Dirk Himpe MD PhD MHE EDIC ZNA Middelheim General Hospital Antwerp Belgium Prime Time ! Fluids during Cardiac Surgery.

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Presentation transcript:

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:

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

Carson J, Lancet 1996, 348:

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

Lowell, CCM :728, 1990 < 10 % % > 20 % Mortality % Weight gain after cardiac surgery

Red blood cell Plate let Polymer INFLAMMATION Blood 1994; 4:

phases: pre-pump-post-ICU targets: interrelated.transfusion/anemia.acid-base status.fluid balance (colloids).inflammation (SIRS) OR

bloodvolume + priming solution Htc: 45 % % 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:

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: Urea-linked GEL in NS Base Excess (mean ± 1.96 SEM)

Base EM. et al. JCTVA 2011, 25: 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 to figured blood elements (foreign surfaces, air, pericardium & pumps)

baseline 120 min 4% MFGelatine 4% Albumin 6% HES 70/0.5 Normal Saline mg/L free haemoglobin -> inflammation Sumpelmann R et al. Anaesthesia 55: 976, 2000 mechanical stress on blood during CPB electrically charged

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

Mortality

Canver C. C. & Nichols R. D. Chest 2000;118: 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;