ing CPB failed to show an improvement in oxygenation
indices, AaDO2, and the length of hospital stay.68
Vasopressors and Inotropes. Calcium is administered after
the aortic cross-clamp has been removed and while
108 Seminars in Cardiothoracic and Vascular Anesthesia 18(2)

Table 4. Hemodynamics and Decision-Making Post-Bypass.

Arterial Pulmonary
BP Artery Pressure
↓ ↓
↓ ↑
↓ Normal
↓ ↑
Cardiac Index TEE Findings Condition Action Plan
Normal Left and right ventricles Hypovolemia Administer fluid volume
small and underfilled; good bolus
ventricular function
↓ Regional wall motion Left ventricular Support LV: milrinone,
abnormalities, global ischemia, failure, epinephrine, dobutamine,
hypokinesis of LV, dilated dysfunction device (IABP, LVAD,
LV ECMO)
↑ Heart may be underfilled, Vasodilation; Add Vasoconstrictor:
no resistance to ejection; vasoplegia vasopressin,
increased contractility norepinephrine,
phenylephrine, dopamine,
methylene blue
↓ RV distention with small Right ventricular Support RV function:
underfilled LV; reduced failure or milrinone, epinephrine,
excursion of RV free wall; dysfunction dobutamine, inhaled
tricuspid regurgitation prostacyclin or inhaled
nitric oxide

weaning from CPB to improve cardiac contractility and
systemic perfusion through vasoconstriction.71 Negative
effects of calcium administration include increased isch-
emic injury, decreased diastolic compliance and relax-
ation, and decreased systolic function during reperfusion
with corresponding stunned myocardium.72 Indications for
calcium administration include hypocalcemia and hyper-
kalemia in order to improve cardiac conduction and
contractility.73
Vasopressors and inotropes are started during bypass
weaning to improve blood pressure and contractility,
respectively. A variety of drugs can be used to assist in
weaning a patient from bypass. An action plan including
vasopressors is reviewed along with arterial blood pres-
sures, pulmonary artery pressures, cardiac index, TEE
findings, and common conditions that occur in weaning or
after bypass in Table 4. There are several newer drugs
including natriuretic peptides (nesiritide) and calcium-sen-
sitizing agents (levosimendan) that may be useful in car-
diac surgery patients. Levosimendan is an inodilator that
functions by increasing inotropy through sensitization of
troponin to intracellular calcium without c-AMP and it has
properties of a phosphodiesterase inhibitor that increases
peripheral and coronary vasodilation. This drug may be
useful in cardiac surgery patients since levosimendan ther-
apy leads to decreased myocardial damage and improved
cardiac function with increased tissue perfusion as well as
earlier time to hospital discharge.74 A recent meta-analysis
showed reduced postoperative mortality in patients who
were given levosimendan as compared to those treated in
the control arm.75 In a nonsurgical meta-analysis, levosi-
mendan was associated with improvements in hemody-
namic status and reduction in mortality as compared to
dobutamine.76 Lomivorotov and colleagues77 studied high
risk, low ejection fraction patients undergoing CABG who
were randomized to levosimendan or intra-aortic balloon
pump (IABP) therapy. They found that patients treated
with levosimendan had lower postoperative troponin lev-
els as well as improved hemodynamics as compared to
patients with IABP.77 Nesiritide is a natriuretic peptide
with rapid onset and short duration that increases cardiac
index and decreases pulmonary capillary wedge pressure
(PCWP), right atrial pressure (RAP), mean arterial pres-
sure (MAP), and systemic vascular resistance (SVR). In
patients with pulmonary hypertension and decreased ejec-
tion fraction, nesiritide may lead to improved postopera-
tive renal function, decreased hospital length of stay and
decreased mortality.78
One of the challenges during separation from CPB and
in the post-CPB phase, particularly after prolonged bypass
time, is vasoplegic syndrome. Vasoplegic syndrome is
characterized by severe, vasopressor-resistant vasodilation
due to activation of nitric oxide synthase, vascular smooth
muscle ATP-sensitive potassium channels, and relative
deficiency of vasopressin. First-line therapy includes ade-
quate fluid resuscitation and vasopressor drugs such as
phenylephrine, norepinephrine, epinephrine, dopamine,
and vasopressin. Methylene blue acts as a competitive
inhibitor of nitric oxide and has been used as a rescue
drug.79 Vasopressin, in the setting of euvolemia, can be
useful for improving vascular tone while separating from
CPB especially since metabolic acidosis does not impair
the function of vasopressin receptors.80
If during the weaning from bypass period despite all
preparation to separate from bypass including vasopres-
sors, inotropes, electrical therapies such as pacing,
Bechtel and Huffmyer
treatment of electrolyte abnormalities, it becomes evident
that the native heart is not functioning well enough to sep-
arate from bypass or life-sustaining blood pressure and
function is absent, mechanical support may be warranted.
An intra-aortic balloon pump or counterpulsation (IABP)
or a ventricular assist device (VAD) should be discussed
and implemented as necessary. In the past, studies have
shown a high mortality rate in patients who receive an
IABP intra- or postoperatively, between 21% to 73% asso-
ciated with rare but serious complications from IABP
placement including limb ischemia, vascular injury, bleed-
ing, infection, and stroke.81 However, a recent meta-analy-
sis82 showed that prophylactic IABP for high-risk patients
undergoing CABG surgery leads to decreased postopera-
tive low cardiac output syndrome and risk of death.
Preoperative IABP in patients undergoing cardiac surgery
leads to decreased length of stay in the hospital and ICU.82
This meta-analysis also revealed a low complication rate
of 7.4%.82
In patients with failure to wean from CPB due to respi-
ratory and/or cardiac failure, extracorporeal membrane
oxygenation (ECMO) may be considered as a bridge to
recovery of heart and lung function.83 However, it is impor-
tant to risk stratify potential ECMO candidates. Prediction
of weaning from ECMO and survival to hospital discharge
appears to be related to a rapid decrease in inflammatory
mediators within 2 days of ECMO initiation.84
Separation From Bypass
Separation from CPB is the process of decreasing venous
return to the venous reservoir and increasing the volume to
the patient’s heart. Successful weaning from CPB con-
cludes with the removal of cardioplegia and venous and
arterial cannulae. TEE is a valuable monitor that can be
used to evaluate cardiac function, valve prosthesis func-
tion and to look for other complications. Eltzschig and col-
leagues report that TEE changed the cardiac surgery
procedure in 9% of surgeries.85 There are several phrases
used to describe difficulty in weaning from CPB including
postbypass inotropic support, which includes the use of
dopamine, dobutamine, or epinephrine for greater than 12
hours in the ICU and low cardiac output syndrome, defined
as the use of an IABP or inotropic medications (dopamine,
dobutamine, milrinone, or epinephrine) to maintain sys-
tolic blood pressure greater than 90 mm Hg and cardiac
output greater than or equal to 2.2 L/min/m2.86 The impor-
tant elements of successful weaning from CPB include
systolic blood pressure as a marker of tissue/end-organ
perfusion pressure, filling pressures including central
venous pressure, diastolic pulmonary artery pressure, pul-
monary capillary wedge pressure, and pharmacological
intervention (Table 4).
Weaning from bypass occurs after the steps above are
completed and anesthesiologist, surgeon, and perfusionist
109
are prepared to support patient hemodynamics. Initially,
the perfusionist allows blood volume to remain in the heart
and circulate to the lungs and left side of the heart by par-
tially clamping the venous line to fill up to the goal PA
pressure or CVP. The patient’s hemodynamics and heart
function in the chest and on TEE are reassessed frequently
paying particular attention to the right ventricle as the
heart receives more volume. When the PA pressures reach
an adequate level, the perfusionist reduces pump flow,
usually at 0.5 to 1 L/min in a gradual fashion. While the
patient is weaning from bypass, the anesthesia team titrates
appropriate vasoactive infusions and inotropic agents to
maintain adequate SVR and contractility. When the patient
is on minimal support from the bypass machine (usually
500 mL to 1 L/min/m2) with stable hemodynamics and the
surgeon, anesthesiologist, and perfusionist all agree, sepa-
ration from CPB is achieved.
After separation from bypass, surgical attention is
turned to removal of cannulae as well as hemostasis.
Protamine is given to reverse heparin anticoagulation. A
common strategy for protamine administration is 1 mg
protamine per 200 units of heparin in the initial heparin
bolus and in the CPB prime solution. Historically, a ratio
of 1:1 (1 mg protamine per 100 units heparin) was given,
but a lower protamine dose is associated with a reduction
in blood loss and blood transfusions after CPB.87
Appropriate heparin–protamine matching for neutraliza-
tion is important to decrease surgical bleeding and avoid
protamine overdose. When anticoagulation was managed
with a heparin–protamine titration system, Hemochron
RxDx, patients received a lower protamine dose and had
less postoperative blood loss.88
Stress Response to CPB. Cardiac surgery with CPB induces
a systemic inflammatory response syndrome characterized
by CPB induces a systemic inflammatory response syn-
drome associated with release of cytokines interleukin
(IL)-2, IL-12, and interferon-γ.89 The early phase of this
inflammatory response occurs as a result of exposure of
blood elements to the CPB circuitry and induces both cel-
lular and humoral responses. Intrinsic and extrinsic coagu-
lation systems, complement system and leukocyte
activations occur liberating thrombin, complement pro-
teins and cytokines such as interleukins and tumor necro-
sis factor.89 The late phase of the inflammatory response to
CPB includes ischemia reperfusion injury and endotox-
emia.90,91 Exaggerated and prolonged activation of immune
system after cardiac surgery leads to increased postopera-
tive complications, morbidity, mortality, and prolonged
ICU and hospital length of stay.92,93
Steroid Use in Cardiac Surgery. The benefits of prophylactic
low-dose steroid use in cardiac surgery patients may
include hemodynamic stability, decreased vasopressor/
inotrope requirements, earlier extubation, decreased
110
hospital length of stay, and improved quality of recovery
with minimal complications.94 The Dexamethasone for
Cardiac Surgery (DECS) study was unable to show a
reduction in the 30-day incidence of major adverse events
with a single high dose of IV dexamethasone (1 mg/kg of
body weight, with 100 mg maximum dose), but did find a
benefit of dexamethasone prophylaxis to decrease postop-
erative infections, respiratory failure, and delirium.95 A
recent best evidence topic in cardiac surgery evaluated the
use of steroids to decrease postoperative atrial fibrilla-
tion.96 The authors concluded that a single dose of cortico-
steroid (50-210 mg of dexamethasone equivalent or
200-1000 mg/day hydrocortisone) reduces the risk of post-
operative atrial fibrillation without any increased risk of
complications.96 The Steroids in Cardiac Surgery (SIRS)
study has completed enrollment of 7500 patients and will
help inform decision making for mortality and other pos-
sible benefits associated with use of methylprednisolone
250 mg on induction of anesthesia and with commence-
ment of CPB. In the smaller SIRS pilot study, this same
dosing of methylprednisolone was effective to reduce
bleeding, improve hemodynamic stability, reduce duration
of mechanical ventilation and length of ICU stay.97 Aside
from its anti-inflammatory effects of reducing IL-6 and
increasing IL-10, methylprednisolone has been shown to
increase endothelin-1, which indicates endothelial cell
activation in patients undergoing CPB. Endothelial dys-
function is purported to be one of the primary causes of
postoperative lung failure.98 Depending on the outcome of
the large-scale SIRS trial, prophylaxis with steroids in the
form of dexamethasone to decrease the inflammatory
response is not indicated.
Lung Management Strategies on Bypass. Impaired pulmo-
nary function is a well-documented and fairly common
complication, occurring in about 25% of patients after
CPB for cardiac surgery99; in the most severe cases acute
respiratory distress syndrome results and contributes to
significant postoperative morbidity and mortality.100,101
Etiologies for this impaired lung function have been stud-
ied and the problem is likely multifactorial, but the inflam-
matory response to CPB, reviewed above, has been
strongly implicated.102 Traditionally, once full flow has
been assured on bypass, mechanical ventilation has been
discontinued. The inflammatory milieu created by use of
CPB impacts pulmonary function after heart surgery,
although surgery without use of CPB has not entirely
reduced postoperative lung dysfunction.103-105 Several
management strategies during the CPB period are reviewed
below that seek to attenuate the inflammatory response
and thus acute lung injury.
Heparin-coated circuits purportedly mimic the normal
physiologic endothelial surface of the vasculature, thus
Seminars in Cardiothoracic and Vascular Anesthesia 18(2)
reducing complement activation and the overall inflamma-
tory reaction as evidenced by reductions in interleukin lev-
els, complement levels, and oxygen free radical levels.106-109
Measures of pulmonary function have improved with hep-
arin-coated circuits but this has not lead to clinically mean-
ingful reduction in mechanical ventilation requirement or
ICU length of stay.106,110,111 Researchers from Norway
studied their patient population of nearly 6000 patients
undergoing CABG with use of heparin-coated CPB cir-
cuits in addition to a reduction in systemic heparin dosing
to achieve ACT 250 seconds (for the lower limit) with the
theory that reduction in systemic heparin dose would
reduce bleeding and need for blood transfusions, which
also have an impact on acute lung injury. In their protocol,
median time to extubation was 1.7 hours, only 7.2% of
patients required blood transfusion, the stroke rate was
1%, and perioperative myocardial infarction rate was
1.2%.112
Miniaturized CPB circuits, also known as minimized
extracorporeal circuits (ECC) with a crystalloid prime vol-
ume of 800 mL as compared to 2000 mL for standard cir-
cuits, have been postulated to minimize foreign body–blood
contact, are heparinized, reduce the inflammatory
response, ameliorate the reduction in end organ function,
including the pulmonary system, as well as reduce hemo-
dilution and need for transfusion.113-115 Sakwa and col-
leagues studied 199 patients undergoing CABG and found
that patients whose CPB period was managed with a min-
iaturized circuit had significantly higher hematocrit, plate-
let count, received fewer red blood cell transfusions, had
reduced chest tube drainage, and had a shorter time to
extubation.114
During the period of CPB, leukocytes become activated
and have been implicated in ischemia reperfusion injury of
multiple organ beds, including and heart and lung.
Leukocyte depletion filters are used to reduce the leuko-
cytes that become trapped within the pulmonary capillar-
ies after CPB and have been shown to decrease heart and
lung reperfusion injury.116 Some studies have shown
improvement in oxygenation, lower extravascular lung
water, and a reduction in postoperative mechanical venti-
lation117 but no longer term outcome differences.118 A
recent meta-analysis of several small studies from 1993 to
2005 has not confirmed the reduction in pulmonary com-
plication related to use of leukocyte filters.119 Additionally,
the process of leukocyte reduction by these filters may
activate white blood cells even further.120
At the time of commencement of CPB, there is mixing
of the patient’s blood with the acellular CPB prime that
causes immediate hemodilution. While some level of
hemodilution may be helpful to facilitate tissue perfusion,
hematocrit levels below 23% have been associated with
increased interstitial edema and dysfunction of end organs
Bechtel and Huffmyer
such as brain, heart, and lungs.121 Methods to reduce
hemodilution and improve the oncotic pressure may help
reduce this interstitial edema. Use of blood cardioplegia
and hemofiltration may accomplish this as well as retro-
grade autologous priming (RAP) of the CPB circuit. RAP
involves removal of some of the crystalloid CPB circuit
prime with the patient’s own circulating blood after venous
and arterial cannulae have been inserted for bypass. A
study by Hwang and colleagues showed that patients who
underwent RAP prior to bypass had significantly higher
hematocrit as well as cerebral oxygenation saturation lev-
els during the bypass period.122 This statistically signifi-
cant increase in hematocrit did not extend into the
postoperative period although a trend toward increase in
hematocrit persisted.122
Ultrafiltration during the CPB period allows removal of
priming volume (acellular crystalloid) and theoretically
helps reduce postoperative weight gain, edema, and totally
body water. This should result in improvement in extravas-
cular lung water and overall oxygenation and pulmonary
function. Aside from removal of fluid, a type of ultrafiltra-
tion, zero balance ultrafiltration (ZBUF) may help amelio-
rate lung injury by removal of destructive and inflammatory
cytokines and toxins such as IL-6, IL-8.123-126 Studies have
also shown improvement in platelet function and reduction
in postoperative blood loss as a result of ultrafiltration
methods.127 Modified ultrafiltration (MUF) is ultrafiltra-
tion that occurs after the majority of the cardiac surgery
has taken place, near the end of the CPB time period for a
short period of time. Torina and colleagues used MUF for
15 minutes at the end of CPB for a group of CABG patients
and demonstrated reduction in chest tube drainage, red
blood cell transfusions, higher hematocrit but either no
reduction or an increase in inflammatory markers such as
IL-6, P-selectin, intracellular adhesion molecule, and solu-
ble tumor necrosis factor.128 Oxygenation and hemody-
namics were not different from patients treated in standard
fashion without MUF.128 Normovolemic MUF has also
recently been shown to reduce the levels of pro-inflamma-
tory lipopolysaccharide-binding protein and terminal com-
plement complex as well as been associated with reduction
in blood loss and postoperative lactate concentrations after
high risk cardiac surgery.129
Another method to reduce extravascular lung water as a
result of increased capillary permeability and decreased
colloid osmotic pressure is use of colloid or hypertonic flu-
ids. Lomivorotov and colleagues randomized patients
undergoing CPB to receive hypertonic saline/hydroxyle-
thyl starch versus 0.9% sodium chloride for 30 minutes
after anesthesia induction.130 They found reduction in
extravascular lung water index, improved arterial oxygen-
ation, reduced alveolar-arterial oxygen difference, and
increased cardiac output in the hypertonic saline/hydroxy-
lethyl starch group that persisted to 4 hours post-CPB.130
111
Cardiotomy suction provides collection of pericardial
blood from the surgical field into the CPB circuit but this
is activated by tissue plasminogen activator as well as
has procoagulant properties. The transfusion of cardiot-
omy suction blood induces an inflammatory response
and leads to reduction in hemostasis and impaired lung
function postoperatively.131,132 Several actions may
reduce this activation of the inflammatory response due
to use of cardiotomy suction blood. Reducing the con-
tact time between the shed cardiotomy blood with the
pericardium and then to retransfusion as well as mini-
mizing the entry or contact of air with the shed blood
may help attenuate the inflammatory response.133 Topical
antifibrinolytic agents introduced into the surgical field
may also improve the accelerated fibrinolysis and
increase hemostasis.134 A recent study by Nakahira and
colleagues evaluated the use of open venous reservoir
CPB circuits with and without cardiotomy suction as
well as a completely closed circuit (with no cardiotomy
suction).135 These authors found activation of coagulofi-
brinolysis only in the group with cardiotomy suction.
The group with the open venous reservoir, but no cardi-
otomy suction, despite the blood–air interface, had simi-
lar thrombin generation as the completely closed circuit
group. Thus, use of perioperative cell-salvage systems
may not only help conserve blood but also may reduce
the inflammatory response associated with CPB and in
turn attenuate acute lung injury.135
Conclusion
Cardiopulmonary bypass has revolutionized the practice
of cardiac surgery and allows safe conduct of increasingly
complex cardiac surgery. Anesthesiologists trained in the
care of cardiac surgery patients allow safe and expert care
of patients during cardiopulmonary bypass. Choice of
anesthetic drugs for induction and maintenance of anesthe-
sia have the potential to impact the outcome of patients
undergoing cardiac surgery with cardiopulmonary bypass.
Bypass management techniques such as ultrafiltration and
use of heparin-coated circuits as well as medications
administered like steroids may modulate immune response
and affect inflammation. More large, randomized con-
trolled trials are necessary to definitively guide practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
112
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