Authors/Task Force Members: Alexander Wahba a,b,*,† (Chairperson) (Norway), Milan Milojevic c,d,*,† (Serbia, Netherlands), Christa Boer e (Netherlands), Filip M.J.J. De Somer f (Belgium), Tomas Gudbjartsson g (Iceland), Jenny van den Goor h (Netherlands), Timothy J. Jones i (UK), Vladimir Lomivorotov j (Russia), Frank Merkle k (Germany), Marco Ranucci l (Italy), Gudrun Kunst m,*,† (Chairperson) (UK) and Luc Puis n,*,† (Chairperson) (Belgium)

/pdf/2019-eacts-eacta-ebcp-guidelines-on-cardiopulmonary-bypass-1cd2vlqmtd.pdf

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery.

Disclaimer 2019: The EACTS/EACTA/EBCP Guidelines represent the views of the EACTS, the EACTA and EBCP and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating. The EACTS, EACTA and EBCP are not responsible in the event of any contradiction, discrepancy and/or ambiguity between the EACTS, EACTA and EBCP Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the EACTS, EACTA and EBCP Guidelines fully into account when exercising their clinical judgement as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the EACTS, EACTA and EBCP Guidelines do not, in any way whatsoever, override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and, where appropriate and/or necessary, in consultation with that patient and the patient’s care provider. Nor do the EACTS, EACTA and EBCP Guidelines exempt health professionals from giving full and careful consideration to the relevant official, updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. The article has been co-published with permission in the British Journal of Anaesthesia, the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery.

When performing coronary artery bypass grafting (CABG), several decisions need to be made: 

1.

The coronary vessel to be grafted.




2.

The choice of conduit (left internal mammary artery, bilateral internal mammary artery, saphenous vein, radial artery).




3.

The site of proximal of anastomosis (aorta, T or Y grafts onto another conduit).




4.

The approach (on cardiopulmonary bypass, off pump)

Coronary Artery Bypass Grafting

The objective of this study is to investigate the impact of every component of extracorporeal life support (ECLS) circuit on hemodynamic energy transmission in terms of energy equivalent pressure (EEP), total hemodynamic energy (THE), and surplus hemodynamic energy (SHE) under nonpulsatile and pulsatile modes in a novel ECLS system. The ECLS circuit consisted of i-cor diagonal pump and console (Xenios AG, Heilbronn, Germany), an iLA membrane ventilator (Xenios AG), an 18 Fr femoral arterial cannula, a 23/25 Fr femoral venous cannula, and 3/8-in ID arterial and venous tubing. The circuit was primed with lactated Ringer's solution and human whole blood (hematocrit 33%). All trials were conducted under room temperature at the flow rates of 1–4 L/min (1 L/min increments). The pulsatile flow settings were set at pulsatile frequency of 75 beats per minute and differential speed values of 1000–4000 rpm (1000 rpm increments). Flow and pressure data were collected using a custom-based data acquisition system. EEP was significantly higher than mean arterial pressure in all experimental conditions under pulsatile flow (P < 0.01). THE was also increased under pulsatile flow compared with the nonpulsatile flow (P < 0.01). Under pulsatile flow conditions, SHE was significantly higher and increased differential rpm resulted in significantly higher SHE (P < 0.01). There was no SHE generated under nonpulsatile flow. Energy loss depending on the circuit components was almost similar in both perfusion modes at all different flow rates. The pressure drops across the oxygenator were 3.8–24.9 mm Hg, and the pressure drops across the arterial cannula were 19.3–172.6 mm Hg at the flow rates of 1–4 L/min. Depending on the pulsatility setting, i-cor ECLS system generates physiological quality pulsatile flow without increasing the mean circuit pressure. The iLA membrane ventilator is a low-resistance oxygenator, and allows more hemodynamic energy to be delivered to the patient under pulsatile mode. The 18 Fr femoral arterial cannula has acceptable pressure drops under nonpulsatile and pulsatile modes. Further in vivo studies are warranted to confirm these results.

In Vitro Hemodynamic Evaluation of a Novel Pulsatile Extracorporeal Life Support System: Impact of Perfusion Modes and Circuit Components on Energy Loss

The aim of this study was to determine whether pulsatile or nonpulsatile perfusion had a greater effect on pulmonary dysfunction in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before April 13, 2013. A meta-analysis was conducted on the effects of pulsatile perfusion on postoperative pulmonary function, intubation time, and the lengths of intensive care unit (ICU) and hospital stays. Eight studies involving 474 patients who received pulsatile perfusion and 496 patients who received nonpulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta-analysis. Patients receiving pulsatile perfusion had a significantly greater PaO2 /FiO2 ratio 24 h and 48 h post-operation (P < 0.00001, both) and significantly lower chest radiograph scores at 24 h and 48 h post-operation (P < 0.00001 and P = 0.001, respectively) compared with patients receiving nonpulsatile perfusion. The incidence of noninvasive ventilation for acute respiratory insufficiency was significantly lower (P < 0.00001), and intubation time and ICU and hospital stays were shorter (P = 0.004, P < 0.00001, and P < 0.00001, respectively) in patients receiving pulsatile perfusion during CPB compared with patients receiving nonpulsatile perfusion. In conclusion, our meta-analysis suggests that the use of pulsatile flow during CPB results in better postoperative pulmonary function and shorter ICU and hospital stays.

A Meta‐Analysis of Pulmonary Function With Pulsatile Perfusion in Cardiac Surgery

Nonpulsatile blood pumps are mainly used in extracorporeal life support systems. Although pulsating blood flow is known to be physiological, a pulsatile pump is not commonly applied in a circuit with a membrane oxygenator because of damage to the blood cells. The hypothesis that the placement of a pressure-relieving compliance chamber in a circuit might reduce blood cell trauma was tested. An extracorporeal life support circuit was constructed in an acute lung injury model of dogs by oleic acid infusion. The animals were divided into three groups. In group I (n = 6) a nonpulsatile centrifugal pump was used as a control. In group II (n = 4) a single-pulsatile pump was used, and in group III (n = 6) a single-pulsatile pump equipped with a compliance chamber was used. Pump flow was maintained at 1.8-2.0 L/min for 2 h. Hemodynamics and blood gas analyses indicated that the pulsatile groups II and III had better results than the nonpulsatile group I. The plasma-free hemoglobin level, which indicates blood cell trauma, was the lowest in group I and the highest in group II but was significantly decreased in group III. A pressure-relieving compliance chamber could significantly reduce high circuit pressures and blood cell trauma.

Application of a pressure-relieving air compliance chamber in a single-pulsatile extracorporeal life support system: an experimental study.

A 37-year-old female patient (height, 161.5 cm; weight, 49.5 kg) was scheduled to undergo robot-assisted total gastrectomy for early gastric cancer. Her past medical history and physical examination were unremarkable. In the operation room, the patient was induced with 2.0-3.0 vol% sevoflurane after receiving 110 mg of propofol by intravenous injection. Tracheal intubation using a 7.0 mm internal diameter endotracheal tube was performed without difficulty 3 minutes after the patient received 10 mg of cisatracurium by intravenous injection. A 16 French silicone nasogastric tube (Levin tube, Yushin Medical, Bucheon, Korea) was inserted through the left nostril with some difficulty. The nasogastric tube was passed to 55 cm and was noted to drain a small amount of turbid fluid. Twenty minutes after induction of anesthesia, a skin incision was made. The duodenum was resected, the esophagus was clamped and stomach was removed. One and a half hours later, the nasogastric tube was removed. The surgeon made a request to insert the OrVil TM transorally and said that the anvil head should be passed as the convex surface of the anvil head is directed at the posterior wall of the esophagus. At first, the OrVil

http://ekja.org/upload/pdf/kjae-63-284.pdf

Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy.

Transient Polyuria during Sevoflurane Anesthesia

Recently, the use of laparoscopy-assisted distal gastrectomy (LADG) has increased in patients with gastric cancer. The insufflation of CO2 and operative position may cause physiologic changes in the patient and complications during the procedure of LADG. The complete understanding of several complications that might occur during LADG is therefore important for appropriate management of the anesthesia. We experienced a case of CO 2 pneumothorax due to iatrogenic diaphragmatic injury which occurred during a LADG. Herein we report this case with a review of the literature.

Occurrence of iatrogenic pneumothorax during laparoscopy-assisted distal gastrectomy

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