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Surgery: Management Open-Heart
Surgery: Management Open-Heart
lents per liter as bicarbonate in the patient's that the pH should be reduced during hy-
arterial blood, it should be corrected with pothermia; to achieve this he advocated the
sodium bicarbonate solution intravenously in use of 0.3 N hydrochloric acid. When carbon
sufficient amount to reduce the base deficit to dioxide is used instead of a hydrochloric acid
zero. It is easier to maintain good acid-base drip to control the pH of the blood in. the
status throughout the bypass period if the pump oxygenator and with a pH-temperature
patient is not in base deficit when bypass is scale similar to that suggested by Edmark
started. (fig. 1), it has been possible to avoid the oc-
currence of base deficit or metabolic acidosis
Bypass Phase during hypothermic bypass.) The pH is re-
Gross acid-base changes may occur during duced by 0.0147 of a pH unit for each degree
bypass. If considerable imbalance does de- Centigrade below 37. Using this technic, we
velop and remain uncorrected at the end of have been able to prevent other phenomena
the bypass period, this may add markedly to usually associated with hypothermia. For ex-
the stress of the phase after bypass and result ample, ventricular fibrillation and cessation of
in increased postoperative morbidity. Dis- spontaneous respiratory effort have been com-
turbances occurring during bypass have been monly observed when the temperature is low-
greatly lessened since the introduction of high- ered below about 30C.; with pH control,
flow perfusion technics. Nevertheless, good however, spontaneous respiratory effort con-
acid-base maintenance still requires constant tinues at temperatures below 25C., and
attention. If gross respiratory alkalosis is per- ventricular fibrillation usually does not occur
mitted during bypass, it may result in a unless there is interference with coronary
progressive base deficit. There is evidence that blood flow or severe cardiac manipulation by
respiratory alkalosis produces a shift in the the surgeon. If ventricular fibrillation is re-
(.JH ida/ion, Vo/lue XXlX, MJarc b 1964
GCID-BASE M1ANAGEMEN 45NT
459
This does not include the CO,, reaching the oxygenator via the coronary suction when tie
surgical field is being flooded with 100 per cent CO, to prevent air embolism.
is advisable, for it
ensures that the heart will matic. Diaphragmatic breathing exercises be-
not be depressed by metabolic acidosis upon fore operation may greatly contribute to the
resumption of the normal circulation. adequacy of the respiration in the recovery
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hyperventilation should be avoided in the interferes with oxygenation of the tissue cells
recovery room just as during the other phases may cause metabolic acidosis.
and for the same reasons. Some means of Poor oxygenation of the blood in the lungs
humidification must be provided or plugs of will result in arterial oxygen desaturation and
accumulated mucus may inspissate and lead to consequently there will be less oxygen avail-
further atelectasis. able to the tissues. The cellular hypoxia so
If atelectasis is not widespread, the periodic produced results in some degree of anerobic
use of a respirator for a few minutes of in- metabolism, which causes metabolic acidosis.
termittent positive-pressure breathing may be This poor oxygenation may arise from several
sufficient. In some cases, it may be necessary causes. There may be a low oxygen concentra-
to use the respirator continuously to avoid tion in the respired gases or ventilation may
respiratory acidosis. Tracheotomy is often be insufficient. Atelectasis hinders oxygenation
necessary in these patients. If such trouble is of the blood, since blood perfusing unven-
especially anticipated, it may be advisable to tilated areas of lung cannot be oxygenated.
perform the tracheotomy several days prior Shift in the hemoglobin oxygen dissociation
to the major surgery, to avoid problems of in- curve to the left, known to occur with
fection or bleeding or the necessity of this respiratory alkalosisj9 may lead to tissue an-
procedure as an emergency under adverse con- oxia, since under these conditions oxygen is
ditions. not liberated as readily by the hemoglobin.
Even in the absence of respiratory acidosis, This is another reason for avoidance of gross
mechanical ventilation may be indicated in hyperventilation following bypass.
some cases. It is sometimes possible for a If the blood is being adequately oxygenated
patient spontaneously to maintain a nearly in the lungs and the oxygen is readily supplied
normal pCO2 but at great cost in oxygen by the blood to the tissue cells, the occurrence
consumption, due to the work of respiration. of metabolic acidosis must then be due to
In the presence of low cardiac output and cellular hypoxia from poor perfusion of tissue,
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fusions, accumulation of citrate may result in that this portion enters the cells 16 where it
low cardiac output which may improve after may act as an intracellular buffer. THAM also
intravenous administration of calcium glu- has an osmotic diuretic action that helps to
conate or calcium chloride. maintain good urinary output.
When correcting metabolic acidosis, we
Correction of Metabolic Acidosis give sodium bicarbonate at first up to a total
It has been well established that metabolic dosage of about 2 mEq./Kg. If this is not
acidosis will cause depression of cardiac func- sufficient to establish and maintain good acid-
tion.14 Since a low cardiac output results in base status, buffer administration is continued
further metabolic acidosis, a vicious circle with 0.3-molar THAM. If possible, the THAM
may be established that must be broken if the is given through a catheter placed into a
patient is to survive. "Flogging" the already central venous stream, as this substance has
failing heart with cardiac stimulants and ad- been shown to cause local tissue necrosis if it
ministering large amounts of vasopressors are extravasates into the subcutaneous tissue.
ill advised and may actually cause the demise The correction of metabolic acidosis with
of the patient because of further vasoconstric- intravenous buffers should not be undertaken
tion and thus more metabolic acidosis. Fur- in haphazard fashion. Administration of a
thermore, vasopressors are less effective in the fixed amount of sodium bicarbonate in a
presence of acidosis,l4 15 and ultimately may dosage according to the weight of the patient
fail to maintain adequate arterial pressure. may produce some temporary improvement
It is more rational to correct the metabolic but is usually inadequate if the cause of the
acidosis and continue to maintain good acid-
base status by the administration of drugs that
will buffer the acid metabolites in thle blood * Talatrol-Abbott Laboratories.
Circulation, Volurme XXIX, March 1964
464 CARSON ET AL.
metabolic acidosis is still active. On the other really considered inoperable but occasionally
hand, when acid-base status is rapidly and re- in a borderline situation surgery is under-
peatedly assessed through blood-gas analyses, taken. After the corrective surgery with elim-
it is then possible to titrate the buffers intra- ination of the shunt, the load of forcing its
venously according to their effect and by this total output through the lungs in the face of
means not only to correct the metabolic aci- the high pulmonary vascular resistance may
dosis but also to maintain good acid-base prove to be too much for the right ventricle.
status as long as is necessary with buffers; i.e., This results in right heart failure and respira-
until the cardiac output is sufficient to main- tory acidosis. Consequent low output from the
tain good circulation. In this way, the heart no left side of the heart results in poor tissue
longer has to cope with the depressant effect perfusion and metabolic acidosis. If the pul-
of the metabolic acidosis and has a better monary vascular resistance is not too high,
chance to recover. The blood gas analyses are then "buying of time" through correction- of
made as often as necessary to maintain good the acidosis with buffers plus medical treat-
control. The buffer is infused by intravenous ment of the heart failure, e.g., by rapid dig-
drip in sufficient amount to reduce the base italization, may be sufficient. If this is to no
deficit to zero, and administration is then avail then surgical re-establishment of the
continued at a rate that will hold the arterial shunt may be necessary to ease the load on
blood at about zero base deficit, the drip the right heart. Even though this is a retro-
being slowed if there is a tendency toward grade step in the operation, it may be the
base excess and increased if base deficit should only way to prevent early death of the patient
recur. It may be necessary to continue ad- from acute right heart failure. Here, once
ministration in this way for several hours and more, repeated blood gas analysis provides
the total dosage of buffer may be quite large. rapid assessment of developing changes and
So far no ill effects have been seen by us with allows interpretations and decisions that facili-
this titration method of administration. Com- tate management.
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but may in fact represent a relative respira- proved postoperative morbidity wlhen optimal
acid-base status is maintained throughout the
tory alkalosis. Because of all these considera- operation and postoperatively.
tions, we believe that severe respiratory al-
kalosis should not be permitted at any time References
during the operation. If acidosis occurs for any 1. BROOKS, D. K., AND FELDMAN, S. A.: Metabolic
acidosis. A new approach to "'neostigmine
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over, the longer the bypass period, the more 1962.
important this becomes. With only a short 2. SEVERINGHAUS, J. W.: Blood 02 dissociation line
time on bypass at normothermia, such as in charts. In Handbook of Respiration. National
Academy of Sciences, National Research Coun-
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unimportant; with prolonged bypass proce- 1958, pp. 72 and 73.
dures and especially under hypothermic con- 3. ASTRUP, P., JORGENSEN, K., SIGGAARD-ANDERSEN,
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exerts on the debilitated cardiovascular system acid-base nomogram revised. Scandinav. J.
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5. CARSON, S. A. A., AND MoRRis, L. E.: Controlled
tient's condition. acid-base status with cardiopulmonary bypass
Much has yet to be learned regarding acid- and hypothermia. Anesthesiology 23: 618,
base metabolism and heart surgery. It is hoped 1962.
6. BRADLEY, A. F., STUPFEL, M., AND SEVERING-
that further data related to these changing HAUS, J. W.: Effect of temperature on PCO2
concepts will be forthcoming in the near and PO of blood in vitro. J. Appl. Physiol. 9:
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Circulation, Volume XXIX, March 1964
466 CARSON ET AL.
7. MARSHALL, R., AND GUNNING, A. J.: The meas- 14. DARBY, T. D., ALDINGER, E. E., GADSDEN, R. H.,
urement of blood gas tensions during pro- AND THROWER, W. B.: Effects of metabolic
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1 1. OSBORN, J. J., POPPER, R. WV., KERTH, W. J., 17. PAYNE, \V. S., THEYE, R. A., AND KIRKLIN, J. WV.:
AND GERBODE, F.: Respiratory insufficiency Effect of carbon dioxide on rate of brain cool-
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on surface activity of lung extracts. Bull. Soc. monary circulation. Perfusion experiments.
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Articles should be so written that not only intelligent people but specialists in
fields other than those of the writer may read them with pleasure and profit. No
article, even the most learned, needs be so written as to rebuff all readers except
those strengthened to their task by animus or malice. An author too great or too
lazy to consider and labor for the comfort of his readers, is either too grand for
the condescension, or too low for the privilege, of print.-WILLIAMI MILLS IVINS,
JR., 1881-1961. Late Curator of Prints, Metropolitan Museum of Art, New York
City. Bulletin of the Metropolitan Museum of Art, February 1963. Submitted by
Miss Dorothy Vickery, American Heart Association, New York.