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

2. Outcome ?

3. Engoren et al. Ann Thorac Surg 2002; 74:1 180-6

4. Koch CC et al. Ann Thorac Surg 2006; 81:1650-7.

5. Carson J, Lancet 1996, 348: 1055-60

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

7. Lowell, CCM 1990 18:728, 1990 < 10 % 10-20 % > 20 % 020406080100 Mortality % Weight gain after cardiac surgery

8. Red blood cell Plate let Polymer INFLAMMATION Blood 1994; 4:3175-81

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

10. bloodvolume + priming solution Htc: 45 % 20-25 % start CPB (few minutes) The “pump”: onset of CPB = massive fluid load

11. Issue: Type of Fluid = Determinant of Outcome ?! (direct or indirect)

12. Blood-loss

16. Fluid-Balance

17. James A. Russel. JCTVA 2004, 18: 429-437

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

19. Acid-Base

20. Succinyl-linked GEL in buffered vehicle Albumin-Hartmann Himpe D. et al. JCTVA 1991, 5:457-66 Urea-linked GEL in NS Base Excess (mean ± 1.96 SEM)

21. Base EM. et al. JCTVA 2011, 25:407-14 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)

22. damage to figured blood elements (foreign surfaces, air, pericardium & pumps)

23. 0 200 400 600 800 1000 1200 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

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

25. Mortality

26. Canver C. C. & Nichols R. D. Chest 2000;118:1616-1620 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

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

28. 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;