Current Cardiac Surgery

Transcription

1 ON BYPASS

2 Current Cardiac Surgery Mehmet C. Oz, MD, and Michael Argenziano, MD SERIES EDITORS On Bypass: Advanced Perfusion Techniques, edited by Linda B. Mongero, BS, CCP, and James R. Beck, BS, CCP, 2008

3 ON BYPASS Advanced Perfusion Techniques Edited by LINDA B. MONGERO, BS, CCP Division ofcardiothoracic Surgery Clinical Perfusion New York Presbyterian/Columbia College ofphysicians and Surgeons JAMES R. BECK, BS, CCP Division ofcardiothoracic Surgery Clinical Perfusion New York Presbyterian/Columbia College ofphysicians and Surgeons ~ HUMANA PRESS ~ TOTOWA, NEW JERSEY

4 2008 Humana Press Inc., a part of Springer Science+Business Media. LLC 999 Riverview Drive, Suite 208 Totowa, New Jersery, All rights reserved. No part of this book may be reproduced. stored in a retrieval system. or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All articles, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Due diligence has been taken by the publisher, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selection and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding. as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physican to determine dosages and treatment strategies for individual patients. Further, it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors arc not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. e ANSI Z (American National Standards Institute) Permanence of Paper for Printed Library Materials. For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the followiog numbers: Tel.: ; Fax: ; humanapr.com; or visit our Website: Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc., provided that the base fee of US $30.00 per copy is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for users of the Transcriptional Reporting Service is: [ $30.00] eisbn: Library of Congress Control Number:

5 FOREWORD In On Bypass: Advanced Perfusion Techniques, editors Linda Mongero and James Beck have distilled the complex field of extracorporeal circulation and intraoperative mechanical support down to its most basic and importantcomponents. By identifying the critical pieces of the complex puzzle that is cardiopulmonary bypass and having these presented by a truly all-star cast of contributing authors, On Bypass represents a comprehensive, in-depth compilation of the current stateof-the-art in cardiopulmonary bypass technology and techniques. In chapters dedicated to engineering, cannulation, blood flow, prime solutions, and ultrafiltration, the reader is exposed to detailed descriptions of the foundations of cardiopulmonary bypass technology. Other chapters illuminate the nuances of perfusion in special situations, such as pediatric, minimally invasive, and aortic surgery. Extension of extracorporeal support beyond the operating room is covered expertly in a chapter on EeMO and long-term pulmonary support. But this book goes beyond the traditional boundaries of a perfusion manual, and it is significantly strengthened by clinically oriented chapters dedicated to separation from cardiopulmonary bypass, the inflammatory response, and echocardiography. Finally, the editors draw upon their more than 50 years of experience as cutting-edge perfusionists in a chapter on policies and procedures, which constitutes required reading for anyone managing a perfusion program. In sum, On Bypass represents an authoritative compendium of the most recent and best knowledge in every area relevant to cardiopulmonary bypass and perfusion. It is certain to become a trusted and wellworn resource on the shelves of clinical perfusionists, cardiac surgeons, anesthesiologists, and all others involved in the care of patients requiring extracorporeal perfusion. Michael Argenziano, MD Mehmet C. Oz, MD v

6 PREFACE CARDIOPULMONARY BYPASS: ATTRACTIVE, BUT HARMFUL? With the introduction of cardiac surgery more than five decades ago, and the use of the heart-lung machine for open heart surgical procedures granting the surgeon unlimited time in which to operate inside the heart, a complex task has been given to the perfusionist. Initially, cardiopulmonary bypass was so deleterious to the patient, and knowledge of bypass was so limited, that the unknown was balanced mostly by trial and error. Once extracorporeal support became feasible in man, a great need for skilled perfusionists sparked authors Charles C. Reed and Diane Clark to write Cardiopulmonary Perfusion. This basic textbook is surely on every perfusionist' s shelf, and is useful as an adjunct to training personnel. The next phase of cardiopulmonary bypass enhanced the skills of the perfusionist and enabled cardiac surgery to grow by leaps and bounds. Because of the complexity of artificial circulation and the importance of the science of perfusion technology, we have gained respect in the surgical arena, but at the same time our task is regarded as insidious, owing to its effect on inflammatory response. The aberrations of normal physiology associated with cardiopulmonary bypass often bring criticism to its use; however, the fact that some patients have no ill effects from the procedure complicates this perception. After years of clinical investigation and publication, cardiopulmonary bypass has been deemed necessary in a controlled environment involving perfusionists, surgeons, and anesthesiologists. Our library was limited to a varied selection of medical surgical textbooks until Joseph Utley et al. published a comprehensive textbook for perfusionists and clinicians addressing both practical and reference needs. We continue to develop new strategie s to enhance our patient care. Along the way, innovations lead us to challenge present technology. Today, it seems that the surgeon and patient would dream to have all procedures done OFF of cardiopulmonary bypass, thereby ameliovii

7 Vlll Preface rating its perceived deleterious effects. However, the nearly 650,000 procedures that require cardiopulmonary bypass and a perfusionist created a need for the development of a textbook that investigates advanced perfusion techniques that are currently being practiced; hence, On Bypass: Advanced Perfusion Techniques. We hope that this collection of techniques and protocols will add to your repertoire and that your patients' care will be enhanced. We paired a perfusionist and a surgeon for each chapter in an effort to share a team approach to difficult and immediate decision making in the operating room. In fact, our practice depends on it. Linda B. Mongero, BS, CCP James R. Beck, BS, CCP

8 CONTENTS Foreword by Michael Argenziano and Mehmet C. Oz Preface Contributors v vii Xl The Engineering of Cardiopulmonary Bypass Ben F. Brian 2 Pediatric Perfusion Techniques for Complex Congenital Cardiac Surgery 29 Kevin A. Charette, Ryan R. Davies, Jonathan M. Chen, Jan M. Quaegebeur, and Ralph S. Mosca 3 Separation from Cardiopulmonary Bypass: Hemodynamic Considerations 59 Marc L. Dickstein 4 Prime Solutions for Extracorporeal Circulation 71 Robert J. Frumento and Elliott Bennett-Guerrero 5 Blood Flow During Cardiopulmonary Bypass Terence Gourlay and Tipo Qureshi 6 The Inflammatory Response to Cardiopulmonary Bypass 125 Roman M. Sniecinski and Jerrold H. Levy 7 Minimally Invasive Perfusion Techniques Sandhya K. Balaram, John Markham, and Joseph J. DeRose, Jr Cannulation and Clinical Concerns for Cardiopulmonary Bypass Access 171 James R. Beck, David Y. Park, and Linda B. Mongero ix

9 x Cont ents 9 Ultrafiltration in Cardiac Surgery Bruce Searles and Edward Darling 10 Echocardiography and Cardiopulmonary Bypass Jack S. Shanewise 11 Surgical Approach to Aortic Surgery and Perfusion Techniques Sanjeev Aggarwal and Allan Stewart 12 ECMO to Artificial Lungs: Advances in Long-Term Pulmonary Support Brittany A. Zwischenberger, Lindsey A. Clemson, James E. Lynch, and Joseph B. Zwischenberger 13 Policy and Procedure Guidelines Index

10 CONTRIBUTORS SANJEEV AGGARWAL, MD Division ofcardiothoracic Surgery, New York Presbyterian/Columbia College of Physicians and Surgeons, SANDHYA K. BALARAM, MD, rhn Division of Cardiothoracic Surgery, St. Luke's-Roosevelt Hospital Center, JAMES R. BECK, BS, CCP Division ofcardiothoracic Surgery, Clinical Perfusion, New York Presbyterian/Columbia College of Physicians and Surgeons, ELLIOTT B ENNETT-GUERRERO, MD Department ofanesthesiology, Duke University Medical Center, Durham, NC BEN F. BRIAN, rhn Vice President, R&D Radiant Medical/nc. K EVIN A. CHARETTE, BS, CCP Division of Cardiothoracic Surgery, Morgan Stanley Children's Hospital ofnew York Presbyterian/ Columbia College of Physicians and Surgeons, JONATHAN M. CHEN, MD Division ofcardiothoracic Surgery, Morgan Stanley Children 's Hospital ofnew York Presbyterian/ Columbia College ofphysicians and Surgeons, LINDSEY A. CLEMSON, MD Department ofsurgery, University of Texas Medical Branch, Galveston, TX EDWARD DARLING, MS, CCP SUNY Upstate Medical University College ofhealth Professions, Syracuse, NY RYAN R. DAVIES, MD Division of Cardiothoracic Surgery, Morgan Stanley Children 's Hospital ofnew York Presbyterian/Columbia College of Physicians and Surgeons, JOSEPH J. DEROSE, JR., MD Division of Cardiothoracic Surgery, St. Luke's-Roosevelt Hospital Center, MARC L. DICKSTEIN, MD Department ofanesthesiology, New York Presbyterian/Columbia College ofphysicians and Surgeons, ROBERT J. FRUMENTO, MS, MPH Department ofanesthesiology, Duke University Medical Center, Durham, NC TERENCE GOURLAY, rhn Professor ofmedical Diagnostics, Bioengineering Unit, University ofstrathclyde, Glasgow, Scotland XI

11 xu Contributors JERROLD H. LEVY, MD Department ofanesthesiology, Emory University Hospital, Atlanta, GA JAMES E. LYNCH, BS, RRT Department ofsurgery, University of Texas Medical Branch, Galveston, TX JOHN MARKHAM, MS, MBA, CCP ChiefofPerfusion, Director, Biomedical Engineering, St. Luke's-Roosevelt Hospital Center, LINDA B. MONGERO, BS, CCP Division of Cardiothoracic Surgery, Clinical Perfusion, New York Presbyterian/Columbia College of Physicians and Surgeons, RALPH S. MOSCA, MD Division of Cardiothoracic Surgery, Morgan Stanley Children 's Hospital ofnew York Presbyterian/Columbia College ofphysicians and Surgeons, DAVID Y. PARK, BS, CCP Division of Cardiothoracic Surgery, Clinical Perfusion, New York Presbyterian/Columbia College of Physicians and Surgeons, JAN M. QUAEGEBEUR, MD, rhn Division of Cardiothoracic Surgery, Morgan Stanley Children's Hospital ofnew York Presbyterian/ Columbia College ofphysicians and Surgeons, TIPo QURESHI, MD Imperial College, London, England BRUCE SEARLES, BS, CCP SUNY Upstate Medical University College ofhealth Professions, Syracuse, NY JACK S. SHANEWISE, MD Department ofanesthesiology, Division of Cardiothoracic Anesthesiology, New York Presbyterian/Columbia College ofphysicians and Surgeons, ROMAN M. SNIECINSKI, MD Department ofanesthesiology, Emory University Hospital, Atlanta, GA ALLAN STEWART, MD Division of Cardiothoracic Surgery, New York Presbyterian/Columbia College ofphysicians and Surgeons, BRITTANY A. ZWISCHENBERGER, MD Department ofsurgery, University of Texas Medical Branch, Galveston, TX JOSEPH B. ZWISCHENBERGER, MD Department ofsurgery, University of Texas Medical Branch, Galveston, TX