Академический Документы
Профессиональный Документы
Культура Документы
was i n t u b a t e d a n d ventilation controlled with oxygen rate were m a d e by varying the s p e e d of the centrifugal
a n d isoflurane, 0.25% e n d - t i d a l concentration. Femoral p u m p . Arterial b l o o d gases were m e a s u r e d at 37°C,
venous a n d arterial catheters were inserted. Fentanyl i n d e p e n d e n t of b o d y t e m p e r a t u r e (alpha-stat blood gas
(10 /~g/kg) was a d m i n i s t e r e d as an intravenous bolus, management).
followed by a continuous infusion of 2 t L g ' k g 1. h - l . Cerebral blood flow was m e a s u r e d before CPB a n d
A d d i t i o n a l boluses of fentanyl were a d m i n i s t e r e d w h e n during each of the four h e m o d y n a m i c conditions during
indicated. M i d a z o l a m was a d m i n i s t e r e d intravenously at CPB. For each determination, 700 /~Ci of xenon 133 in
a continuous rate of 0.03 m g - kg ~ • h 1. V e c u r o n i u m was 0.8 mL of saline solution was injected into the c o m m o n
a d m i n i s t e r e d intravenously for n e u r o m u s c u l a r blockade. carotid artery a n d flushed with 2 mL of normal saline
Electrocardiogram, arterial b l o o d pressure, a n d tym- solution [11]. Single collimators directed at the superior
panic, esophageal, a n d rectal t e m p e r a t u r e were r e c o r d e d parietal cortex detected radioactive washout with a Novo
continuously. End-tidal carbon dioxide tension ( p C O 2 ) C e r e b r o g r a p h 10a (Novo Diagnostics Systems, Bags-
a n d isoflurane concentration were m e a s u r e d b y infrared vaard, Denmark). Additional detectors were placed over
analysis (Datex CapnoMac, Helsinki, Finland). A n 18- the aortic cannula to confirm the absence of significant
gauge n e e d l e was inserted into a l u m b a r intervertebral recirculation of isotope. Clearance was r e c o r d e d for at
space until cerebrospinal fluid was aspirated, after which least 12 minutes, and CBF was d e t e r m i n e d by the initial
a thin Teflon catheter was t h r e a d e d into the subarach- slope, as described by Olesen a n d associates [12], fitting
noid space. a m o n o e x p o n e n t i a l decay curve to activity recorded from
After m e d i a n sternotomy, the right c o m m o n carotid the scalp for 60 seconds b e g i n n i n g 3 seconds after attain-
artery a n d its internal a n d external b r a n c h e s were ex- ing its p e a k value [13]. S p a h n and colleagues [14] have
p o s e d surgically. A 19-mm, 24-gauge Teflon catheter v a l i d a t e d the technique of washout of arterial 133Xe
(Angiocath; Becton Dickinson, Sandy, UT) was inserted d u r i n g CPB by comparison with the m e t h o d of Kety-
into the c o m m o n carotid artery, a n d p r e s s u r e s were Schmidt. Values for the blood-tissue partition coefficient
transduced. The ipsilateral external b r a n c h e s of the ca- for 133Xe were corrected for hematocrit and t e m p e r a t u r e
rotid artery were occluded t e m p o r a r i l y d u r i n g m e a s u r e - [15]. Arterial and jugular venous samples were d r a w n
m e n t of CBF. A thin catheter was inserted into the right a n d analyzed at 37°C in a blood-gas analyzer a n d CO-
jugular vein a n d a d v a n c e d to the jugular bulb. Oximeter (Instrumentation Laboratory, Lexington, MA).
The s u p e r i o r vena cava, inferior vena cava, a n d aorta Arterial a n d venous oxygen content were calculated by
were cannulated, a n d c a r d i o p u l m o n a r y b y p a s s was ini- s t a n d a r d formulas [16]. Cerebral metabolic rate for 0 2
tiated. The b y p a s s circuit consisted of a Medtronic- was calculated as the product of CBF and the arterial-
M i n i m a x oxygenator (Medtronic, Minneapolis, MN), a venous oxygen content difference. Values for cerebral
BP-50 Centrifugal Bio-Pump (Medtronic), a n d 1/4-inch b l o o d flow, arterial venous 02 content difference, cere-
tubing. The system was p r i m e d with 175 mL of Nor- bral oxygen metabolic rate, arterial blood pressure, he-
mosol-R a n d 175 mL of 6% H e s p a n (DuPont, W i l m i n g - matocrit, arterial carbon dioxide tension and t e m p e r a t u r e
ton, DE). All surgical b l o o d loss was collected a n d pro- were c o m p a r e d by r e p e a t e d m e a s u r e s analysis of vari-
cessed with a Cell Saver I (Haemonetics, Braintree, MA) ance. Multiple comparisons were m a d e with Fisher's
a n d then a d d e d to the b y p a s s circuit. H e p a r i n was protected least significant difference testing. A value of p
a d m i n i s t e r e d to maintain activated clotting time greater less than 0.05 was considered significant.
than 480 seconds.
Nonpulsatile c a r d i o p u l m o n a r y b y p a s s was initiated at
a flow rate of 2.25 L . rain ~ • m 2, a n d b a b o o n s were then
Results
cooled until t y m p a n i c m e m b r a n e t e m p e r a t u r e d e c r e a s e d The p r e d e t e r m i n e d h e m o d y n a m i c c o n d i t i o n s w e r e
to 28°C. T y m p a n i c m e m b r a n e t e m p e r a t u r e has b e e n achieved in all baboons. In 3 b a b o o n s nitroprusside was
shown to a p p r o x i m a t e brain t e m p e r a t u r e reliably [10]. At a d m i n i s t e r e d after spinal block to reduce m e a n arterial
that point, CPB p u m p flow rate a n d arterial b l o o d pres- blood pressure to less than 30 m m Hg during full-flow
sure were altered in varied s e q u e n c e to each of four bypass. In I animal the full-flow p u m p rate was set at 2.1
conditions: (1) full flow (2.25 L" min - 1 . m 2) a n d m e a n L- rain 1. m- 2, which was the m a x i m u m rate achievable
arterial p r e s s u r e of 60 m m Hg, (2) full flow (2.25 without volume loading that w o u l d have resulted in
L- rain 1. m - 2 ) at arterial p r e s s u r e of 20 m m Hg, (3) low h e m o d i l u t i o n c o m p a r e d with previous bypass condi-
flow (0.75 L- min 1 . m - 2 ) at arterial pressure of 60 m m Hg, tions.
and (4) low flow at arterial blood pressure of 20 m m Hg. Temperature, arterial pCO2, arterial oxygen tension,
Arterial p r e s s u r e was m e a s u r e d as m e a n p r e s s u r e trans- pH, a n d hematocrit were similar for all four h e m o d y -
d u c e d from the c o m m o n carotid artery catheter. Reduc- namic conditions during CPB (Table 1). Cerebral blood
tions in arterial b l o o d p r e s s u r e were achieved by sub- flow was greater at high blood pressure during both
a r a c h n o i d injection of lidocaine 2% solution. If a dose low-flow and full-flow CPB w h e n c o m p a r e d with low
sufficient to p r o d u c e spinal block d i d not result in the blood pressure at low-flow or full-flow CPB (34.0 _+ 8.3
target b l o o d pressure, n i t r o p r u s s i d e was a d m i n i s t e r e d as a n d 27.6 ± 9.9 v e r s u s 14.1 ± 3.7 a n d 16.8 ± 3.7
an intravenous infusion. Elevations of arterial blood m L - m i n - l . 1 0 0 g 1, respectively; p ~ 0.01) (Fig 1).
p r e s s u r e were achieved b y variable tension on a snare Changes in p u m p flow rate alone without changes in
encircling the d e s c e n d i n g aorta. C h a n g e s in b y p a s s flow m e a n arterial b l o o d pressure resulted in no change in
A n n Thorac S u r g S C H W A R T Z ET AL 167
1995;60:165-70 CEREBRAL B L O O D F L O W D U R I N G BYPASS
a Values are m e a n -+ s t a n d a r d deviation (n = 7); arterial blood gas analyses w e r e p e r f o r m e d at 37°C. b p < 0.01 c o m p a r e d with others, c p < 0.05
c o m p a r e d with others, a p < 0.05 c o m p a r e d with full-flow high BP, full-flow low BP, low-flow low BP.
A-VO2 = cerebral a r t e r i o v e n o u s oxygen content difference; BP arterial blood pressure; CPB = c a r d i o p u l m o n a r y bypass; CBF = cerebral
blood flow; C M R O 2 = cerebral oxygen metabolic rate; MABP = m e a n arterial blood pressure; p C O 2 ~ carbon dioxide tension; pO 2 =
oxygen tension.
1
n o t significantly different, b l o o d p r e s s u r e s w e r e n o t c o n -
o
_o t r o l l e d at c o n s t a n t values.
al V a n d e r L i n d e n a n d c o l l e a g u e s [19] also s u p p o r t e d t h e
10. c o n c l u s i o n t h a t p u m p flow rate a n d n o t p e r f u s i o n p r e s -
,1o s u r e d e t e r m i n e s c e r e b r a l b l o o d flow. T h e y r e p o r t e d t h a t
m i d d l e c e r e b r a l artery b l o o d flow velocity, m e a s u r e d by
0 t r a n s c r a n i a l D o p p l e r e c h o g r a p h y , in c h i l d r e n d u r i n g
0
0 20 30 40 50 60 70 d e e p h y p o t h e r m i c l o w - f l o w CPB c o r r e l a t e d w i t h p u m p
flow rate (r = 0.73) b u t n o t c e r e b r a l p e r f u s i o n p r e s s u r e
Mean Arterial Pressure (mm Hg) (r = 0.14).
Fig 1. Cerebral blood flow at low and high blood pressure during In a n o t h e r clinical study, M u r k i n a n d c o - w o r k e r s [20]
low-flow (open bars) and full-flow (solid bars) cardiopulmonary m e a s u r e d CBF b y 133Xe c l e a r a n c e in 38 cardiac s u r g e r y
bypass. (*Significantly different than at low blood pressure, p < patients. D u r i n g CPB, in w h i c h total flow rate w a s m a i n -
O.01.) t a i n e d b e t w e e n 2.0 a n d 2.5 L . m i n 1. m 2 m e a n c e r e b r a l
168 SCHWARTZET AL Ann Thorac Surg
CEREBRALBLOOD FLOW DURING BYPASS 1995;60:165-70
4. Javid H, Tufo HM, Najafi H, Dye WS, Hunter JA, Julian OC. during cardiopulmonary bypass. J Cereb Blood Flow Metab
Neurological abnormalities following open-heart surgery. J 1992;12:155-61.
Thorac Cardiovasc Surg 1969;58:502-9. 15. Chen RYZ, Fan F-C, Kim S, Jan K-M, Usami S, Chien S.
5. Lee WH Jr, Brady MP, Rowe JM, Miller WC Jr. Effects of Tissue-blood partition coefficient for xenon: temperature
extracorporeal circulation upon behavior, personality, and and hematocrit dependence. J Appl Physiol 1980;49:178-83.
brain function: Part II. Hemodynamic, metabolic, and psy- 16. Prough DS, Rogers AT, Stump DA, et al. Cerebral blood flow
chometric correlations. Ann Surg 1971;173:1013-23. decreases with time whereas cerebral oxygen consumption
6. Rogers AT, Stump DA, Gravlee GP, et al. Response of remains stable during hypothermic cardiopulmonary bypass
cerebral blood flow to phenylephrine infusion during hypo- in humans. Anesth Analg 1991;72:161-8.
thermic cardiopulmonary bypass: influence of Paco2 man- 17. Govier AV, Reves JG, McKay RD, et al. Factors and their
agement. Anesthesiology 1988;69:547-51. influence on regional cerebral blood flow during nonpulsa-
7. Rogers AT, Prough DS, Stump DA, et al. Cerebral blood flow tile cardiopulmonary bypass. Ann Thorac Surg 1984;38:592-
does not change following sodium nitroprusside infusion 600.
during hypothermic cardiopulmonary bypass. Anesth Analg 18. Soma Y, Hirotani T, Yozu R, et al. A clinical study of cerebral
1989;68:122-6. circulation during extracorporeal circulation. J Thorac Car-
8. Rogers AT, Prough DS, Roy RC, et al. Cerebrovascular and diovasc Surg 1989;97:187-93.
cerebral metabolic effects of alterations in perfusion flow 19. Van der Linden J, Priddy R, Ekroth R, et al. Cerebral
rate during hypothermic cardiopulmonary bypass in man. J perfusion and metabolism during profound hypothermia in
Thorac Cardiovasc Surg 1992;103:363-8. children: a study of middle cerebral artery ultrasonic vari-
9. Newman MF, Croughwell ND, Blumenthal JA, et al. Effect of ables and cerebral extraction of oxygen. J Thorac Cardiovasc
aging on cerebral autoregulation during cardiopulmonary
Surg 1991;102:103-14.
bypass: association with postoperative cognitive dysfunc-
20. Murkin JM, Farrar JK, Tweed WA, McKenzie FN, Guiraudon
tion. Circulation 1994;90 (Suppl 2):243-9.
G. Cerebral autoregulation and flow/metabolism coupling
10. Stone JG, Young WL, Smith CR, Solomon RA, Ostapkovich
N, Wang A. Do temperatures recorded at standard monitor- during cardiopulmonary bypass: the influence of Paco 2.
ing sites reflect actual brain temperature during deep hypo- Anesth Analg 1987;66:825-32.
thermia? [Abstract]. Anesthesiology 1991;75:A483. 21. Fox LS, Blackstone EH, KirklinJW, Bishop SP, Bergdahl LAL,
11. Schwartz AE, Kaplon RJ, Young WL, Sistino JJ, Kwiatkowski Bradley EL. Relationship of brain blood flow and oxygen
P, Michler RE. Cerebral blood flow during low-flow hypo- consumption to perfusion flow rate during profoundly hy-
thermic cardiopulmonary bypass in baboons. Anesthesiol- pothermic cardiopulmonary bypass: an experimental study.
ogy 1994;81:959-64. J Thorac Cardiovasc Surg 1984;87:658-64.
12. Olesen J, Paulson OB, Lassen NA. Regional cerebral blood 22. Tanaka J, Shiki K, Asou T, Yasui H, Tokunaga K. Cerebral
flow in man determined by the initial slope of the clearance autoregulation during deep hypothermic non-pulsatile car-
of intra-arterially injected 133Xe:theory of the method, nor- diopulmonary bypass with selective cerebral perfusion in
mal values, error of measurement, correction for remaining dogs. J Thorac Cardiovasc Surg 1988;95:124-32.
radioactivity, relation to other flow parameters and response 23. Hindman BJ, Funatsu N, Harrington J, et al. Differences in
to Paco 2 changes. Stroke 1971;2:519-40. cerebral blood flow between alpha-stat and pH-stat man-
13. Young WL, Prohovnik I, Schroeder T, Correll JW, Ostap- agement are eliminated during period of decreased systemic
kovich N. Intraoperative 133Xecerebral blood flow measure- flow and pressure: a study during cardiopulmonary bypass
ments by intravenous v e r s u s intracarotid methods. Anesthe- in rabbits. Anesthesiology 1991;74:1096-102.
siology 1990;73:637-43. 24. Michenfelder JD. Cerebral blood flow and metabolism. In:
14. Spahn DR, Quill TJ, Hu W-C, et al. Validation of 133Xe Cucchiara RF, Michenfelder JD, ed. Clinical neuroanesthe-
clearance as a cerebral blood flow measurement technique sia. New York: Churchill Livingstone, 1990:28-9.
INVITED COMMENTARY
Case Reports I, Clinical Studies in Extracorporeal Circulation As for the format, the case reports vary widely in terms of
Edited by Trudy B. Stafford, John M. Toomasian, and Mark Kurusz organization and presentation. In some instances they are diffi-
Houston, PREF Press, 1994 cult to follow. There are no illustrations provided, although in
250 pp, not illustrated, $50.00
many cases this would be extremely helpful in terms of under-
Reviewed by Edward Y. Sako, MD, PhD standing the actual apparatus set up. Although the book does
give some indication of the increasing breadth and application
This book represents a compilation of case reports presented at of extracorporeal circulation technology, the content and focus
meetings of the American Society of Extracorporeal Technology clearly are aimed at perfusionists. There is minimal background
and the newly formed Perfusion Research and Education Foun- and detail regarding the actual surgical procedures. The result is
dation in 1992 and 1993, respectively. Each chapter represents a to limit the interest and usefulness the book may have for the
separate case report, including a presentation as was given at practicing cardiothoracic surgeon. Certainly, an extremely good
the meeting, followed by a verbatim transcript of the discussion understanding of extracorporeal circulation technology is nec-
that followed. The chapters themselves are organized into sec- essary, but this probably is better served by the more standard
tions entitled Patient Pathophysiology, Hematogic Aspects, Me- reference texts.
chanical Problems, Extracorporeal Membrane Oxygenation,
Ventricular Assist, Nonroutine Applications, Cardiopulmonary
Support, and Legal Considerations. San AntoniG Texas