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Anaesthesia for cardiovascular
surgery with extracorporeal
Key points
• Understanding of the pathophysiology of
the heart diseases
• Undestanding of pharmacology
• Cardiopulmonary bypass
• Myocardial preservation
Cardiopulmonary bypass (CPB)
• Collection of venous blood (reservoir)
• Adds oxygen (oxygenator)
• Returns blood to a large artery (heat
• Level of fluid in reservoir is critical (type of
• Activation of stress hormones
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
Myocardial preservation
• What is a damage to the myocardium?
• Imbalance between oxygen supply and
• Ischemia, Stunning, Hibernation, Infarction
• Aortic cross clamping
• Ventricular fibrillation and distension
• Coronary vessels emboli
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
• ACE Inhibitors: captopril, enalapril
• Nitrovasodilatators: NTG, NPS,
molsidomina, hydralazyna
• Calcium channel blockers
• Potassium channel activators: diazoxide,
minoxidil, pinacidil, cromakalin
Nitrate sides of action
• ACT 400-450 sec
• Heparin 300-400 U/kg (3 mg/kg) by central
• Resistance to heparin (antithrombin III
deficiency): reversed by 2 U FFP,
antithrombin III concentrate
• Heparin induced thrombocytopenia
(alternatives: hirudin, bivalirudin, ancrod)
Bleeding prophylaxis
• Aprotinin (4-6 mln KIU)
• Tranexamic acid (10 mg/kg) followed by
• Epsilon-aminocapronic acid 5-10 g
followed by 1 g/h
Bypass period
• Monitoring
• Flow and pressure MAP = Pump flow x
• Hypothermia, cardioplegia,
• Ventilation
• pH stat management (need CO2)
• Alpha-stat management
Important points
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