Boot camp cardiac faculty john alexander, md brian bethea, md jim fann, md dave fullerton, md eugene grossi, md george hicks, md john ikonomidis, md william jakobleff, md. Indeed, the present uncertainty in antibiotic dosing requirements for prophylaxis during major cardiac surgery is manifest in the lack of consensus between available guidelines in terms of antibiotic choice, dose, frequency and total duration. Innovations in pediatric cardiopulmonary bypass a continuous process of quality improvement hanna dorota golab. Initiation of cardiopulmonary bypass open anesthesia. Typically, blood is gravity drained from the heart and lungs to a reservoir via venous cannulation and tubing, and returned oxy. Bivalirudin angiomax, the medicines company is a directacting synthetic antithrombotic agent that has been approved as an alternative to unfractionated heparin for patients with acute coronary. Most priming solutions in adults are bloodfree, as the drop in hematocrit allows substantial decreases in temperature without adversely affecting blood viscosity. The adverse effects of the cardiopulmonary bypass machine. Thought to be result of nonpulsatile blood flow, increase of circulating catecholamines and inflammatory mediators, embolic results to the kidney, and release of free hemoglobin from traumatized red cells. Cardiopulmonary bypass in patients with type ii heparin inducedthrombocytopenia poses significant challenges. Heparin for cardiopulmonary bypass in typei heparininduced. Gas embolism during cardiopulmonary bypass amr arafat. Patients receiving heparin infusions have an attenuated activated clotting time act response to heparin given for cardiopulmonary bypass cpb. We present the case of a patient with heparin hypersensitivity.
Reconstituted material may be stored at 28c up to 24 hours. Bivalirudin anticoagulation for cardiopulmonary bypass ncbi. Priming dose of bivalirudin 50 mg in cpb circuit, bivalirudin, 11. While the use of this machine during the surgery has been beneficial in stopping the heart for surgery, it poses many physical. Bivalirudin anticoagulation for cardiopulmonary bypass. Pdf bivalirudin anticoagulation for cardiopulmonary bypass. However, this model of cpb in rats presents an important starting point as it allows to incorporate further insults like emboli and hypoperfusion. And about 2,000 such surgeries performed every 24 hours worldwide these days. Anticoagulation during cardiopulmonary bypass society of.
Cardiopulmonary bypass is a surgical technique that temporarily supports or replaces the function of the heart and lungs during various cardiothoracic surgical procedures, such as coronary artery bypass surgery, cardiac valve surgery, thoracic aorta surgery, and thoracic organ transplantation. Cardiac surgery with cpb cannot occur if the heart is still beating. However, at lower hematocrits or periods of higher oxygen consumption these flows become inadequate. We measured white blood cell counts and complement component c3a, c4a, and c5a and prostacyclin levels, and studied lung biopsy specimens, in 16 patients undergoing cardiopulmonary bypass and compared them with four patients undergoing other pulmonary procedures. During surgery with cardiopulmonary bypass cpb, a 2. Guidelines for using bivalirudin during cardiopulmonary. Technology rules the world a physician at the bedside of a child dying of an intracardiac malformation as recently as 1952 could only pray for a recovery. Pharmacologic preservation of the hemostatic system. Argatroban and bivalirudin for perioperative anticoagulation in. Diluted bivalirudin with a concentration between 0. Heparin is the most common agent used, but in selective circumstances, alternate form of anticoagulation may be considered. Mar 11, 2004 the purpose of this study is to demonstrate that in patients undergoing coronary artery bypass grafting cabg or cabgvalve, or isolated cardiac valve surgery on cpb cardiac surgery, angiomax is a safe and effective alternative anticoagulant to heparin with protamine reversal. Cpb causes substantial decreases in renal blood flow and gfr, and increases renal vascular resistance. Blood returning to the heart is diverted through a heartlung machine a pumpoxygenator before it is returned to the arterial circulation.
Atelectasis was the most frequent pulmonary complication except for small pleural effusions, with an incidence of 64 per cent. Use of bivalirudin as an anticoagulant during cardiopulmonary bypass article pdf available in the journal of extracorporeal technology 373. Several types of atelectasis frequently coexisted, with a predominance of the less. Description a 19yearold man was transferred to our institution for management of newly diagnosed idiopathic dilated cardiomyopathy and for heart transplant evaluation.
The development of cardiopulmonary bypass cpb in the 1960s so. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Dosing antibiotic prophylaxis during cardiopulmonary. We present the case of a patient with heparin hypersensitivity who was anticoagulated with bivalirudin during cardiopulmonary bypass for coronary artery bypass grafting. Dosing recommendation for cardiopulmonary bypass cpb. Understanding the cardiopulmonary bypass machine and its. Anticoagulation for cardiac surgery in patients receiving. Monitoring of anticoagulation with bivalirudin is more challenging. On admission, his ejection fraction was 15% and noted on echo was the presence of a large mural thrombus in the left.
Guidelines for using bivalirudin during cardiopulmonary bypass surgery during cardiopulmonary bypass procedures, systemic anticoagulation to prevent thrombosis in the patient as well as the circuit is utilized. We compared patients receiving preoperative heparin group h to those not receiving heparin ref group with respect to act, highdose thrombin time hitt, and markers of thrombin generation during cpb. Duration of cardiopulmonary bypass is an important confounder when using biomarkers for early diagnosis of acute kidney injury in cardiac surgical patients hauke paarmann 1, efstratios i. The direct thrombin inhibitor bivalirudin is an option for anticoagulation in patients with heparin induced thrombocytopenia hit requiring cardiopulmonary bypass cpb. Cardiopulmonary bypass gill ford, md saturday, august 20, 2016. Duration of cardiopulmonary bypass is an important confounder. Bivalirudin anticoagulation for cardiopulmonary bypass in. Gravlee gp1, haddon ws, rothberger hk, mills sa, rogers at, bean ve, buss dh, prough ds, cordell ar. This presented unusual challenges surrounding the monitoring of anticoagulation and the method of myocardial protection. Switching from lovenox to angiomax in patients with acute. Angiomax bivalirudin dosing, indications, interactions. The optimal fluid for priming the cardiopulmonary bypass machine is not known.
Alternative methods of anticoagulation are required for patients with heparin hypersensitivity. Cardiopulmonary bypass with bivalirudin in type ii heparin. Pdf bivalirudin is a shortacting direct thrombin inhibitor that has been used in. Mar 11, 2004 the purpose of this study is to demonstrate that in patients with heparininduced thrombocytopenia hitheparininduced thrombocytopenia and thrombosis syndrome hitts type ii undergoing cardiac surgery on cardiopulmonary bypass cpb, angiomax is a safe and effective anticoagulant. Angiomax in patients with hithitts type ii undergoing cpb. In many operations, such as coronary artery bypass grafting cabg, the heart is arrested i. When angiomax is used in cardiac surgery, techniques that allow blood or bloodbased solutions to lie stagnant should be avoided. The first attempt to use a heartlung machine for total cpb occurred at the university of minnesota in 1951. Anticoagulation with bivalirudin during cardiopulmonary bypass in cardiac surgery. Each curve depicts decreasing reservoir volume plotted as a function of flow rate and time in seconds in the event there is a cessation in venous drainage. Bivalirudin, with its short halflife and ease of monitoring during cpb, is a promising alternative to heparin. At the end of bypass, the tubes come out in the reverse order they were put in.
Transient hypotension maps as low as 30 mm hg is common following initiation of cpb, and should not be treated unless prolonged. Cardiopulmonary bypass cpb is a technique in which a machine temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the patients body. Anticoagulation with bivalirudin during cardiopulmonary. Administration of heparin to patients with heparininduced thrombocytopenia hit type ii can result in thromboembolic events, severe bleeding, and death. Bivalirudin, a semisynthetic direct thrombin inhibitor, was recently approved for use in patients undergoing percutaneous coronary interventions. Bivalirudin angiomax, a direct thrombin inhibitor, has been recently used with success as an antithrombotic agent during the treatment of acute coronary syndromes 2, 3. Statin prophylaxis and inflammatory mediators following. This combined advent of cardiac surgery and cardiopulmonary bypass techniques constituted a major advance in the history of healthcare, as it enabled direct manipulation of. Induction of an inflammatory response is thought to have a significant role in the complications that follow cardiopulmonary bypass cpb. This was following four years of experiments with dogs. Heparin dosing and monitoring for cardiopulmonary bypass. Cardiopulmonary bypass gill ford, md saturday, august 20, 2016 duration.
One or two oxygenator options and one or two custom tubing packs are frequently sufficient to handle the patient population within an adult perfusion practice. Resistance in cardiopulmonary bypass heparin resistance reported in 22% of cpb patients most common cause. Patients undergoing major cardiac surgery are at significant risk of postoperative infections by virtue of the prolonged highly invasive procedure and the presence of multiple foreign devices e. Cardiopulmonary bypass and the anesthesiologist 517 determinants of pump flow requirements. History the first operation performed using cardiopulmonary bypass and open cardiotomy was on april 5, 1951 by dr. Cardiopulmonary bypass pumps are operated by perfusionists. Cardiopulmonary bypass and neurologic dysfunction results from animal models 149 ic deficits which is in accordance to clinical trials 23,24. In a trial that randomly assigned 1094 patients undergoing coronary artery bypass grafting cabg to receive either a central venous catheter or a pulmonary artery catheter to assist in perioperative management, there were no significant differences in the length of intensive care unit stay, occurrence of postoperative myocardial infarction, in.
The technique allows the surgical team to oxygenate and circulate the patients blood, thus allowing the surgeon to operate on the heart. Its effective use during cardiopulmonary bypass cpb has also been. Bivalirudin as an alternative anticoagulant for cardiopulmonary. A bivalirudin dosing strategy, initiated 20 minutes before anticipated ligation of left internal mammary artery, used a 1. Bivalirudin angiomax, the medicines company is a directacting synthetic antithrombotic agent that has been approved as an alternative to unfractionated.
The standard agent used for systemic anticoagulation during cardiopulmonary bypass is heparin. Since that time, cardiopulmonary bypass has become a standard, widelyused, lowrisk procedure. The dosing presented below is a guide to aid in the initiation of bivalirudin infusion during cpb surgery. Recommendations for standards of monitoring and alarms. In order to use the cpb, the heart must be stopped. Bypass of the heart and lungs for example, during openheart surgery. Cardiopulmonary bypass provides the surgeon with a stable and relatively bloodless surgical field while maintaining adequate tissue perfusion. Effects are dose and concentrationdependent and reversible. The right atrium ra or both superior and inferior vena cavae are cannulated to divert blood through the venous line of the cpb circuit, with return of the blood via an. Inadequate pharmacokinetic profiles, monitoring, reversibility, and availability often limit alternative anticoagulation strategies.
Pdf cardiopulmonary bypass for complex cardiac surgery. Cardiopulmonary bypass in patients with type ii heparin. Pharmacologic preservation of the hemostatic system during. The first successful pulmonary embolectomy was carried out by kirschner 17 in 1924, while the first success in the united states was reported by steenburg and associates 29 at peter bent brigham hospital in 1958. Duration of cardiopulmonary bypass is an important. The purpose of this study is to demonstrate that in patients undergoing coronary artery bypass grafting cabg or cabgvalve, or isolated cardiac valve surgery on cpb cardiac surgery, angiomax is a safe and effective alternative anticoagulant. During cardiopulmonary bypass, initially, 1 mgkg by direct iv injection followed by 2. Cardiopulmonary bypass for complex cardiac surgery using bivalirudin anticoagulation in a patient with heparin antibodies.
Radiological evidence of pulmonary complications and possible aetiological factors were investigated in 50 consecutive patients after heart operations with cardiopulmonary bypass. Recommendations for standards of monitoring and alarms during cardiopulmonary bypass s. Innovations in pediatric cardiopulmonary bypass a continuous. The purpose of this study is to demonstrate that in patients with heparininduced thrombocytopenia hitheparininduced thrombocytopenia and thrombosis syndrome hitts type ii undergoing cardiac surgery on cardiopulmonary bypass cpb, angiomax is a safe and effective anticoagulant. Although the origins of cardiopulmonary bypass can be traced back to the 19th century, the field has developed rapidly in the last 50 years. Furthermore, mochizuki and colleagues 16 have shown that excess protamine can further alter coagulation and coagulation tests, and the careful exact titrated reversal of heparin.
Description a 19yearold man was transferred to our institution for management of newly diagnosed idiopathic dilated cardio myopathy and for heart transplant evaluation. The goal of the trial was to evaluate the safety of treatment with bivalirudin among patients pretreated for up to 12 hours with enoxaparin undergoing percutaneous coronary intervention pci for acute coronary syndrome without st elevation. Effects of cardiopulmonary bypass on pulmonary leukostasis. Management of unusual problems encountered in initiating and maintaining cardiopulmonary bypass. Charitos2, anna beilharz 1, hermann heinze 1, 1julika schon, astrid berggreen 1, matthias heringlake 1 1 d ep art m nofa sh il g y,u v lub ck g.
A comparison of techniques with measurement of subclinical plasma coagulation. Cardiopulmonary bypass cpb is a form of extracorporeal circulation in which the patients blood is diverted from the heart and lungs and rerouted outside of the body. Further experience is necessary to standardize this technique. Moderate respiratory distress was evident, associated with pulmonary congestion caused by mitral regurgitation. The predominant cause of hypotension following initiation of cpb is decreased svr secondary to reduced blood viscosity, dilution of endogenous catecholamines in priming solution, and differences in. The cpb pump itself is often referred to as a heartlung machine or the pump. Cardiopulmonary bypass for adult acquired cardiac disease commonly has limited variation in the equipment required for each perfusion setup. Use of bivalirudin for anticoagulation during implantation of. Boot camp cardiac faculty john alexander, md brian bethea, md. Do not freeze reconstituted or diluted bivalirudin. Bivalirudin during cardiopulmonary bypass in patients with.
Cardiopulmonary bypass is commonly used in operations involving the heart. It incorporates an extracorporeal circuit to provide physiological support. The statin drugs are increasingly being recognized as having potent antiinflammatory effects and hence have potential to influence an important mechanism of injury in cpb, although there is no current confirmation that this is. The use of cardiopulmonary bypass cpb technology allows cardiac surgical procedures to be performed in a motionless, bloodless surgical field. Bivalirudin for patients with acute coronary syndromes nejm. Dosing antibiotic prophylaxis during cardiopulmonary bypassa. Comparing angiomax to heparin with protamine in patients.
By simulating these factors it can be distinguished. Trendelenburg 31 first proposed his operative procedure for the removal of pulmonary emboli in 1908. Comparing angiomax to heparin with protamine in patients undergoing cardiopulmonary bypass cpb. Guidelines for using bivalirudin during cardiopulmonary bypass. Bivalirudin for cardiopulmonary bypass in the setting of heparin. Use of bivalirudin for anticoagulation during implantation. A bivalirudin dosing strategy, initiated 20 minutes before anticipated ligation of left internal mammary. Understanding the cardiopulmonary bypass machine and its tubing. Gas embolism during cardiopulmonary bypass youtube. Steps towards bloodless neonatal and infant cardiopulmonary bypass. Local bivalirudin levels may decrease due to metabolism by proteases from blood exposed to wound or foreign surfaces, potentially leading to local clot formation.
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