Anesthetic agents in cardiopulmonary bypass

麻醉科 Ri潘聖衛 羅立凱

2003/9/24

A case of VSD status post OP with CPB on 9/15

A 3-year-old male Chief complaint: Heart murmur found

accidentally at local clinic at 2 m/o

Brief history

Anesthesia records

Anesthetic agents in cardiopulmonary bypass

Cardiac Anesthesia

Anesthesia in Adult Induction

Narcotic: Remifentanil; Fentanil or Sufentanil plus

Sedative-Hypnotic:Pentothal; Etomidate; BZD; Propofol

Maintenance Narcotic plus Propofol, BZD, or low dose

inhalation drug CTSNET http://www.ctsnet.org/

Cardiac Anesthesia

Pediatric Anesthetic Agents Induction

Ketamine IM 5 mg/kg ,IV 1-2mg/kg Inhalation using Halothane or Sevoflurane

Maintenance Narcotic plus Hypnotic or Inhalation

CTSNET http://www.ctsnet.org/

Ketamine attenuates the interleukin-6 response after cardiopulmonary bypass.

Anesth Analg. 1998 Aug;87(2):266-71

CPB involved systemic inflammatory response Serum IL-6 as a good indicator of

1.activation of the inflammatory cascade 2.predictor of organ dysfunction and death

Small dose of Ketamine (0.25 mg/kg) attenuates the interleukin-6 response after CPB

Anesth Analg. 1998 Aug;87(2):266-71

Ketamine attenuates neutrophil activation after cardiopulmonary bypass.

Anesth Analg. 2002 Sep;95(3):531-6

Superoxide production generated by neutrophils Interleukin-6 (IL-6) delays neutrophil apoptosis

Small dose of Ketamine (0.25 mg/kg) attenuates superoxide anion and the percentage of neutrophils.

Anesth Analg 2002;95: 531–536

Maintenance of anesthesia in CPB

Maintenance of anesthesia in bypass period

Complex pharmacokinetics of IV anesthetics Haemodilution Hypothermia Hypotension altered visceral perfusion advanced age and systemic atheroma

oxygenator and tubing may bind large amount of drugs and influence the uptake of gas

Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

Maintenance of anesthesia in bypass period

Benefits of volatile agent anesthesia 1.avoidance factor such as hemodilution 2.relatively independent of liver and renal

function 3.potentially rapid, predictable offset. 4.enhance ischemic preconditioning

ATP-dependant potassium channels volatile agents all have a similar effect ischemic

preconditioning

Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

Does isoflurane optimize myocardial protection during cardiopulmonary bypass?

isoflurane before aortic cross-clamping optimize the myocardial protective effect of cardioplegia.

in prolonged periods of aortic cross-clamping or inadequate delivery of cardioplegia

Journal of Cardiothoracic and Vascular Anesthesia Volume 15, Issue 4 , August 2001, Pages 418-421

Effect of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients

Sevoflurane and desflurane but not propofol preserved LV function after CPB.

Anesthesiology Aug 2003;V99,No2:314-23

Use of sevoflurane during cardiopulmonary bypass decreases incidence of awareness

The difference in the incidences of awareness was significant (P < 0.05), Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery.

European Journal of Anaesthesiology,2002, Volume: 19 Number: 4 Page: 283 -- 287

group Maintenance in CPB awareness

group1 fentanyl & dehydrobezperidol

5/30 16.67%

group2 Fentanyl & Sevoflurane

0/29 0%

hypothermic VS nomorthemic

cardiopulmonary bypass

hypothermic CPB

Cooling in CPB as a anesthetic agent Decreased level of consciousness and metabolic rate

cerebral and myocardial protection harmful effects of rewarming on neurological

outcome Deficits in memory, attention, concentration & learning CBF/CMRO2 mismatch (decreased SjvO2) Incidence of CNS hyperthemia

The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002; 94: 4–10

The Rewarming and Alter Neurocognitive Outcome

slower rewarming rates are better than standard rewarming in improving neurocognitive outcome.

The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002; 94: 4–10

normothermic CPB

cardioplegia avoids any harmful effects of rewarming early extubation increased requirement for anaesthesia

no comparable additional cerebral protection anaesthesia may be inadequate increased risk of awareness

Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

level of sedation between hypothermic and normothermic CPB

Normothermic:highest BIS values hypothermic :

solely a result of brain cooling or if increased serum propofol concent.

Monitoring level of sedation with bispectral EEG analysis: comparison between hypothermic and normothermic cardiopulmonary bypass British Journal of Anaesthesia, 2001, Vol. 86, No. 6 769-776

Take home message

Induction of ketamine attenuates the IL-6 response and neutrophil activation after CPB.

volatile agents all have a similar effect of ischemic preconditioning & myocardial protection and decreases incidence of awareness.

Normothermic CPB avoid harmful effects of rewarming on neurological outcome but increase risk of awareness.

Thanks for your attention!