Priming and Hemodilution in cardiopulmonary bypass

1. Mei 2013
UNIT PERFUSI RS JANTUNGUNIT PERFUSI RS JANTUNG
DAN PEMBULUH DARAHDAN PEMBULUH DARAH
HARAPAN KITAHARAPAN KITA
M.BADRUSHSHALIH,S.Kep.
Ns
CardiopulmonaryCardiopulmonary BypassBypassooff

2. The cardiopulmonary bypass (CPB) circuit must
be primed with a fluid solution, so that adequate
flow rates can be rapidly achieved on initiation
of CPB without risk of air embolism.
S. Ghosh, F. Falter and D. J. Coo.2009.
Fills both venous and arterial limbs of the
circuit and maintains an adequate reserve
volume in the venous reservoir to ensure that
air is not entrained into the arterial side of the
circuit during initiation of CPB.

3. HISTORICAL PERSPECTIVE (Gravlee, 2008)
• John H. Gibbon, Jr (the mid-1930s)
– Using blood prime  “normal” flow rates (70-
80 mL/kg/min) and normal blood pressure
• Lillehei et al
– Flow rates (30 to 35 mL/kg per minute)
– Hypothermia was added to many high flow rate
and most low flow rate

4. HISTORICAL PERSPECTIVE
• Blood was used to prime the CPB circuit in an attempt
to preserve a high hematocrit; early in the evolution of
CPB this was thought to be an important determinant
for successful outcome.
• It later became clear, however, that use of allogenic
blood in the prime may have worsened, rather than
improved, outcomes

5. • Panico dan Neptunus (1960)
– Crystalloid solutions or plasma-expanding
colloids to reduce or eliminate blood from the
prime
– Hypothermia was now increasingly applied to
protect organs from the "adverse effects" of not
only low flow, but also hemodilution.
– Hemodilution increasing popularity, and
presently it is used almost universally.

6. • In 1962, Cooley and coworkers showed
improved outcome by adding 5% dextrose
to the prime instead of just blood. Five
percent dextrose later fell out of favor for
two reasons: firstly, the realization that
metabolism of glucose leads to a hypotonic
solution; and secondly, fears about
hyperglycemia worsening neurological
outcome.

7. Historical Perspective of Priming
Solutions and Use of Hemodilution
During Cardiopulmonary Bypass
Surgeon(s) Priming Solution Technique
Gibbon Whole blood High flow
Kirklin et al Whole blood High flow
Lillehei et al Whole blood Low flow
DeWall et al 5% Dextrose Hemodilution and
hypothermia
Greer et al 5% Dextrose Hemodilution and
hypothermia
Panico and Neptune Saline solution Hemodilution
Long et al Dextran and 5% albumin Hemodilution and
hypothermia
Cooley et al 5% dextrose Hemodilution and
hypothermia

8. BENEFITS OF HEMODILUTION
(Gravlee et al, 2008)
• Decreased blood viscosity
• Improved regional blood flow
• Improved oxygen delivery to tissues
• Decreased exposure to homologous blood
products
• Improved blood flow at lower perfusion
pressure (lower shear stress), especially during
hypothermic perfusion

9. Acceptable Hemodilution
• 25% -30% (Kay, 2004)
• < 30% (Ghosh, 2009)

10. P R I M I N G
BLOOD PRIMING NON BLOOD
(Clear Priming)
Priming adalah suatu cara untuk mengisi sirkuit CPB dengan
cairan tertentu sehingga sirkuit bebas dari udara dan terjadi delusi
yang diinginkan selama CPB

11. non-blood solutions
• Priming the heart and lung machines with non-
blood solutions was a major advance in heart
sugery.
• Have a similar electrolyte-to-plasma content and a
similar osmolarity
• Improved tissue perfusion
• Reduced hemolysis
• Avoided exposure to donor blood
• Type
– Crystalloid Primes
– Colloidal Prime

12. Crystalloids as priming solution
(Gu et all, 2006)
• Dextrose
Dx 5% is slightly hypotonic and acidotic and becomes
more so as dextrose is metabolised in vivo.
Fungsion :
1. Reducing the mechanical damage to erythrocytes and
onimproving intraoperative and postoperative diuresis.
2. Crystalloid prime containing dextrose has also been
found to lead to decreased peri-operative fluid requirement
and reduced postoperative fluid retention.

13. Disadvantages :Disadvantages :
1. Dextrose is metabolised the dilutional effect on plasma1. Dextrose is metabolised the dilutional effect on plasma
bicarbonate may causebicarbonate may cause systemic metabolicsystemic metabolic acidosisacidosis
2. As serum glucose and insulin concentrations are elevated2. As serum glucose and insulin concentrations are elevated
due to the effects of cardiopulmonarydue to the effects of cardiopulmonary bypass, addingbypass, adding
dextrose to the prime may further increase the level ofdextrose to the prime may further increase the level of
blood glucose. This isblood glucose. This is especially a concern for diabeticespecially a concern for diabetic
patients.patients.
The glucose-containing priming solution may increase
the risk of CPB related neurological complications
although there was a lack of significant clinical evidence.

14. Balanced crystalloids are fluids formulated to have a neutral
pH and concentrations of electrolyte ions similar to that of
human plasma. Ringer’s lactate fluid, or Hartmann’s solution,
is a typical example of a balanced crystalloid, and contains
lactate as a source of bicarbonate.
However, a large volume of fluid containing lactate should
be used with caution in diabetic patients, as lactate
may be converted into glucose in vivo through the
gluconeogenic pathway.
A further example of a balanced crystalloid is plasmolyte
solution, which contains acetate and gluconate for bicarbonate
production. It also contains magnesium which is an important
intracellular cation involved in cellular process of energy
transfer and in myocardial adenosine triphosphate metabolism.
Balanced crystalloid fluids

15. Mannitol
Mannitol is a hypertonic, low molecular weight
crystalloid widely used in clinical practice to stimulate
diuresis. A particular advantage of mannitol is its
protective effect on renal function
As a volume expander, mannitol draws fluid initially
across the capillary into the plasma. Then it rapidly
diffuses into the interstitial fluid and increases the
volume of the whole extracellular phase by
withdrawing water from the body cells..

16. Colloids as priming solution
Albumin
• Molecular weight of about 69,000 daltons.
• Accounts for 75% to 80% of the plasma oncotic pressure
esponsible for the maintenance of body plasma volume.
• Addition of 200 ml of 25% albumin in the bypass circuit had
no beneficial effect on perioperative fluid balance,
cardiopulmonary function and renal function.
• Albumin prime reduced postoperative bleeding where a
shydroxyethyl starch prime did not
• Albumin may induce anaphylactic or anaphylactoid reactions
and may also carry the risk of transmission of viral disease.
• For these reasons, and also because albumin is rather
expensive, a number of synthetic colloid fluids are chosen as
priming fluids.

17. • Molecular weight of either 40,000 daltons (Dextran
40) or 70,000 daltons (Dextran 70).
• The dextran molecule is a polysaccharide, produced
from sucrose by the bacterium Leuconostoc
mesenteroides.
• Dextran 40 has a colloid osmotic pressure twice as
high as that of plasma, and so has a strong effect in
mobilising water from the extravascular into the
intravascular space.
• Dextran 40 prepared in 10% solution is a more
effective volume expander tha dextran 70 is, as it
contains almost twice as much colloid per litre.
However, the action of the dextran 40 is much less
sustained, as the small molecules allow it to be
rapidly eliminated by the kidneys.
Dextrans

18. • As a priming fluid for cardiopulmonary bypass,
dextrans reduce blood viscosity and prevent the
adhesion of leukocytes in the microcirculation.
It is recommended that the total dose of dextran
infusion does not exceed 1.5 g/kg/day as dextrans
may impair haemostasis. This dose should be
further limited in patients undergoing
cardiopulmonary bypass because heparin is used
in these patients. Anaphylactoid reactions to
dextrans may occur, but the incidence of reaction
is much lower than that caused by gelatin.

19. • From bovine collagen
• Molecular weight of 30,000 to 35,000 dalton.
• Two types of gelatins : urea-linked gelatin and succinyl-
linked gelatin.
• A further disadvantage of gelatin is its relatively high
incidence of anaphylactoid reactions compared with
other artificial colloids.
Gelatins

20. • Hydroxyethyl starch is a synthetic colloid that consists of
hydroxyethylated polymers of glucose, derived from
amylopectin.
• Compared with albumin as a colloid priming fluid,
hydroxyethyl starch appeared to achieve the similar
clinical effects of volume expansion in cardiac surgical
patients with low incidence of anaphylactoid reactions.
• Containing balanced electrolytes sodium, chloride,
calcium, magnesium, and potassium, as well as glucose
and lactate
Hydroxyethyl starch

21. Blood Priming
• Reducing the degree of hemodilution
• Pediatric
• Low Hct

22. Factors Affecting Hematocrit
During Cardiopulmonary Bypass
o Patient's weight
o Sex
o Preoperative anemia/polycythemia
o Preoperative hypovolemia/hypervolemia
o Cardiopulmonary bypass circuit volume
o Cardiopulmonary bypass prime volume
o Pre-cardiopulmonary bypass blood loss
o Pre-cardiopulmonary bypass volume administration
o Crystalloid cardioplegia volume
o Added crystalloid or colloid prime to maintain flow
o Urin output
S. Ghosh, F. Falter and D. J. Coo.2009.

23. Additional Components
(Gravlee,2008; Gosh, 2009)
Component Amount Rationale
Heparin 10-25 mg (1,000-2,500
U)/L of priming volume
Additional safety
factor if systemic
heparinization is
inadequate
Mannitol 25-50 g Helps prevent
tissue edema and
induce an osmotic
diuresis
Free radical
scavenger

24. Calcium 200 mg/L of
priming volume
Prevents chelation
of circulating
calcium if citrated
blood is added to
the prime; may be
especially
important in
pediatric patients
because of
frequent use of
blood in the prime

25. Corticosteroids 200 mg/L of
priming volume
Prevents or
attenuates
activation of
inflammatory
processes by
cardiopulmonary
bypass
Bicarbonate 25mmol/L
prime
Buffer when
unbalanced
priming solution
are used

26. ASSESSING ADEQUACY OF
PERFUSION WITH HEMODILUTION
• Global cerebral function
– Electroencephalographic means,
• Blood flow velocity
– Transcranial Doppler
• Oxygen saturation by near-infrared spectroscopy
• Renal function, urinary output
• Arterial blood gases will monitor oxygenator
function, and measurement of mixed venous
oxygen tension

27. References
• Kay,P.,H.,Munsch,C.,2004. Techniques in Extracorporeal Circuit 4th
Edition.Oxford University Press: New York.
• Holtby,H.Cardiopulmonary Bypass in infant and children: The impact
of priming solution and volume.Hospital for sick Children Toronto.
• Greeley,W.J.,et al.Anesthesia for Pediatric Cardiac
Surgery.2000.Churchill Livingstone.
• Gravlee, Glenn P.; Davis, Richard F.; Stammers, Alfred H.;
Ungerleider, Ross M.2008. Cardiopulmonary Bypass: Principles and
Practice, 3rd Edition. Lippincott Williams & Wilkins: USA.
• Gu,Y.,J.,Boonstra,P.w. 2006.Selection Of Priming Solutions For
Cardiopulmonary Bypass In Adults. European Association for Cardio-
thoracic Surgery. doi:10.1510/mmcts.2005.001198