History Teaches Everything Including the Future - Alphonso De Lamartine

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1 10/17/2017 Markers of Safety in Pediatric Cases Utilizing DHCA and Low Flow Cerebral Perfusion Justin Sleasman CCP, MS, FPP Seattle Children s Hospital History Teaches Everything Including the Future - Alphonso De Lamartine 1

Circulatory Arrest Bloodless Surgical Field* DHCA at 18 C Safe Circulatory Arrest

2 Universal Cooling Tools Prior to Bypass Room Temperature Cooling Blanket Ice Heater Cooler Patient Pressure Access Directive Temperatures Cooling Cap Deep Hypothermic Circulatory Arrest Bloodless Surgical Field* DHCA at 18 C Safe Circulatory Arrest Time Even Cooling Twenty Minute Minimum for Cooling Neuroprotective Pharmacologic Agents 2

Low Flow ACP and RCP Decrease CMRO 2 Cannulation Strategy ACP Flow Rates RCP Flow Rates System Pressure Limit Patient Pressures Cerebral Embolization or Edema Our Technique of Low Flow PH to Cool

3 Low Flow ACP and RCP Decrease CMRO 2 Cannulation Strategy ACP Flow Rates RCP Flow Rates System Pressure Limit Patient Pressures Cerebral Embolization or Edema Our Technique of Low Flow PH to Cool and Alpha to Rewarm Temperature C Hematocrit 30% Migrate Arterial Cannula to Innominate Artery SACP Flow Rate of 40 ml/kg/min Radial Pressure less than 40 mmhg System Line Pressure of 100 mmhg 3

4 Perioperative Monitoring During Low Flow ACP Used at SCH Lactate CDI Point of Care Testing CW-NIRS Should we use? EEG SJO2 Trans-cranial Doppler FD-NIRS/DCS* Combined Strategy In the absence of definitive data favoring one strategy over the other, it might be prudent to use a combined strategy in which ph-stat is used while cooling, thus using the benefits of cerebral vasodilatation to enhance the rate and homogeneity of brain cooling; followed by the alpha-stat strategy from the interval immediately before cessation of circulation to the time of rewarming, thus minimizing extracellular acidosis and aiming for the preservation of CBF-CMRO2 coupling during reperfusion and rewarming. -Svyatets 2010, JCVA 4

5 Variation in Low Flow Technique Norwood vs. Isolated Arch Hypoplasia DHCA is better than SACP if not delivered correctly Literature Range of ml/kg/min Intermittent Cerebral Perfusion and Lower Body Communication* Rewarming Period Period of Initial Hypothermic Perfusion Extra-cranial Temperature Perfusate Temperature Maximum in Temperature Minimize Bypass Time Pressure to Rewarm from Surgical Field 5

Postoperative Outcome to Verify Practice Morbidity/Mortality Rates Periventricular Leukomalacia AKI SUMO2/3 Protein Conjugation Cognitive Studies 1. Aorta (Stamford). 2014 Aug; 2(4): 129 134.

6 Postoperative Outcome to Verify Practice Morbidity/Mortality Rates Periventricular Leukomalacia AKI SUMO2/3 Protein Conjugation Cognitive Studies 1. Aorta (Stamford) Aug; 2(4): The History of Deep Hypothermic Circulatory Arrest in Thoracic Aortic Surgery. Rimmer L 1, Fok M 1, Bashir M J Cardiothorac Vasc Anesth Aug;24(4): Perioperative Management of Deep Hypothermic Circulatory Arrest. Svyatets M, Tolani K, Zhang M, Tulman G, Charchaflieh J. 3. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2008:61-8. Principles of Antegrade Cerebral Perfusion During Aortic Arch Reconstruction in Newborns/Infants. Fraser C 1, Andropoulos DB 2 4. J Thorac Cardiovasc Surg Mar;139(3): Optimal Flow Rate for Antegrade Cerebral Perfusion. Sasaki T 1, Tsuda S, Riemer RK, Ramamoorthy C, Reddy VM, Hanley FL. 5. Artif Organs Nov; 34(11): Cerebral oxygen metabolism during total body flow and antegrade cerebral perfusion at deep and moderate hypothermia. Sasaki T 1, Boni L, Riemer RK, Yeung JT, Ramamoorthy C, Beckman R, Gisner C, Shuttleworth P, Hanley FL, Reddy VM. 6. Transl Pediatr Jul; 5(3): Antegrade cerebral perfusion at 25 C for arch reconstruction in newbornsand children preserves perioperative cerebral oxygenation and serum creatinine. Gupta B 1, Dodge-Khatami A 1, Tucker J 1, Taylor MB 2, Maposa D 3, Urencio M 1, Salazar JD Interact Cardiovasc Thorac Surg Sep;23(3): Is moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion superior to deep hypothermic circulatory arrest in elective aortic arch surgery? Poon SS 1, Estrera A 2, Oo A 1, Field M Anaesthesia Oct;57(10): Pharmacological agents as cerebral protectants during deep hypothermic circulatory arrest in adult thoracic aortic surgery. A survey of current practice. Dewhurst AT 1, Moore SJ, Liban JB. 9. J Thorac Cardiovasc Surg Aug;120(2): An Improved Method for Topical Cerebral Cooling During Deep Hypothermic Circulatory Arrest. Lighthall GK 1, Cartwright CR, Haddow GR. 10. Semin Cardiothorac Vasc Anesth Dec;11(4): Cerebral Autoregulation: The role of CO2 in Metabolic Homeostasis. Murkin J. 11. Nature. Scientific Reports. March 2017; 7: Non-Invasive Assessment of Cerebral Blood Flow and Oxygen Metabolism during Hypothermic Cardiopulmonary Bypass: Feasibility and Clinical Implications. Ferradal S 1, Yuki K 2, Vyas R 1, Ha C 1, Yi F 1, Stopp C 3, Wypij D 3, Cheng H 3, Newburger J 3, Kaza A 4, Kussman B 2, Grant E Int J Clin Exp Med. 2014; 7(11): Selective antegrade cerebral perfusion reduces brain injury following deep hypothermic circulatory arrest in the piglets model by decreasing the levels of protein SUMO2/3-ylation. Bin Li, 1,2 Yaobin Zhu, 1,2 Aijun Liu, 1,2 Wei Lu, 2,3 Junwu Su, 1,2 Jing Zhang, 1,2 Zhiqiang Li, 1,2 Xiangming 6

Major Aortic Reconstruction; Cerebral protection and Monitoring

Major Aortic Reconstruction; Cerebral protection and Monitoring N AT H A E N W E I T Z E L M D A S S O C I AT E P R O F E S S O R O F A N E S T H E S I O LO G Y U N I V E R S I T Y O F C O LO R A D O S