Dirk Himpe MD PhD MHE EDIC

ZNA Middelheim General Hospital

Antwerp Belgium

Prime Time !Fluids during Cardiac

Surgery

Outcome ?

Engoren et al. Ann Thorac Surg 2002; 74:1 180-6

Koch CC et al. Ann Thorac Surg 2006; 81:1650-7.

Carson J, Lancet 1996, 348: 1055-60

Factors: .preoperative anemia,.perioperative RBC transfusions .postoperative re-exploration

Lowell, CCM 1990 18:728, 1990

< 10 %

10-20 %> 20 %

0 20

40

60

80

100Mortality

%

Weight gain after cardiac surgery

Red blood cell

Platelet

Polymer

INFLAMMATION

Blood 1994; 4:3175-81

phases: pre-pump-post-ICU

targets: interrelated

.transfusion/anemia .acid-base status .fluid balance (colloids) .inflammation (SIRS)

OR

bloodvolume + priming solution

Htc: 45 % 20-25 % start CPB

(few minutes)

The “pump”: onset of CPB = massive fluid load

Issue:

Type of Fluid = Determinant of Outcome ?!

(direct or indirect)

Blood-loss

Fluid-Balance

James A. Russel. JCTVA 2004, 18: 429-437

Himpe D, Act Anaesth Belg, 54:207-15, 2003

Acid-Base

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)

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)

damage tofigured blood elements(foreign surfaces, air, pericardium & pumps)

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

CPB

electrically

charged

Himpe D, Act Anaesth Belg, 54:207-15, 2003

Mortality

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

Himpe D, Act Anaesth Belg, 54:207-15, 2003

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;