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Management of cardiopulmonary bypass in adults

Authors
Albert T Cheung, MD
Mark Stafford-Smith, MD, CM, FRCPC, FASE
Michele Heath, LP, CCP
Section Editor
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Cardiopulmonary bypass (CPB) is a form of extracorporeal circulation in which the patient's blood is diverted from the heart and lungs and rerouted outside of the body. The normal physiologic functions of the heart and lungs, including circulation of blood, oxygenation, and ventilation, are temporarily taken over by the CPB machine. The ascending aorta is typically cross-clamped and cardioplegia administered to allow the cardiac surgeon to safely operate on a nonbeating heart in a field largely devoid of blood, while other end organs remain adequately oxygenated and perfused.

This topic will discuss general principles, preparation, initiation, and management of CPB. The process of weaning from CPB and common problems in the immediate postbypass period are addressed separately. (See "Weaning from cardiopulmonary bypass".)

GENERAL PRINCIPLES

Equipment and physiology — Components of the cardiopulmonary bypass (CPB) machine include pumps, tubing, and gas (oxygenator) and heat exchange units (figure 1A) [1]. Modern CPB circuits are also equipped with systems that continuously monitor blood pressure, temperature, and blood samples (eg, oxygen saturation, blood gases, hemoglobin (Hgb), and electrolytes), as well as safety features such as oxygenator air and fluid level detection systems and blood filters in the arterial line.

During CPB, venous blood is drained from the right atrium (RA; or both superior and inferior vena cavae) and is diverted through the venous line of the CPB circuit into a venous reservoir (figure 1A-B). CPB machines are typically equipped with vacuum-assisted technology that facilitates drainage to maintain a bloodless surgical field and allow use of smaller venous cannulae and reduced CPB circuit volumes. The arterial pump functions as an artificial heart by withdrawing blood from this reservoir and propelling it through a heat exchanger, an artificial lung (oxygenator or gas exchanger), and finally an arterial line filter. The blood is then returned to the patient via an arterial cannula positioned in the ascending aorta or other major artery. Additional CPB circuit components and pumps are employed as needed to suction blood from the surgical field, deliver cardioplegia solution to produce cardiac electromechanical silence, decompress the heart via a vent, and remove fluid (ultrafiltration). Thus, the cardiopulmonary circuit and its components temporarily take over the functions of the heart, lungs, and, to a lesser extent, the kidneys.

Contact of blood with nonendothelial surfaces of the CPB circuit induces an intense inflammatory response [1,2]. This results in platelet activation, initiation of the coagulation cascade, and decreased levels of circulating coagulation factors. Endothelial cells and leukocytes are activated, releasing mediators that may contribute to capillary leakage and tissue edema. Many of the challenges encountered during weaning from CPB and the postbypass period (eg, myocardial dysfunction, vasodilation, bleeding) are thought to be consequences of this inflammatory sequence [3-5]. Also, the priming solution for the CPB circuit (typically 1 to 2 L of a balanced crystalloid solution) results in hemodilution with temporary or persistent anemia and coagulopathy.

                                            
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Literature review current through: Oct 2017. | This topic last updated: Sep 13, 2017.
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