Deep hypothermic circulatory arrest in pediatric cardiac surgery

1. Deep Hypothermic Circulatory
Arrest in Pediatric Cardiac Surgery
Manu Jacob
Perfusionist
KMCT MCH

2. • Cessation of the blood circulation for some time
during surgery of the arch and repair of congenital
heart defects is normally required to allow a
bloodless operation field..
• Hypothermia is the most important mechanism for
end-organ protection, particularly the brain, during
such operations.
• Cardiopulmonary bypass is used for core cooling
before deep hypothermic circulatory arrest (DHCA)
is initiated .

3. WHAT IS DHCA?WHAT IS DHCA?

4. DEEP HYPOTHERMICDEEP HYPOTHERMIC
CIRCULATORY ARREST (DHCA)CIRCULATORY ARREST (DHCA)
• Mild hypothermia – 30 C to 34 CMild hypothermia – 30 C to 34 C
Moderate hypothermia – 25 C to 30 CModerate hypothermia – 25 C to 30 C
Deep hypothermia – 15 C to 22 CDeep hypothermia – 15 C to 22 C
• Circulatory arrest – no flow in the blood vesselsCirculatory arrest – no flow in the blood vessels
• DHCA – no blood flow during deep hypothermiaDHCA – no blood flow during deep hypothermia

5. HOW DO WE DOHOW DO WE DO
DHCA?DHCA?

6. TECHNIQUE OF DHCATECHNIQUE OF DHCA
• Usually plannedUsually planned
• Most protocols involving DHCA involve the following :Most protocols involving DHCA involve the following :
– Administration of barbiturates, usually thiopental for the reduction ofAdministration of barbiturates, usually thiopental for the reduction of
cerebral metabolism.cerebral metabolism.
– Mannitol to help reduce potential increased intracranial pressure and toMannitol to help reduce potential increased intracranial pressure and to
reduce free radicals.reduce free radicals.
– Steroids to promote cell membrane integrity and reduce brain swelling.Steroids to promote cell membrane integrity and reduce brain swelling.
– Cooling is started before CPB by simply cooling the operating room andCooling is started before CPB by simply cooling the operating room and
with ice packing to the headwith ice packing to the head After systemic heparinization andAfter systemic heparinization and
cannulation are performed, CPB is started and cooling is begins for atcannulation are performed, CPB is started and cooling is begins for at
least 20-30 minutes. The patient's body temperature is monitored byleast 20-30 minutes. The patient's body temperature is monitored by
means of esophageal, tympanic, and rectal routes. After adequatemeans of esophageal, tympanic, and rectal routes. After adequate
cooling is achieved, the circulation is arrested to allow the surgeon tocooling is achieved, the circulation is arrested to allow the surgeon to
perform the critical part of the reconstruction. The duration of DHCA isperform the critical part of the reconstruction. The duration of DHCA is
limited to the shortest time possible. After circulation is restarted, thelimited to the shortest time possible. After circulation is restarted, the
rest of the repair is performed during the rewarming phase.rest of the repair is performed during the rewarming phase.
– The anesthetic and surgical plan involves mutual goals of tissue andThe anesthetic and surgical plan involves mutual goals of tissue and
organ protection by decreasing cellular metabolism and substrateorgan protection by decreasing cellular metabolism and substrate
delivery during the absence of perfusion.delivery during the absence of perfusion.

7. WHY DHCA?WHY DHCA?

8. ADVANTAGES OF DHCAADVANTAGES OF DHCA
• Bloodless operating field with improved exposureBloodless operating field with improved exposure
• Decreased exposure to cardiopulmonary bypass with itsDecreased exposure to cardiopulmonary bypass with its
sequelae (such as activation of white cells and endothelium,sequelae (such as activation of white cells and endothelium,
activation of cascades, consumption of coagulation factorsactivation of cascades, consumption of coagulation factors
and platelets, hemolysis, etc.)and platelets, hemolysis, etc.)
• Diminished risk of embolism (solids and gases)Diminished risk of embolism (solids and gases)
• No cannulas in the operating fieldNo cannulas in the operating field
• Less distortion of heart - cannulas are not in placeLess distortion of heart - cannulas are not in place
• DHCA offers brain protection for a period of about 30-60DHCA offers brain protection for a period of about 30-60
minutes.minutes.
• Reduced CMROReduced CMRO22 to be approximately 10%-15% of itsto be approximately 10%-15% of its
normothermic base line.normothermic base line.
• Lower plasma activated complement (C3a), interleukin 8,Lower plasma activated complement (C3a), interleukin 8,
interleukin 6 (when compared with low-flow CPB)interleukin 6 (when compared with low-flow CPB)
Bellinger DC, et al. N Engl J med. 1995;332:549-555

9. • The duration of DHCA is limited to the shortest time
possible as (landmark boston circulatory arrest study,
march 2007)
– 3-5 mins of cerebral ischemia can be tolerated at 37 c.
– 15 mins 27 c.
– 41 mins 17 c.

10. 0
0.2
0.4
0.6
0.8
1
1.2
0 3 5 10 15 30 45
Duration of total circulatory arrest (min)
Probabilityof"safe"circulatory
arrest
37 c
27 c
17 c

11. CEREBRAL PHYSIOLOGY DURING
CARDIAC SURGERY
•CLINICAL STUDIES (Greeley, Kern, Ungerdeider)
HAVE BEEN UNDERTAKEN IN THE LATE 1980s
TRHOUGH MID 1990s TO UNDERSTAND
NEUROPHYSIOLOGY IN INFANTS AND CHILDREN
DURING CARDIAC SURGERY INVOLVING CPB
AND DHCA
•CNS HAS A HIGH METABOLIC NOTE & LIMITED
ENERGY STORES
•CNS IS THE MOST SENSITIVE ORGAN TO ISCHEMIA
•ATTENTION HAS BEEN CENTERED ON NEUROLOGIC
OUTCOME WHEN PERFUSION IS REDUCED, LEADING
TO NEUROLOGIC COMPLICATIONS IN THE
POSTOPERATIVE PERIOD.

12. THE REPORTED INCIDENCE OF
NEUROLOGICAL COMPLICATIONS
AFTER PEDIATRIC CARDIAC SURGERY
RANGES FROM 2% TO 25%
Austin EH III,Edmonds HI,Auden SM et al.
Benefit of neurophysiological monitoring for pediatric
Cardiac surgery.J Thorac Cardiovasc Surg 1997;114 :707-15
Menache CC,du Plessis AJ,Wessel DL et al.
Current incidence of acute neurologic complications
After open heart operation in children
Ann Thorac Surg 2002; 73:1752.8

13. • Neurologic morbidity include
– seizures
– stroke
– changed tone and mental status
– motor disorders -
– time to recovery of EEG activity .
– Abnormal cognitive function
– Post Pump choreoatherosis paraplegia
• Areas most vulnerable to ischemic Injury :
– Neocortex
– Hippocompus
– Striatum

14. mechanism of brain injury involves binding of
glutamate to NMDA receptor , increasing the
intracellular ca++ and subsequently activates
proteases phospholipases and
deoxyribonucleases , promotes the generation
of free radicals cell injury , cell death .
Hypothermia the release of glutamate
During DHCA , microemboli can be detected .

15. THE ETIOLOGY OF NEUROLOGICAL
DYSFUNCTION IN CHILDREN IS FOR THE MOST
PART ISCHEMIA
PATHOPHYSIOLOGIC MECHANISMS ACCOUNTING
FOR NEUROLOGIC INJURY INCLUDE:
rate and extent of cooling and rewarming
management of CPB
prolonged DHCA
anemia
low cardiac output

18. •UNDER DEEP HYPOTHERMIC CPB
CBF IS REDUCED BUT THERE IS AN
EXPONENTIALLY GREATER REDUCTION
IN CMRO2.
•A STATE OF LUXURY PERFUSION EXISTS
WITH AN EXCESS OF FLOW RELATIVE
TO OXYGEN CONSUMPTION; 1:75 (conferring cerebral protection)
•IN PATIENTS UNDERGOING DHCA CBF AND
CMRO2 REMAIN DECREASED AFTER
REWARMING AND WEANING FROM CPB
Sara Lozano, MD , Emad Mossad, MD – Journal of Cardiothoracic and Vascular
Anesthesia. Volume 18, Issue 5, Pages 645-656 (October 2004)

20. IMPROVINGIMPROVING
NEUROLOGICNEUROLOGIC
OUTCOMESOUTCOMES

21. BLOOD GAS MANAGEMENT (a-stat vs pH-stat)
DURING CPB SIGNIFICANTLY AFFECTS
CEREBRAL PHYSIOLOGY AN MAY HAVE
AN IMPACT ON NEUROLOGICAL OUTCOME
Acid -- Base ManagementAcid -- Base Management

22. • Changes in cellular pH during hypothermia are mediatedChanges in cellular pH during hypothermia are mediated
through pcothrough pco22 homeostasis.homeostasis.
• When blood is cooled during cardiopulmonary bypass, pHWhen blood is cooled during cardiopulmonary bypass, pH
becomes more alkaline.becomes more alkaline.
• pH-stat strategy – adding carbon dioxide - compensates forpH-stat strategy – adding carbon dioxide - compensates for
this shift.this shift.
• This situation causes pH to increase as temperatureThis situation causes pH to increase as temperature
decreases and electrochemical neutrality to be maintained.decreases and electrochemical neutrality to be maintained.
• Carbon dioxide is a potent cerebral vasodilator.Carbon dioxide is a potent cerebral vasodilator.
• αα-stat strategy – electrochemical neutrality is maintained by-stat strategy – electrochemical neutrality is maintained by
keeping pH normal in temperature-uncorrected gases.keeping pH normal in temperature-uncorrected gases.

23. i.e,
αα-stat strategy – arterial blood measured at 37 C with-stat strategy – arterial blood measured at 37 C with
pH of 7.40 and arterial pCO2 of 40 mm HgpH of 7.40 and arterial pCO2 of 40 mm Hg
(the hypothermic blood is alkalemic and(the hypothermic blood is alkalemic and
hypocapneic)hypocapneic)
pH-stat strategy – hypothermic arterial blood at pH ofpH-stat strategy – hypothermic arterial blood at pH of
7.40 and arterial pCO2 of 40 mm Hg7.40 and arterial pCO2 of 40 mm Hg
(blood at 37 C is acidemic and hypercapneic)(blood at 37 C is acidemic and hypercapneic)

24. 28 o
C
pH 7.56 pH 7.56 +CO2 pH 7.4
PaCO2 26 mmHg PaCO2 26 mmHg PaCO2 40 mmHg
∝Stat pH stat
pH 7.4 pH 7.26
PaCO2 40 mmHg PaCO2 56 mmHg
lab 37o
C

25. ADVANTAGES/DISADVANTAGESADVANTAGES/DISADVANTAGES
• αα-stat strategy: preserves autoregulation, optimizes-stat strategy: preserves autoregulation, optimizes
cellular enzyme activity, but less metaboliccellular enzyme activity, but less metabolic
suppressionsuppression
• pH-stat strategy: improves cerebral blood flow,pH-stat strategy: improves cerebral blood flow,
cerebral oxygenation, and brain cooling efficiencycerebral oxygenation, and brain cooling efficiency
during CPB, but greater risk of microembolism andduring CPB, but greater risk of microembolism and
free radical-mediated damagefree radical-mediated damage

26. Higher Hematocrit Improves
Cerebral Outcome After Deep
Hypothermic Circulatory Arrest
Shin’oka T, Shum-Tim D, Jonas RA, Lidov HGW, Laussen PC, Miura T and du Plessis AShin’oka T, Shum-Tim D, Jonas RA, Lidov HGW, Laussen PC, Miura T and du Plessis A
Children’s Hospital Boston/Harvard Medical SchoolChildren’s Hospital Boston/Harvard Medical School
J Thorac Cardiovasc Surg 1996;112:1610-21J Thorac Cardiovasc Surg 1996;112:1610-21
Extreme hemodilution (hematocrit < 10%) causesExtreme hemodilution (hematocrit < 10%) causes
inadequate oxygen delivery during early coolinginadequate oxygen delivery during early cooling
and higher hematocrit (30%) achieved with bloodand higher hematocrit (30%) achieved with blood
prime results in improved cerebral recovery afterprime results in improved cerebral recovery after
circulatory arrest.circulatory arrest.

27. Temperature Management
No difference between surface and core cooling.
Provide adequate duration of cooling (> 20 min)
before institution of DHCA. Avoid rapid cooling,
avoid rapid rewarming and hyperthermia in
postoperative period.
Sharma R, et al. Neurological evaluation and intelligence testing in the child
with operated congenital heart disease. Ann Thorac Surg 2000; 70: 575–581
Cottrell SM et al. Early postoperative body temperature and developmental
outcome after open heart surgery in infants. Ann Thorac Surg 2004; 77: 66–71

28. Neuroprotective drugs

29. DrugDrug BasisBasis Current recommendations andCurrent recommendations and
results of clinical trialsresults of clinical trials
Pre-operative use of
methyl prednisolone
Lesser inflammatory response
after CPB;
cerebral function recovers
earlier.
Intravenous methyl prednisolone
10 mg/kg administered 8 hours
and 2 hours prior to surgery in high
risk groups like neonates
Barbiturates Suppresses EEG activity; can
cause reduction
in high-energy phosphates
which is
detrimental after circulatory
arrest.
Not recommended prophylactically
Aprotinin Beneficial effect on recovery
of cerebral high
energy phosphates and
intracellular pH.
No clear evidence favoring use in
pediatric CPB.

30. Allopurinol, NAC May reduce injury due to
free radicals. NAC
may improve myocardial
function.
No clear data.
NMDA antagonists
(magnesium, selfotel)
Reduce excitotoxicity No benefit in human
trials.
Nimodipine (calcium
channel antagonist)
Reduces cellular injury mediated
by calcium influx during reperfusion.
Negative results in
human stroke trials.
Erythropoetin (EPO) EPO switches off apoptosis
Limits excitotoxic cell death
Mediated by NMDA - R
Blocks the inflammatory cascade
EPO is a cerebral vasodilator
EPO 1000 units/kg IV for 3 doses –
12 hours pre-op / after CPB then 24
hours after.

31. CPB: cardiopulmonary bypass; EEG: electroencephalograph; NAC: N-acetyl cysteine; NMDA: N-methyl D-aspartate
Langley SM, et al. Eur J Cardiothorac Surg 2000.
Clancy RR, et al. Pediatrics 2001.
Miller SP, et al. Ann thorac Surg 2004.
Bickler PE, Fahlman CS. Anesth Analg 2006, 103.
Inhaled anesthetics
Isoflurane
Desflurane
Slowing of neuronal metabolism
Slow apoptosis and block iCa++
neuronal injury and death.
Be placed in the CPB sweep gas flow
Vasodilation
It would appear desirable to
use this agents liberally on
CPB.
Even seeking to achieve a
target blood level while
cooling. Especially if DHCA
or other such techniques are
to be used.

33. •EEG
it is a rough guide to anesthetic depth
it is affected by temperature,CPB,anesthetics
not easy to use
•BIS (BISPECTRAL INDEX)
it is currently used to guide the depth of anesthesia
easy to use - less reliable during hypothermia
•SjVO2 (JUGULAR VENOUS BULB OXYMETRY)
it is considered the gold standard of global cerebral
oxygenation
it is invasive
Unilateral SjVO2 may not reflect contralateral events

34. •TCD (TRANSCRANIAL DOPPLER ULTRASOUND)
it is a sensitive real-time monitor of CBF, can detect microemboli
it monitor the middle cerebral artery
Absent signal during DHCA.
•S- 100B (Biochemical marker)
Detects preexisting neurologic deficit
Multiple sampling periods required
•NIRS (NEAR-INFRARED SPECTROSCOPY)
it is a non-invasive optical technique
most devices utilize 2-4 wavelengths of infrared light
at 700-1000 nm, where oxygenated and deoxygenated
hemoglobin have distinct absorption spectra
two depth of light penetration are used to subtract
out data from the skin and skull resulting in brain
oxygenation value
Changes in cerebral vascular composition will affect rSO2 reading
Useful during DHCA.

37. Conclusion
• Survival after neonatal and infant cardiac surgery
has improved dramatically, but quality of life,
including neurodevelopmental outcomes, still needs
study and improvement. It is important to protect the
brain using established strategies,and test new
strategies with carefully designed follow-up studies.
Potential exists for significant improvement in this
area.