Difficult Weaning From Cardiopulmonary Bypass Final Edit Lia

DIFFICULT WEANING FROM
CARDIOPULMONARY
Juni Kurniawaty
BYPASS
INTRODUCTION
•Goal CPB
•Safe Weaning
•Difficult weaning CPB
•Management of weaning from CPB
WEANING FROM
CARDIOPULMONARY BYPASS
•(CPB)
Primary goal
smooth transition
Artificial circulation spontaneous systemic
of mechanical pump circulation
Licker, M et al, 2012, Clinical Review: Management if weaning from cardiopulmonary bypass after cardiac surgery, Annals of Cardiac Anesthesia
WEANING FROM CPB anesthe
siologis
t
•The keys of successful
weaning: teamwork and
communication
successful
weaning
•Technical errors and poor
communication has been perfusi
surgeon
associated with failure to wean onist
DIFFICULT WEANING FROM
CPB
Activation of Vasoplegia,
Artifical
platelets, coagulopathy,
surface of Inflammatory Coagulation Difficult
endothelial depression of
CPB response cascade weaning
cells, myocardial
circulation
leukoocytes function
CPB creates numerous insults to normal physiology

Separation from CPB machine may trigger hemodynamic instability
Monaco F, et al, 2020, Review Article: Management of Challenging Cardiopulmonary Bypass Separation, Journal of Cardiothoracic and Vascular Anesthesia; 34: 1622-1635
SAFE WEANING
A
• Airway
Rhythm
Rate
B
• Beating heart
Resistance
Warm Respiration
C
• Crit
WA A A R R R R M M D
• Drugs
Anesthesia Metabolis E
• Electrolytes
Adjuvant drugs m
Air Monitor F
• Fahrenheit
G
• Gradient
SAFE WEANING
 Temperature
 Output
O K T O P R O C E E D
 Oxygen and ventilation  Procedural outcome

 K+ and other  RBCs
electrolytes  Optimizing inotropy
 Coagulation status
 Entrained air
 Electrical activity
 Distention
DIFFICULT TO WEAN
Difficult
Require ≥ 2 inotropes/vasopressors for a successful 1st weaning
process
Difficulties in
weaning from
No clear Very difficult
CPB are
definition The 1 weaning process fails
st
Require mechanical device
encountered in 10-
45% of patients
Complex
Risk factor: acute right heart
A life-threatening complication
failure
VASOACTIVE AND INOTROPIC
SCORE (VIS)
•Aid in decision making in patients with
complex CPB separation
•Interpretation
< 10 (easy)
10-30 (difficult)
> 30 (complex, MCS usually added to
inotropic support)
Guyron, R.A, et al, Cardiopulmonary bypass, Principles and Techniques of Extracorporeal Circulation, 1995
ROLE OF
TRANSESOPHAGEAL
ECHOCARDIOGRAPHY (TEE)
Detection Diagnosis Role

• Cardiac underfilling • Structural abnormalities • Pivotal role in cardiac
• Conditions in right • Dynamic abnormalities surgery
ventricle and atrium • Ventricular systolic • Is superior to TEE
dysfunction
• Vasoplegic syndrome
CONDITIONS CAUSING
COMPLEX WEANING OF
CARDIOPULMONARY BYPASS
Vasoplegic syndrome
Right ventricular failure +- pulmonary hypertension
Pulmonary hypertension with N/low RV function
Left ventricular failure
VASOPLEGIC SYNDROME
Criteria
• MAP <50 mmHg, or
9% incidence rate
hypotension • SBP <85 mmHg
• SVR <600-800 dynes s cm-5, or

Low SVR • SVR indices <1800 dyne s cm-5 m2
5-25% mortality rate N/high systemic

flows
• Cardiac index >2.5 L min m2
N/reduced central • CVP <10 mmHg

• Pulmonary wedge pressure <10 mmHg
Trigger factors : filling pressures
 Anemia
Increased need • 0.2-0.5 mg/kg/min of norepinephrine
 hemodilution for vasopressors
with normal intravascular volume
Pathophysiology
Vasopressin
•Vasodilation due to lack of vascular smooth deficiency
muscle cell contraction High levels of
NO, Other factors
natriuretic inhibiting
peptide, contraction
adenosine
Low
CPB and vasoplegic syndrome smooth
muscle
•CPB -> massive inflammatory response with contractio
increased nitric oxide and decreased n
vasopressin level -> vasoplegia Monaco F, et al, 2020, Review Article: Management of
Challenging Cardiopulmonary Bypass Separation, Journal of Cardiothoracic and Vascular
Anesthesia; 34: 1622-1635
VASOPLEGIC SYNDROME
Treatment
Rescue
if failed
• Vasoactive drugs • Methylene blue* therapy
• Transfusion (target • *caution for • Vitamin C
Hb 9 g/dL) patients at risk for
• Thiamine
serotonic
• Epinephrine
syndrome or
• Steroid G6PDdeficiency
if failed • diphenhydramine If failed
Busse, L.W. et al, 2020, Review : Vasoplegic syndrome
following cardiothoracic surgery- review of pathophysiology
and update of treatment options, Critical care : 24-36
RIGHT VENTRICULAR
FAILURE
Severe RV failure post-CPB -> high mortality (up to 86%)
Causes:
 poor myocardial inotropism (preop CAD, post-CPB myocardial stunning, arrhythmia)
 myocardial hypoperfusion (air embolism or thromboembolism in the right coronary
artery, kinking of venous graft, low aorta-coronary pressure gradient)
Acute RV dysfunction in CPB is usually associated with high CVP

 Due to depressed contractility after CPB
Aim of therapeutic interventions in RV dysfunction:
preload, afterload, contractility
RV FAILURE +- PULMONARY
HYPERTENSION
Treatment for difficult CPB separation due to RV failure
• 1st line: gas exchange and preload optimization (general agreement)
• 2nd and 3rd line: lack of convincing data  different approaches in
different institutions
Treatment should consider the presence or absence of
PH
• Without PH: most centers use dobutamine or epinephrine, few use
nitroglycerine, dopamine and vasopressin as 2nd line option
• With PH: inodilators and/or inhaled NO
Drug choices for difficulty of weaning due to RV failure:
Drug of choice Indication

Dobutamine Moderate RV dysfunction
Epinephrine Severe RV failure
Selective phosphodiesterase III Severe pulmonary
inhibitor (milrinone or hypertension
enoximone)
PULMONARY HYPERTENSION WITH
N/LOW RV FUNCTION
SEVERE PH
Inhaled
nitric
no clear evidence
treatment oxide
on efficacy
and
Pharmacologic iloprost
approach potent
vasodilator, Inhaled
•reduce pulmonary pulmonary prostagl
vascular resistance circulation- andin E1
without affecting the selective
systemic vascular Combin
resistance ation of Improve RV
inhaled function (low
NO + evidence study)
PGE1
LEFT VENTRICULAR FAILURE
Suboptimal cardiac Pathophysiology of LV failure:
protection
•decreased preload
•depressed contractility
Causes of LV •increased afterload
failure post-CPB -> these can be assessed by TEE
Prolonged aortic clamping Others: underlying ventricular

time function (global/regional)
LV
LV FAILURE
Preload
low preload may lead to systolic anterior motion (SAM) of the anterior leaflet
of the mitral valve (mimic LV dysfunction  importance of TEE
Treatment for SAM:
•decrease HR to 60 to 70 beats/min
•stop epinephrine and/or switch to Beta-blockers
•increase afterload with α1 agonists
Contractility
•Myocardial contractility is the most important determinant of successful CPB
separation
•MAP, filling pressure, CO are key parameters
Cardiac Filling MAP SVR Drug of choice

output pressure
↓ N/↑ ↔ ↔ Epinephrine
↓ ↔ ↔ ↑ Inodilator
↓ ↔ ↓ ↓ More epinephrine
Contractility (cont.)
Myocardial ischemia (ST segment changes and new wall motion
abnormalities) may required going back to CPB
myocardial
ST elevation revascularizatio
n +- IABP
low dose
Myocardial
ST depression nitroglycerine
ischemia
+- IABP
New wall
motion IABP
abnormalities
Contractility (cont.)
Other
Goals
MCS
>70
MAP
mmHg
ECMO, Urinary >1
LVAD output ml/kg/h
SvO2 >=65%
•Indication: Low cardiac output syndrome refractory to IABP

•After MCS insertion, continue support RV function with inotropes and optimize
preload and HR
Afterload
•Increased afterload post-CPB ->
sympathoadrenergic reaction, release of
various vasoactive mediators -> low Clavidipin
CO syndrome e is
recommnd
•Clevidipine: short half life, quick onset ed
and offset, direct arterial vasodilation DOC: short acting
vasodilators (i.e
•Avoid long acting vasodilators -> nitroglycerine or
nitroprussiate)
possibility of sudden hemodynamic
changes
LV DIASTOLIC DYSFUNCTION
Diastolic dysfunction alone
rarely leads to failure of CPB
separation Diastolic dysfunction
• Postcardiotomy cardiogenic may predict pending
shock is due to conjunction myocardial ischemia
with comorbidities (SVT,
reduced coronary perfusion,
HT)
Treatment depends on
the underlying
mechanisms
MANAGEMENT OF Algorithm
WEANING FROM CPB
CHECKLIST BEFORE
WEANING
APPROACH FOR CPB
MANAGEMENT
MECHANICAL CIRCULATORY
SUPPORT
Indication
• refractory myocardial or pulmonary dysfunction
Devices
• IABP
• VAD
• ECMO
Considerations
• patient hemodynamic factors
• surgical preferences
• institutional resources
REFERENCES
Busse, L.W. et al, 2020, Review : Vasoplegic syndrome following cardiothoracic
surgery- review of pathophysiology and update of treatment options, Critical care :
24-36
Guyron, R.A, et al, Cardiopulmonary bypass, Principles and Techniques of
Extracorporeal Circulation, 1995
Licker, M et al, 2012, Clinical Review: Management of weaning from
cardiopulmonary bypass after cardiac surgery, Annals of Cardiac Anesthesia
Monaco F, et al, 2020, Review Article: Management of Challenging
Cardiopulmonary Bypass Separation, Journal of Cardiothoracic and Vascular
Anesthesia; 34: 1622-1635
THANK YOU

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DIFFICULT WEANING FROM

CPB creates numerous insults to normal physiology

 Oxygen and ventilation  Procedural outcome

Detection Diagnosis Role

Right ventricular failure +- pulmonary hypertension

Pulmonary hypertension with N/low RV function

Left ventricular failure

• SVR <600-800 dynes s cm-5, or

5-25% mortality rate N/high systemic

N/reduced central • CVP <10 mmHg

Acute RV dysfunction in CPB is usually associated with high CVP

Drug of choice Indication

Prolonged aortic clamping Others: underlying ventricular

Cardiac Filling MAP SVR Drug of choice

•Indication: Low cardiac output syndrome refractory to IABP

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