Professional Documents
Culture Documents
PerfEd International
Reprinted: Vinas, M.S., Chapter 3 "Extracorporeal Circulation," Kambam, J., Editor,
Cardiac Anesthesia for Infants and Children, the C.V. Mosby, Co., St. Louis, MO, 1994
The application of extra-corporeal circulation (ECC) was pioneered by the experiments of Dr. Jack
Gibbon in 1934 at Massachusetts General Hospital. However, it was not until 1953 that the first
successful human open-heart procedure, closure of an atrial septal defect, was performed by this
surgeon on a young female patient (Bone).
It is estimated that there are 750,000 cardiopulmonary bypass (CPB) procedures performed annually
in the United States. Of this number approximately 6% involve infant/ pediatric cardiac surgical
intervention (AHA).
A 1990 Pediatric Perfusion survey cited a 127 responses from community, government and university
medical centers performing infant/ pediatric open-heart surgery. The centers reported performing
14,473 open-heat surgery (OHS) procedures requiring extra-corporeal circulation (Hill). Stammers
and Riley compiled data on over 1016 infant/ pediatric treated with cardiopulmonary bypass (CPB) at
University of Michigan Hospitals, between 1986-1990, 869 were able to be placed into sixteen
categories. The majority of the surgical procedures consisted of the following:
INFANT/ PEDIATRIC SURGICAL PROCEDURES/ PERCENTILE
The application of extracorporeal circulation requires careful assessment of hematologic values and
the effects of hemodilution and hypothermia. All attempts should be made to design an
accommodating extracorporeal circuit while minimizing, preferrably eliminating, blood product
requirements.
HEMOGLOBIN/ HEMATOCRIT
The hemoglobin in infant and pediatric patient's has been surveyed and reported between the ranges
of 12.5-22 gm./dL (Hartley-Winkler). Hemodilutional calculations, however, are predicated on
hematocrit values.
AGE HEMOGLOBIN VALUES
1 Day 18-22 GM/DL
2 Weeks 17 GM/DL
3 Months 10 GM/DL
3-5 Years 12.5-13 GM/ DL
A non-haemic or asanguinous prime of the heart-lung console circuit may dilute an infant with a
standard hematocrit to a calculated value less than 15%, a polycythemic individual not as critical. It is
the cardiovascular perfusionist's responsibility to estimate, via calculations, the degree of
hemodilution and any blood products requirements needed to adjust the hematocrit to a value of 20-
PLASMA VOLUME
Plasma normally comprises 55-65% of the estimated blood volume. A 3.0 kilogram infant, for
example, may have a plasma volume of 180 ml. A 700 ml. non-plasma prime would dilute the
respective clotting factors, fibrinogen and platelets below 20%, which is inadequate for proper
hemostasis. The plasma volume in infants/ pediatrics should be calculated to assess hemodilution of
these factors, with the possibility of adding fresh frozen plasma (FFP) to the extra-corporeal circuit.
90
3-6 months
85
10-2 months
80
> 12 months
70
Several calculations are required to assess hemodilution and blood product requirements. The
following depicts a patient with a weight of 10 kilograms, blood volume factor of 85 ml./Kg., hematocrit
of 40% (HCT1) and an ECC priming volume of 700 ml. The resultant calculations will estimate the
patient's blood volume (PBV), patient red cell volume or mass (RCM1), total system or ECC
circulating volume (TSV), hemodilutional hematocrit (HCT2) and hemodilutional or ECC circulating
red cell mass (RCM2) required (Vinas):
HEMODILUTIONAL CALCULATIONS
PBV
= 850 ml.
= 85 ml./Kg. x 10 Kilograms
RCM1
= 340 ml.
TSV
= 1550 ml.
HCT2
= 22 %
RCM2
= 465 ml.
RCM1-2
= -125 ml.
125 ml. RCM is required to be added to the ECC prime to achieve a circulating hematocrit of 30%.
The relative body size, compared to the perfusate, required to prime the extra- corporeal circuit, will
cause a neonate or infant to be more adversely affected by hemodilution than a pediatric.
INFANT
PEDIATRIC
ADULT
25
70
85
70
70
425
1750
4900
Hematocrit (%)
40
40
40
170
700
1960
255
1050
2940
700
1000
1750
15
25
30
FIBRINOGEN
A critical consideration is plasma fibrinogen dilution. Normal plasma fibrinogen levels are 150-400
mg./dL (Ecklund). The infant/ pediatric patient's relative low blood volume with priming requirements
of the ECC circuit causes the fibrinogen concentration to be adversely diluted. During CPB, it is
desirable to maintain the plasma fibrinogen concentration above 100 mg./dL. in order to prevent
impairment of post-ECC hemostasis (Ecklund, Pfefferkorn p. 61, Taylor p.274).
Given an example of a 10 Kilogram patient with a patient blood volume of 850 ml., a pre-bypass
hematocrit of 40%, fibrinogen level of 250 mg./dL. and a 700 ml. ECC prime volume, additional
fibrinogen via FFP is needed. Given the previous parameters mentioned, the calculation of fibrinogen
dilution, and subsequent reconstituting, would be calculated as follows:
Plasma Volume
= 5.1 dL.
= 1275 mg.
= 15.5 dL
= (1550 ml./1000) x 10
= 82 mg./dL
The calculated fibrinogen value derives a deficit of 18 mg./dL. x 15.5 = 279 mg. If Fresh Frozen
Plasma, diluted with CPD-A contains 200 mg./ 100 ml. (dL) of Fibrinogen, an additional 140 ml. of
fresh frozen plasma should be administered to raise the circulating level to 100 mg./dL (Pfefferkorn
pp. 61-62).
PLATELETS
Platelet concentration values range from 150,000-400,000/ cu. mm. (Reed and Stafford p.127). The
classification of thrombocytopenia is given to levels less than 100,000/ cu. mm.. Levels below this
value may result in prolonged bleeding times (Orland p. 273).
Blood exposure to the foreign components of the extracorporeal circuit may deplete platelet
concentrations. This phenomenon may be observed in electron photomicrographs of the arterial filter
and blood reservoirs. Albumin, added to the ECC prime, reduces platelet aggregation on these
foreign surfaces thus minimizing loss to the circuit components (Gurjar, Hedlund). Platelet
reconstitution, if indicated, should be reserved until post-bypass in order to optimize the effects of the
platelets and their effect on hemostasis.
CRYSTALLOID SOLUTIONS
In the event that crystalloid priming solutions are administered they should be pH balanced and
isotonic. The electrolyte composition should approach the values of normal blood chemistries to
ensure normal electrolyte levels. Calcium Chloride may be added to solutions that do not contain the
electrolyte to a value of 10 mg./ dL or 100 mg./L. Blood chemistries such as Sodium, Potassium,
Magnesium, Chloride, Glucose, Total Protein, Total and Ionized Calcium along with hematologic
values should be monitored every 20-30 minutes during cardiopulmonary bypass. Patient's with
relatively high potassium levels, renal failure for example, should not be administered potassium
containing solutions, at least caution is advised. 0.9% Sodium Chloride solutions, buffered to a pH of
7.4, may be substituted. Lactated Ringers solution should not be administered to patients exhibiting
clinical signs of lactic acidosis.
WEIGHT
Kg./ Lbs.
HEIGHT
Cm./In.
BSA
M2
Kg./M2
0.0-0.5
0.5-1.0
6/ 13
9/ 20
60/ 24
71/ 28
0.32
0.42
18.75
21.43
Children
1- 3
4- 6
7-10
13/ 29
20/ 44
28/ 62
90/ 35
112/ 44
132/ 52
0.57
0.79
1.01
22.80
25.30
27.70
Adult
18-45
70/ 154
178/ 70
1.89
37.00
Infants
Average
ml/m/Kg.
Kg.
METS
l./min.
Average
VO2
7.5-9.58
5.05
2.43
42.5
7.5-9.00
8.25
10
2.36
82.5
6.5-8.50
7.50
15
2.00
112.5
6.0-7.5
6.75
20
1.93
135.0
5.5-6.5
6.00
25
1.71
150.0
5.0-6.0
5.50
30
1.57
165.0
4.5-5.5
5.00
35
1.43
175.0
4.5-5.0
4.75
40
1.36
190.0
4.0-5.0
3.50
70
1.00
250.0
ADULT
Adopted from: Galletti, P.M. and Brecher, G.A., Heart- Lung Bypass: Principles and Techniques of
Extracorporeal Circulation, Grune & Stratton, New York; 1962.
Oxygen consumption is normally derived from the Fick equation. This method calculates the arterial
and venous oxygen content difference and multiplies that value by the cardiac output in L/M x 10
(Bolen, Miller).
VO2 (ml./min.) = (CaO2-CvO2) x CO x 10
During ECC, if the Hgb, C.O. and A/V venous saturations are known, oxygen consumption may be
calculated without knowing the PO2 values since dissolved oxygen normally contributes less than 0.3
Volumes %. of the arterial O2 content.
Newborns to
Extracorporeal perfusion flowrates are adjusted during hypothermia to ensure adequate arterial/
venous oxygen transferability. Oxygen consumption in humans decreases normally at a rate of 7%
per degree Celsius . Therefore, decreasing the temperature from 37 C to 30 C would reduce oxygen
consumption requirements to 50%, 25% at 23 C. A pediatric patient with a calculated basal VO2 of 84
ml./min. at 37C may experience a reduction to 42 ml./min. at 30 C, 21 ml./min. at 23 C via
hemodilution and hypothermia (Reed and Stafford p. 325). Other investigators have reported a 5060% reduction in total body oxygen consumption at 28 C to 30 C a 80-90% reduction at 18 C to 20 C
and 90% between 8 to 10 C (Greeley, Mitchell).
Formulas are subject to estimations and do not consider alterations in cardiopulmonary and
hemodynamic pathophysiology. Adequacy of extracorporeal perfusion flowrates and accommodation
of oxygen metabolic requirements mandates frequent, if not continuous, arterial and venous blood
gas analysis in conjunction with hematology and chemistry values. The assessment of oxygen
delivery vs. oxygen consumption is advisable to determine the adequacy of perfusion flowrates and/or
assessment of anesthesia levels.
BSA
(M2)
FLOWRATE
(ml./min.)
ARTERIAL CANNULA
(mm)
VENOUS CANNULA
(mm)
0.1
240
2.0
4.0
0.3
720
2.0
4.0
0.5
1200
2.0
4.0
0.7
1680
3.0
5.0
0.9
2160
3.5
6.0
1.0
2400
4.0
6.0
1.5
3600
4.5
6.0
1.6
3840
5.0
7.0
1.8
4000
6.5-8.0
11.0-15.0
Adopted from K.M. Taylor, Cardiopulmonary Bypass; Principles and Management, Williams and
Wilkins, Batimore, MD, p. 117, 1990.
Arterial Line
Venous Line
DIAMETER
(in.)
CALCULATED FLOW
(ml./min.)
3/16
0-1100
1/4
0-2000
3/8
0-6500
1/4
0-1100
3/8
0-2300
1/2
0-6500
1/4
0-1100 Infant
3/8
1000-2300 Pediatric
1/2
2300-6500 Adult
Heparin bonded or coated circuits are available from several manufacturer's. These circuits present
evidence of increased biocompatability with a corresponding decrease in heparin requirement as well
a compliment activation (Bennett, Stenach, von Segesser).
Extracorporeal circuit priming volumes vary according to the components and accessories used. The
values presented are an average depiction of typical infant/ pediatric ECC circuits providing 200-300
ml. residual volume in the perfusate reservoir, 500 ml. in the adult
It should be remembered that the H+ ions in the acidotic prime will combine with HCO3- to form
H2CO3- carbonic acid This further dissociates into CO2 and H2O (Reed and Stafford p. 202-203).
Immediate dissociation in ECC primes may produce PCO2 values in excess of 70-80 mm. Hg.
(clinical observation). Therefore, a blood prime buffered with sodium bicarbonate should be ventilated
for several minutes to reduce the resultant hypercapnea.
HEPARINIZATION
Beef lung sodium heparin is the anticoagulant of choice during extracorporeal circulation. It acts by
potentiating the activity of plasma protease inhibitor antithrombin III which inhibits thrombin formation
and factors Xa, IXa, XIa. (Orland p.281). A standard average dose is 300 IU/ Kg. to obtain an
Activated Clotting Time of over 400 seconds (Berryessa, Bull, Taylor, p.46). However, at Vanderbilt
University loading heparin doses for infants, pediatric and adults is 100 IU/ Kg., 200-300 IU/ Kg. and
400 IU/ Kg. respectively.
It is preferable to perform a heparin titration analysis or the Bull protocol to determine Heparin
resistance or sensitivity. During ECC an activated clotting time should be performed every 30 minutes
to assay the adequacy of anticoagulation, exceeding 400 seconds. Bull concluded that the response
to heparin administration is linear . Therefore, once a dose response curve is established addition
heparin or reversal with protamine is a matter of plotting the heparin dose response graph (Bull).
Reversal of sodium Heparin with Protamine Sulfate varies from institution to institution. The Bull
protocol recommends a reversal of 1: 1.1 mg. of Heparin:Protamine. Many institutions use Heparin to
Protamine reversal ratios between 1:1.1 - 1:2.0 (Bull, Friesen, LaDuca). Vanderbilt University
reverses the heparin dose with protamine at a 1:2 to 1:3 ratio. Heparin: Protamine analysis systems
are designed to provide the most accurate method of determining the amount of protamine required
to reverse the heparin in a sample of blood (Harloff and Taraskiewicz). Caution should be used in the
administration of Protamine sulfate. Numerous cases involving protamine reactions and hypotension
have been reported, therefore, diligent cardiopulmonary and hemodynamic monitoring is in order.
INITIATION of EXTRA-CORPOREAL CIRCULATION
After the administration of sodium heparin, the heart- lung machine arterial pumphead should be
increased to the patient's maximum blood flowrate, the lines should be "tapped" to dislodge residual
micro/ macro air bubbles. The surgical assistant at the operative filed should do likewise. The
extracorporeal circulation should be slowly terminated and the arterial and venous lines clamped. 3-5
minutes after heparin administration, the heart-lung machine pump sucker may be activated to
recover mediastinal shed blood. Once aortic and vena cava cannulation has been achieved and the
arterial and venous lines connected the patient is prepared for extracorporeal circulation.
Upon initiation of ECC the patient's arterial blood pressure will generally be between 30-40 mm. Hg.
with full flowrates (Mitchell). The perfusion pressure should be kept between 50-70 mm. Hg. to
maintain adequate cerebral perfusion at normocapnia levels (Taylor p.47).
CARDIOPLEGIA
Cardioplegia solutions administered to induce asystole. These solutions may be composed of
crystalloids, blood and crystalloid. There are several cardioplegia solutions available to the surgeon.
Some are pre-manufactured, many are mixed in the medical center's pharmacy. Many cardioplegic
solutions are modifications of the popular St. Thomas' Hospital cardioplegic solution No. 2 (Plegisol,
Abbott Laboratories, Chicago) (Stammers, Taylor p. 381):
St. THOMAS CARDIOPLEGIA SOLUTION
Na+ 110 mmol/L
K+ 16 mmol/L
Ca++ 1.2 mmol/L .
Mg++ 16 mmol/L .
CL- 160 mmol/L .
NaHCO3 10 mmol/L
pH 7.8 * Contains Sodium 145 mEq/L
Osmolality 32O mOsm/L Potasssium < 2 mEq/L
The principle chemical ingredient is potassium chloride 15-20 mEQ/L. Some institutions use a blood/
crystalloid ratio of 1:1, 1:2 or 1:4 employing an administration set with an integrated cooling coil
(McCormick, Stammers). Cardioplegia typically is administered antegrade, sometimes retrograde or
both. Cardioplegia is administered at an initial dose of 10- 30 ml./ Kg. at 7-10 C with subsequent
doses every 20-30 minutes if desired, myocardial temperatures should be monitored to maintain
relatively low temperatures of 15 C or less (Garcia, Reed and Kuruz p.140, Taylor p. 121 and p.384).
HYPOTHERMIA
Bigelow in 1949 suggested the use of hypothermia in conjunction with intracardiac surgery requiring
circulatory arrest (Mitchell, Taylor p.7). Today most cardiac surgical cases are performed during
hypothermia between 25-30 C. The lower temperatures decreases the basal metabolic rate and
provides cerebral and myocardial protection. Cooling and rewarming the patient is accomplished by
exposing the perfusate in the oxygenator to an integrated heating/ cooling coil. The regulated water
temperature circulates countercurrent to the perfusate for maximum efficiency.
Many surgeons prefer to cool the patient immediately to the target temperature thus decreasing
metabolic rate. If circulatory arrest is the goal an arterial/ venous blood gas sample is obtained after 5
minutes of cardiopulmonary bypass to access oxygenation and acid-base status. Any acidotic pH,
PCO2 and Base Excess levels are adjusted immediately and prior to circulatory arrest. If the patient
is not to be subjected to circulatory arrest it is advisable to obtain a routine blood gas profile after 5
minutes of ECC or upon obtaining the target temperature.
Hypothermia increases the solubility and affinity of oxygen and carbon dioxide. The pK, thus the pH,
is also affected causing the oxyhemoglobin dissociation curve to shift to the left. This leftward shift
readily binds the oxygen to the hemoglobin as oxyhemoglobin. This leftward shift is observed while
monitoring venous blood oxygen saturation levels during normothermia vs. hypothermia
(Reed and Stafford p.195, Riley, Shoemaker pp.233-234, Taylor p.153, Mitchell).
DEEP HYPOTHERMIC CIRCULATORY ARREST (DHCA)/ PROFOUND HYPOTHERMIA
Infants under twelve months and/or 10 Kilograms body weight who undergo profound hypothermia
and circulatory arrest may be pre-cooled by a Subramanian Cooling Chamber. Another alternative is
systemic hypothermia via extracorporeal circulation, the patient's head should be packed in ice. The
Subramanian device externally cools the patient to 30 C. All patient's scheduled for circulatory arrest
are administered Dextran 40 at a dose of 10 ml./ Kg. to prevent aggregation of blood elements at the
hypothermic ranges encountered, usually 18-20 C. The following is a classification of the various
degrees of hypothermia (Reed and Stafford p.286).
DEGREE of HYPOTHERMIA
DEGREES CELSIUS
Mild
37 - 32
Moderate
32 - 28
Deep
28 - 18
Profound
18 - 0
Prior to circulatory arrest the patient's arterial blood gases are corrected for metabolic and/or
respiratory acidosis. Safe circulatory arrest, to prevent irreversible cerebral damage and their
respective temperatures are depicted.
TEMP.
O2 CONSUMPTION
CIRC. ARREST
MINUTES
37
100 %
4-5
29
50
8-10
22
25
16-20
16
12
32-40
10
64-84
Adopted from Gordon, et. al. Open heart surgery using deep hypothermia without an oxygenator.
Journal of Thoracic and Cardiovascular Surgery, 1960: 40; 787-812.
B) To maintain constant CO2 content during cooling more carbon dioxide must be removed than with
pH-Stat.
C) To maintain constant CO2 content, the gas ventilation rate will be higher than pH-Stat.
ALPHA-STAT
Actual Results
37 C
Normothermia
pH=7.40
PCO2=40
pH=7.40
PCO2=40
Hypothermia
pH=7.40
PCO2=40
pH=7.57
PCO2=23
(temp. corrected to 25 C)
Normothermia
pH=7.40
PCO2=40
pH=7.40
PCO2=40
Hypothermia
pH=7.22
PCO2=67
pH=7.40
PCO2=40
A 1990 pediatric perfusion survey documented that approximately 80% of the reported surgical
centers employed to use the Alpha-Stat. Our institution was among the 80%. The remaining 20% use
the pH Stat method. Some centers reported blood gas values using both methods (Hill).
On-line or continuous arterial/ venous (A/V) oxygen blood gas monitoring has been available clinically
for the past several years. These devices allow for continuous display of pH, PO2, PCO2, Base
Excess and Hematocrit (Basha, Bolen, Ferries, Harloff, Molina, Parault, Riley and Burgess, Riley and
Fletcher, Rubsamen). Some online monitors analyze Na+, K+ and Ca++ electrolytes (Riley and
Burgess). A survey reported that 62% of the infant/pediatric cardiac surgical centers used on-line A/V
blood gas monitoring (Hill) Centers not employing on-line blood gas monitoring should elect to at least
monitor continuous A/V oxygen saturation to access the adequacy of perfusion and oxygen
requirements via the A/V saturation differential (Baraka, Baris, Bolen, Miller, Page and Birenbaum).
ACID-BASE CORRECTION
The conduct of perfusion attempts to maintain normal arterial/venous acid-base physiology with
arterial PO2 value less than 200 mm. Hg. Correction of metabolic acidosis via sodium bicarbonate is
obtained by recommendation of the American Heart Association standard for administration:
diverted to the right ventricle and ejected into the pulmonary system.
Rewarming times vary with the size of the patient and the level of hypothermia and may require 25-45
minutes to obtain a 37 C core temperature. Warming the room to 70-75 F enhances rewarming and
reduces the possibility of post-bypass hypothermia.
TERMINATION of CARDIOPULMONARY BYPASS
Discontinuation of cardiopulmonary bypass is considered when the surgical procedure has been
completed, the esophageal and nasopharyngeal or core temperature has reached 37 C. Likewise
when all hematologic and chemistry values have been corrected for any deficits. The anesthesiologist
begins ventilating with warm/ humidified gases and the venous return line is partially clamped to
permit the patient to eject blood into the right side of the heart and thus through the pulmonary
system. Venous saturations should be maintained above 70% while the patient is slowly weaned from
bypass. Once the command is given by the surgeon the venous line is clamped, the pumphead
rotation terminated and the arterial line clamped proximal to the central line pressure transducer
which should emulate the peripheral line pressures. Volume may be infused from the heart-lung
machine until a desired filling pressure has been obtained. The remaining perfusate may be
processed by draining the venous line and "chasing" the perfusate with physiologic I.V. solution. This
technique should yield 300-500 ml. of perfusate with a 25-30% hematocrit. This fluid may be
hemoconcentrated and washed as packed cells or given directly to the patient. In the case of the
latter, additional protamine sulfate may need to be administered to neutralize the additional heparin in
solution.
POST-OPERATIVE COMPLICATIONS
It is obvious that the more complex the surgical procedure the greater the possibility of post-operative
complications. Relatively simple procedures such as repair of atrial and/or ventricular septal defects
present less cardiovascular and hemodynamic complications than the more complex procedures
such as an anomalous left coronary artery, Norwood procedure or arterial switch. The most common
challenge is non-mechanical post operative bleeding caused by a coagulopathy, therefore, complete
coagulation profiles, including clotting Factor assays, especially Factor's VIII and X should be
considered. Ionized calcium levels should not be overlooked in determining hemostasis. Postoperative replacement regimen may include the administration of calcium chloride, fresh frozen
plasma, cryoprecipitate and platelets.
SUMMARY
The application of extracorporeal circulation in the neonate, infant and pediatric patient populations is
demanding. These patient's present a multitude of variables primarily assessing the effects of
hemodilution, hypothermia and flowrate resitrictions of the arterial cannula's, venous catheter's and
arterial/venous circuit conduits that are employed.
The cardiovascular perfusionist must be cognizant of the pathophysiology of the defect, the cardiac
catheterization values concerning pressure, flow, saturation and intra- cardiac shunts.
Cardiopulmonary, hemodynamic, thermal, hematologic and chemistry data must be carefully
observed for rapid changes. Much preparation is required to assess and accommodate basal
metabolic demands of the anesthetized patient during normo and hypothermia. ECC flowrates,
hemodilution, blood product and chemistry reconstitution, hypothermia, oxygen consumption, critical
to decreasing morbidity.
Research has been continuous. The priming volumes of the circuits are constantly being reduced,
thus the effects of hemodilution. Vital organ, including myocardial and cerebral protection, has been
greatly improved. Investigation is continuous for the development of an artificial blood product
capable of normal oxygen carrying capacity and gas exchange to the tissues.
The responsibility of neonatal, infant and pediatric cardiopulmonary bypass mandates that we
scrutinize the medical literature and adopt the techniques that our peers have discovered to be more
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August 08, 1999