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Anaesthesia for cardiovascular surgery with extracorporeal circulation

Anaesthesia for cardiovascular surgery with extracorporeal circulation. Key points. Understanding of the pathophysiology of the heart diseases Undestanding of pharmacology Cardiopulmonary bypass TEE Myocardial preservation. Cardiopulmonary bypass (CPB).

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Anaesthesia for cardiovascular surgery with extracorporeal circulation

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  1. Anaesthesia for cardiovascular surgery with extracorporeal circulation

  2. Key points • Understanding of the pathophysiology of the heart diseases • Undestanding of pharmacology • Cardiopulmonary bypass • TEE • Myocardial preservation

  3. Cardiopulmonary bypass (CPB) • Collection of venous blood (reservoir) • Adds oxygen (oxygenator) • Returns blood to a large artery (heat exchanger) • Level of fluid in reservoir is critical (type of pumps) • Activation of stress hormones

  4. Systemic hypothermia • Core body temperature (20-30 oC) • Metabolic oxygen requirements halved with each of 10 oC) • Rewarming via CPB • Profound hypothermia (15-18 oC ) • Total circulatory arrest • Adverse effects of hypothermia: platelet dysfunction, reversibly coagulopathy

  5. Myocardial preservation • What is a damage to the myocardium? • Imbalance between oxygen supply and demand • Ischemia, Stunning, Hibernation, Infarction • Aortic cross clamping • Ventricular fibrillation and distension • Coronary vessels emboli

  6. Potassium and blood cardioplegia • Kalium 10 – 40 mEq/L • Sodium < 140 mEq/L • Calcium, Magnesium • Others compounds like: glucose, buffers, lidocaine, glucocoticoids • Antegrade and retrograde (via sinus venosus) route of administartion

  7. Vasodilators • ACE Inhibitors: captopril, enalapril • Nitrovasodilatators: NTG, NPS, molsidomina, hydralazyna • Calcium channel blockers • Potassium channel activators: diazoxide, minoxidil, pinacidil, cromakalin

  8. Nitrate sides of action

  9. Anticoagulation • ACT 400-450 sec • Heparin 300-400 U/kg (3 mg/kg) by central line • Resistance to heparin (antithrombin III deficiency): reversed by 2 U FFP, antithrombin III concentrate • Heparin induced thrombocytopenia (alternatives: hirudin, bivalirudin, ancrod)

  10. Bleeding prophylaxis • Aprotinin (4-6 mln KIU) • Tranexamic acid (10 mg/kg) followed by 1mg/kg/h • Epsilon-aminocapronic acid 5-10 g followed by 1 g/h

  11. Bypass period • Monitoring • Flow and pressure MAP = Pump flow x SVR • Hypothermia, cardioplegia, • Ventilation • pH stat management (need CO2) • Alpha-stat management

  12. Important points • Anesthesia • Cerebral protection • Termination of and weaning from CPB • Reversal of anticoagulation (Protamine 1-1,3 mg protamine per 100 U of heparin) • Persistent bleeding • Transportation • Postoperative period

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