Prime Time ! Fluids during Cardiac Surgery
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Transcript of Prime Time ! Fluids during Cardiac Surgery
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Dirk Himpe MD PhD MHE EDIC
ZNA Middelheim General Hospital
Antwerp Belgium
Prime Time !Fluids during Cardiac
Surgery
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Outcome ?
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Engoren et al. Ann Thorac Surg 2002; 74:1 180-6
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Koch CC et al. Ann Thorac Surg 2006; 81:1650-7.
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Carson J, Lancet 1996, 348: 1055-60
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Factors: .preoperative anemia,.perioperative RBC transfusions .postoperative re-exploration
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Lowell, CCM 1990 18:728, 1990
< 10 %
10-20 %> 20 %
0 20
40
60
80
100Mortality
%
Weight gain after cardiac surgery
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Red blood cell
Platelet
Polymer INFLAMMATION
Blood 1994; 4:3175-81
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phases: pre-pump-post-ICU
targets: interrelated
.transfusion/anemia .acid-base status .fluid balance (colloids) .inflammation (SIRS)
OR
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bloodvolume + priming solution
Htc: 45 % 20-25 % start CPB
(few minutes)
The “pump”: onset of CPB = massive fluid load
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Issue:Type of Fluid = Determinant of Outcome ?! (direct or indirect)
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Blood-loss
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Fluid-Balance
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James A. Russel. JCTVA 2004, 18: 429-437
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Himpe D, Act Anaesth Belg, 54:207-15, 2003
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Acid-Base
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Succinyl-linked GEL in buffered vehicle
Albumin-Hartmann
Himpe D. et al. JCTVA 1991, 5:457-66
Urea-linked GEL in NS
Base Excess (mean ± 1.96SEM)
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Base EM. et al. JCTVA 2011, 25:407-14
Hydroxyethyl Starch 6% 130/0.4
in NS (Voluven)
Hydroxyethyl Starch 6% 130/0.4 in a Balanced Electrolyte Solution
(Volulyte)
Base Excess (mean ± SD)
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damage tofigured blood elements(foreign surfaces, air, pericardium & pumps)
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0
200
400
600
800
1000
1200
baseline
120 min
4% MFGelatine4% Albumin6% HES 70/0.5Normal Saline
mg/L
free haemoglobin -> inflammation
Sumpelmann R et al. Anaesthesia 55: 976, 2000
mechanical stresson blood during
CPBelectricall
ycharged
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Himpe D, Act Anaesth Belg, 54:207-15, 2003
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Mortality
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Canver C. C. & Nichols R. D. Chest 2000;118:1616-1620
I. crystalloid (211 pts) II. 25 % human albumin (217 pts) III. 6% hetastarch (298 pts) IV. 6% hetastarch & 25% human albumin (161 pts)
Comparison of types of priming solutions used for CPB with the survival rate of coronary bypass patients.
NS
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Himpe D, Act Anaesth Belg, 54:207-15, 2003
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Conclusions from the available evidence to date: - outcome after cardiac surgery: there is more than priming fluids between heaven and earth;but:
- always colloids in the CPB prime;- electrically charged colloids may reduce blood damage (inflammation ?);- balanced solutions abolish the CPB acid-base problem;- minimizing volume of extracorporeal circuits may help;
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