cardiac anesthesia update charles e. smith, md professor, cwru school of medicine director, ct...
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Cardiac Anesthesia Update
Charles E. Smith, MD
Professor, CWRU School of Medicine
Director, CT Anesthesia
MetroHealth Medical Center
Objectives
1. ASE guidelines- IOTEE
2. ACC/AHA guidelines- Valves
3. Diabetes + hyperglycemia
4. Neurocognitive dysfunction
5. Transfusion
ASE/SCA Guidelines- TEE
• Accelerated growth of IOTEE by anesthesia
• Complexity of US technology
• Conduct of exam
• Interpretation of results
Mathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in Perioperative Echo. JASE + Anesth Analg 2006.
Training + Credentialing
• 2 levels of training: basic + advanced– Basic: within usual practice of anesthesia
– ventricular fct, gross valve lesions
– Advanced: full diagnostic potential of echo
• ASE /SCA/NBE:– Testamur status: exam
– Board certified: 1 yr TEE/ CT fellowship [vs alternate training, 2-4 yr, 300 exams]
• Credentialing: hospital-specific process
Mathews JP et al: JASE + Anesth Analg 2006.
Standard TEE Exam: Guidelines
• Comprehensive: 20 cross-sectional views
– UE level: Asc aorta, MPA, L+R atria, AV+PV
– ME level: L+R atria, L+R ventricles, MV+TV
– TG: L+R ventricles
– Thoracic Aorta: Desc + distal archMathews JP et al: ASE / SCA Recommendations and Guidelines for CQI in Perioperative Echo. JASE + Anesth Analg 2006.
Transgastric view: L+R ventricles
ME views: L+R atria, L+R ventricles, MV+TV
UE views: Asc aorta, MPA, L+R atria, AV+PV, pulm veins
Thoracic Aorta: prox asc aorta, distal arch, descending
ACC/AHA Guidelines• Review of literature by experts• Grade evidence: Level A →C [RCT→opinion]• Recommendations: • Class I: beneficial• Class IIa: generally in favor• Class IIb: less well established• Class III: not useful, potentially harmful?
AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS
Valvular Heart Disease
• Decision to repair/replace valve should be made before surgery
• IOTEE should be used to confirm dx, evaluate repair + evaluate new findings (e.g., moderate AS in setting of CABG, moderate AI if ↓ EF or ↑ LVEDD, aortic root reconstruction if dilated > 5 cm)
AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS
IOTEE Indications
• Class I: valve repair, valve replacement- stentless / autograft (Ross), valve surgery in setting of endocarditis – Level of evidence= B
• Class IIa: all valve surgeries – Level of evidence =C
AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS
Aortic Stenosis
• Check annulus size
• Verify size of aortic root (mismatch? aneurysmal?)
• After bypass: problems w prosthesis: immobility, leaks
AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS
Severe Aortic Stenosis
5.7 m/s
2.0 cm
1.3 m/s 2.0 2 1.3AVA = 3.14 ( ------) X ------ = 0.72 cm2
2 5.7
Severe Aortic RegurgitationT 1/2 = 84 msT 1/2 = 84 ms
Vena Contracta = 11 mmVena Contracta = 11 mm
Mitral Regurgitation
AAC/AHA Task Force on Practice Guidelines. Circulation 2006;114(5)e84-231. Endorsed by SCA, STS
Functional vs structural
After bypass:
Residual MR, MS, SAM
Leaks
Immobility of prosthesis
Severe Mitral Regurgitation
PISA ROAPISA ROA
rrnn=1.1cm=1.1cm
vvnn=59 cm=59 cm
vvpp=450 cm=450 cm
= 2= 2ΠΠ(1.1)(1.1)22(59/450)(59/450)= 0.99 cm= 0.99 cm22
MR QuantitationMild Severe
Jet Area (cm2) <4; <20% LA ≥40% LA
VC (cm) <0.3 >0.6
RV (cc/beat) <30 ≥60
RF (%) <30 ≥50
ERO (cm2) <0.2 ≥0.4
Pulm vein flow
Blunted systolic Systolic reversal
LA size N or dilated 1+ Dilated +++
SAM
Outflow Tract Obstruction
Cardiac Tamponade
RA Diastolic CollapseRA Diastolic Collapse
Type A Dissection: TEE
MHMC #0777095
Type A dissection with flap extending to just superior to RCA ostium
Aortic Dissection:
MHMC #0777095
Demonstration of extension of dissection distally
TEE Distal Thoracic Aorta
Diabetes + Hyperglycemia
neuro injury after focal + global ischemia myocardial infarct size WBC function
• Impaired wound healing risk infection, especially gluc > 250
Reasons for Hyperglycemia
1. insulin requirements w obesity, steroids, stress response to surgery + CPB
2. Excess glucose in pump prime, cardioplegia
3. gluconeogenesis + glycogen breakdown (CPB + stress response)
4. glucose utilization: hypothermia
5. insulin production: pancreatic hypoperfusion
Smith et al: J Cardiothorac Vasc Anesth 2005;19:201
Portland Protocol: Starr Center for Cardiac Surgery. www.starwood.com/research/insulin.html
Diabetes + Deep Sternal Wound Infection
• Hyperglycemia - major role in impaired wound healing + deep sternal wound infection
• Insulin infusion + moderate control – Titrate infusion to gluc 125-175 mg/dl– Start in OR, continue to POD 3
incidence to 0.3%, similar to non-diabetics
N Engl J Med 2001;345:1359-67
Van Den Berge Study
• RCT, 1548 diabetic + non-diabetic SICU patients– 60% had cardiac surgery
• Compared tight vs. conventional glucose control– Tight: 80-110 mg/dl– Conventional: insulin only if glucose > 210; endpoint
180-200
mortality in tight group 4.6 v. 8% infections, dialysis dependent RF, # transfusions
required, need for prolonged mechanical ventilation
How Tight Should Intraop Control Be?
• Furnary- 99: < 200 w insulin infusion ↓ mortality • Van den Berghe- 01: 80-110 w insulin infusion ↓
mortality (vs 180-220)• Furnary- 03: < 150 w insulin infusion ↓ mortality
(vs > 250)• Finney- 03: < 145 • Lazar- 04: < 200 w insulin infusion (vs > 250)• Ouattata- 05: < 200 w insulin infusion
MHMC Study
• Prospective, non-randomized, n=40• Diabetics received continuous infusion regular
insulin, 10 u/m2/h + variable D10W, starting rate 100 ml/h or 9.4 gm gluc/h
• Target glucose 101- 140• Standardized anesthetic, bypass, cardioplegia• POC glucose testing + multiple biochemical
measurements
J Cardiothorac Vasc Anesth 2005;19:201
MHMC Study- Results
• 53% achieved adequate intraop control + 35% had control by end of surgery [total =88%]
• 12% never had control (starting glucose 307-550)
• 25% had hypoglycemia requiring D50 (mean gluc 57, range 33-74, mostly CRF pts)
J Cardiothorac Vasc Anesth 2005;19:201
Smith et al: J Cardiothorac Vasc Anesth 2005;19:201
Current Approach- Diabetics
• Insulin infusion- mix 250 units regular insulin in 250 ml 0.9% saline
• Flush line w 25 ml [insulin binds to tubing]• Starting dose: gluc/100 per hr, continue in ICU• Target glucose 100 - 150• Measure gluc q 1h• Bolus doses can be given IV• Be careful with renal failure +after CPB-
accumulation of insulin + risk hypoglycemia
Cognitive Dysfunction
• Inability to perform normal activities after surgery
• 4 major domains of function1. Verbal memory + language comprehension2. Abstraction, visuo-spatial orientation3. Attention, psychomotor processing speed,
concentration4. Visual memory
Newman MF: SCA Annual Meeting, 2007
Newman MF: N Engl J Med 2001;344:395. Duke, n=261
Cognitive Decline, CABG
0
25
50
75
Discharge 6 weeks 6 months 5 years
%
Social + Economic Costs
• Cognitive dysfunction– ↓ quality of life– ↓ return to work– Altered personality, relationships – ↓ sexual function
Implications• Abrupt decline in cognitive function
heralds:– Loss of independence
– Withdrawal from society
– Death
Seattle Longitudinal Study of AgingBerlin Aging Study
Potential Mechanisms1. High-risk patients2. High-risk surgical procedures3. High-risk anesthetic techniques
Patient Risk Factors
• Predictors: ↓ baseline cognition, deficit at discharge, ↑ age, ↓ yrs of education
• Not predictive: EF, HTN, DM, surgical factors: XC time, CPB time
• Etiology: ASVD of proximal aorta, genetics, anesthetics, pre-existing brain disease
Newman MF: SCA Annual Meeting, 2007
Genetic Factors
• ApolipoproteinE ε-4 hyp: APOE allele- ↓ cognitive outcome
• Single nucleotide polymorphisms: SNPs- modulate inflammation, cell matrix adhesion/interaction, lipid metabolism, vascular reactivity, PEGASUS study:– minor alleles of CRP 1059G/C + SELP
1087G/A associated w POCD
Newman MF: SCA Annual Meeting, 2007
Surgical Factors: Aortic Manipulation
Emboli detected by TEE after unclamping; Barbut D: 1996
Microemboli or SCADs
• Small capillary + arteriolar dilations: 10-70 microns
• “Footprint” of embolic material during CPB– density correlates with
CPB duration after CPB, most gone
by 1 wk
Moody DM: AnnThorac Surg 1995;59:1304
Anesthetic Factors
• May interact w peptides- ↑ oligomerization, amyloid deposition + protein folding
• Low BIS levels were associated w ↑ risk in elderly [cumulative hr BIS < 45]
• Longitudinal studies in progress to assess POCD, delirium + effect of anesthetics
Monk TG: Anesthesiology 2004;A62Newman MF: SCA Annual Meeting, 2007
Hyperthermia + POCD
Anesthetic Risk Factors
• Anesthetic agents affect release of CNS neurotransmitters– acetylcholine, dopamine, norepinephrine
• Effects of anesthetics on cholinergic neurons in the basal forebrain [memory regulation]?
• Effects of aging on choline reserves• Difficult to evaluate effects of anesthesia on long
term memory + cognition
Blood Trx + Blood Conservation
• Cardiac surgery consumes >80% blood products transfused at operation
• Blood products may be assoc w major morbidity + mortality: TRIM, TRALI, infection, death
• Trx practices vary greatly• High risk pts: Elderly, Preop anemia / coagulation
defect, Preop antiplatelet drugs, Redo or complex procedure, Emergency, co-morbidities
Optimal hematocrit-1
• Therapeutic dilemma: Anemia is bad, but so is transfusion
• Anemia– ↑ mortality– ↓ quality of life– Jeopardizes organ viability, especially in
presence of limited vasodilator reserve
Gravlee GP. SCA Annual Meeting, 2007
Optimal hematocrit- 2
• Therapeutic dilemma, cont’d
• Transfusion is bad– ↑ mortality + morbidity – immediate ↑ O2 transport is limited– TRIM, ↑ inflammation [role of leukoreduction],
TRALI– Viral/bacteria/parasites
Gravlee GP. SCA Annual Meeting, 2007
Transfusion Avoidance Techniques
• High yield: – ↑ preop Hct
– ↓ CPB priming volume
– RAP: retrograde autologous priming
– Effective intraop cell saver
– Ultrafiltration
• Lower yield: – Antifibrinolytics
– Protamine dosing
Gravlee GP. SCA Annual Meeting, 2007
Retrograde Autologous Priming
• Replace crystalloid prime w pts own blood
• Limits degree of HD
• Fewer pts reach critical trx trigger
Murphy GS. SCA Annual Meeting, 2007
Retrograde Autologous Priming- 2
• How to do this?– Heparinize, place arterial cannula, allow pts
blood to flow backwards + displace crystalloid [perfusionist: “rapping”]
– Maintain SBP > 100 using small doses of PHE (80-400 ug). Turn off vasodilators
– Primary risk- hypotension
Murphy GS. SCA Annual Meeting, 2007
Retrograde Autologous Priming-3
• What is the data?1. Rosengart, 98: ↑ Hct, ↓ RBC trx
2. Shapira, 98: ↑ Hct, ↓ RBC trx
3. Balachandran, 02: ↑ Hct, ↓ RBC trx
4. Eising, 03: ↑ COP, ↓ extravascular lung water+ earlier time to mobilization
5. Murphy, 04 + 06: ↑ Hct, trend to ↓ mortality, delirium, afib, + vent > 24 hr
Cell Salvage- 1• After bypass: transfer blood from prime to cell
saver bowl for washing• Can also collect shed blood for washing• Hct of processed blood: 60%, 2-3 DPG but
processing eliminates platelets +factors• Savings: ~ 1-2 units allogeneic blood
Cell Salvage- 2
• Requirements: CPB– Anticoagulated blood
– Centrifuge bowl + tubing
• Shed Blood– Aspiration assembly
– Reservoir
– Tubing
Cell Salvage- 3 – Few disadvantages in heart room because have:– Dedicated perfusionist + heparinized pump
prime and– Wound is clean– Risks:– Air embolism w infusion under pressure– DIC if use “cell saver suction” for
thrombogenic material
Ultrafiltration
• Remove water + low MW substances under a hydrostatic pressure gradient
• Induces hemoconcentration: ↓ total body water accumulation + inflammatory mediators
• ↓ bleeding, blood trx, morbidity + mortality
• Initially validated in peds, but also adults
Tassani 99; Kiziltepe 01; Leyh 01; Luciani 01;
Reasons Why Trx Avoidance Techniques Fail
• Had PVCs, PACS
• Had to start vasopressors/ inotropes
• Looked a little oozy
• BP a little low
• CI was a little low
• Pt was old
• Pt was high risk
Gravlee GP. SCA Annual Meeting, 2007
Summary
1. IOTEE: routinely use for valves, often helpful for CABG
2. Hyperglycemia: treated w insulin infusion, target glucose < 150, especially if diabetic
3. Cognitive dysfunction: high risk pts + surgery; genetics + anesthetic factors play a role
4. Multimodal blood conservation techniques work well: RAP, cell saver, ultrafiltration, amicar, protamine dosing