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Cardiopulmonary bypass can

Disturbs normal reflex and chemoreceptor control of


the circulation
Initiate coagulation.
Activate blood cells.
Release circulating cell-signaling proteins.
Generate vasoactive and cytotoxic substances.
Produce a variety of microemboli.
Reversible and irreversible cell injury may
occur.

Ischemia-reperfusion injury augments damage


to the heart and on occasion to other organs.
Mechanism
CARDIAC INJURY
Postoperative cardiac dysfunction occurs from
CPB
Ischemia/reperfusion
Direct surgical trauma
The disease being treated
Maladjustment of preload and afterload to
myocardial contractile function.
NEUROLOGIC INJURY
Because the brain controls all body activity,
even small injuries may produce symptomatic,
functional losses that are not detectable or
important in other organs.

Regional hypo perfusion


Edema
Microemboli circulating
Cytotoxins
Assessment

Complete neurologic examination by a trained


neurologist
The basic, structured examination includes a
mental state examination; cranial nerve, motor,
sensory, and cerebellar examinations; and
examination of gait, station, deep tendon, and
primitive reflexes.
Populations at Risk
Risk Factors
Mechanism

Microemboli

Hypoperfusion
Neuroprotective Strategies
Primary strategies for avoiding air
atherosclerotic particulates, and blood-
generated microembolism.

Mild hypothermia (32 to 34 C)

Hematocrit above 25%.


Temporary increases in cerebral venous
pressure caused by superior vena cava
obstruction should be avoided

Excessive rewarming above blood


temperatures of 37C should be avoided
LUNG INJURY

Patient factors
The separate effects of operation
CPB
Respiratory protective strategies
Restoring normal pulmonary capillary permeability and
interstitial lung volume

Preventing atelectasis

Reinflating atelectatic Segments

Maintaining normal arterial blood gases

Preventing infection

Facilitating removal of bronchial mucus.


RENAL INJURY
Microembolic, cellular, and regional malperfusion.

Preoperative state determines how it can withstand it

Risk factors for postoperative renal dysfunction include


Age over 70 years
Diabetes mellitus
Previous cardiac surgery
Congestive heart failure
Complex prolonged operation
The incidence of acute renal failure requiring
dialysis after CPB

1%

5% with complex operations


INJURY TO THE LIVER

Microemboli, Cytotoxins, and regional


malperfusion.

Enormous functional reserve and reparative


processes of the normal liver nearly always
overcome the injury without consequences
10 to 20% of patients are mildly jaundiced.

Persistent and rising bilirubin two or more


days after CPB may precede development of
liver failure.
PANCREATIC INJURY
Less than 1% of patients develop clinical
pancreatitis after CPB

Approximately 30% develop a transitory,


asymptomatic increase in plasma amylase
and/or lipase.
Risk Factors

Recurrent pancreatitis
Perioperative circulatory shock
Hypotension
Excessively prolonged CPB
Continuous high doses of inotropic agents are
risk factors for developing
STOMACH AND GUT INJURY

Before PPI the mortality was 33 to 50 %

Duodenal and/or gastric erosion, ulcer, and


bleeding were frequent complications
following clinical cardiac surgery