1. Anesthetic agents in cardiopulmonary bypass 麻醉科 Ri 潘聖衛 羅立凱 2003/9/24

2. A case of VSD status post OP with CPB on 9/15 A 3-year-old male Chief complaint: Heart murmur found accidentally at local clinic at 2 m/o

3. Brief history

4. Anesthesia records

5. Anesthetic agents in cardiopulmonary bypass

6. Cardiac Anesthesia Anesthesia in Adult Induction Narcotic: Remifentanil; Fentanil or Sufentanil plus Sedative-Hypnotic:Pentothal; Etomidate; BZD; Propofol Maintenance Narcotic plus Propofol, BZD, or low dose inhalation drug CTSNET http://www.ctsnet.org/

7. Cardiac Anesthesia Pediatric Anesthetic Agents Induction Ketamine IM 5 mg/kg,IV 1-2mg/kg Inhalation using Halothane or Sevoflurane Maintenance Narcotic plus Hypnotic or Inhalation CTSNET http://www.ctsnet.org/

8. Ketamine attenuates the interleukin-6 response after cardiopulmonary bypass. Anesth Analg. 1998 Aug;87(2):266-71 CPB involved systemic inflammatory response Serum IL-6 as a good indicator of 1.activation of the inflammatory cascade 2.predictor of organ dysfunction and death

9. Small dose of Ketamine (0.25 mg/kg) attenuates the interleukin-6 response after CPB Anesth Analg. 1998 Aug;87(2):266-71

10. Ketamine attenuates neutrophil activation after cardiopulmonary bypass. Anesth Analg. 2002 Sep;95(3):531-6 Superoxide production generated by neutrophils Interleukin-6 (IL-6) delays neutrophil apoptosis

11. Small dose of Ketamine (0.25 mg/kg) attenuates superoxide anion and the percentage of neutrophils. Anesth Analg 2002;95: 531 – 536

12. Maintenance of anesthesia in CPB

13. Maintenance of anesthesia in bypass period Complex pharmacokinetics of IV anesthetics Haemodilution Hypothermia Hypotension altered visceral perfusion advanced age and systemic atheroma oxygenator and tubing may bind large amount of drugs and influence the uptake of gas Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

14. Maintenance of anesthesia in bypass period Benefits of volatile agent anesthesia 1.avoidance factor such as hemodilution 2.relatively independent of liver and renal function 3.potentially rapid, predictable offset. 4.enhance ischemic preconditioning ATP-dependant potassium channels volatile agents all have a similar effect ischemic preconditioning Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

15. Does isoflurane optimize myocardial protection during cardiopulmonary bypass? isoflurane before aortic cross-clamping optimize the myocardial protective effect of cardioplegia. in prolonged periods of aortic cross-clamping or inadequate delivery of cardioplegia Journal of Cardiothoracic and Vascular Anesthesia Volume 15, Issue 4, August 2001, Pages 418-421

16. Effect of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients Sevoflurane and desflurane but not propofol preserved LV function after CPB. Anesthesiology Aug 2003;V99,No2:314-23

17. Use of sevoflurane during cardiopulmonary bypass decreases incidence of awareness The difference in the incidences of awareness was significant (P < 0.05), Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery. European Journal of Anaesthesiology,2002, Volume: 19 Number: 4 Page: 283 -- 287 groupMaintenance in CPBawareness group1fentanyl & dehydrobezperidol 5/3016.67% group2Fentanyl & Sevoflurane 0/290%

18. hypothermic VS nomorthemic cardiopulmonary bypass

19. hypothermic CPB Cooling in CPB as a anesthetic agent Decreased level of consciousness and metabolic rate cerebral and myocardial protection harmful effects of rewarming on neurological outcome Deficits in memory, attention, concentration & learning CBF/CMRO2 mismatch (decreased SjvO2) Incidence of CNS hyperthemia The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002; 94: 4 – 10

20. The Rewarming and Alter Neurocognitive Outcome slower rewarming rates are better than standard rewarming in improving neurocognitive outcome. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002; 94: 4 – 10

21. normothermic CPB cardioplegia avoids any harmful effects of rewarming early extubation increased requirement for anaesthesia no comparable additional cerebral protection anaesthesia may be inadequate increased risk of awareness Which anaethetic agent for maintenance during normothermic cardiopulmonary bypass. British J. Anaesth. 2003 90: 118-121.

22. level of sedation between hypothermic and normothermic CPB Normothermic:highest BIS values hypothermic : solely a result of brain cooling or if increased serum propofol concent. Monitoring level of sedation with bispectral EEG analysis: comparison between hypothermic and normothermic cardiopulmonary bypass British Journal of Anaesthesia, 2001, Vol. 86, No. 6 769-776

23. Take home message Induction of ketamine attenuates the IL-6 response and neutrophil activation after CPB. volatile agents all have a similar effect of ischemic preconditioning & myocardial protection and decreases incidence of awareness. Normothermic CPB avoid harmful effects of rewarming on neurological outcome but increase risk of awareness.

24. Thanks for your attention!