post cardiopulmonary bypass complications · embolic/thromboembolic/hemorrhagic cva ... et al....

Post Cardiopulmonary Bypass Complications:

The Common and the Outliers

April 6, 2018

Seth B. Zebrak, MS, PA-C

Lead Provider, CVICU

Asst Director, URMC Critical Care Medicine APP Fellowship

Financial Disclosure

I have no Financial Affiliations or Conflicts to Disclose

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How Do We ATTACK Post CBP Complications

1. ICU Perspective

2. Organ Systems Approach

3. Diagnoses

3

History of CBP

1885: von Frey & Gruber developed the first

device to oxygenate blood extracorporally for

perfusing isolated organs

1915: Richards & Drinker report use of a

screen oxygenator (gravity drawn blood flow

down a cloth in an oxygen rich atmosphere)

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1916: McLean & Howell discover Heparin

History of CPB

Russians Brukhonenko and Tchetchuline 1929

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History of CPB

Gibbons, 1953

◆ 4 Patients attempted

◆ 3 Intraoperative mortalities

◆ 1 Survivor (almost died, but almost!)

1937 Modified Extracorporial Circuit

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Modern CPB Systems

Downloaded from researchgate.net, 2018

Maquet.com, 2018

Neurological Concerns

➢ Stroke: Embolic and Hemorrhagic

➢ Cognitive Dysfunction & Delirium

➢ DHCA and Rates of Rewarming

➢ CO2 & Selected Flow to the Brain

➢ Air to the Brain

➢ Tranexamic Acid and Seizures

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Embolic/Thromboembolic/Hemorrhagic CVA Predictors?

➢ Infective Endocarditis and Pre-existing Vegetations

➢ Atherosclerotic Disease: Aortic and/or Carotid

➢ Intraoperative Debris: debrided annuli, calcified valves, intraventricular

thrombi

➢ Air Embolism

➢ Repeated Exposure to Heparin / HIT

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Intraoperative Screening / Predictors

◆ Cerebral Oximetry

◆ Complexity of Procedure: Arch reconstruction, duration of CPB run,

manipulations of the Aorta

◆ Hypotension and/or Low Flow states

◆ Anemia

10Researchgate.net, 2018

Presentations in the CVICU

❖ Delayed Emergence / Persistent Coma

❖ Seizure / Myoclonus

❖ Hemianopsia

❖ Hemiparesis

❖ Aphasia

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CVA??? Initial Response

➢ Stroke Team? NIHSS

➢ Imaging? Stable? With or without contrast? MRI?

➢ “Neurointerventionalists”

➢ Limited to Basilar or Anterior Circulatory Occlussion

➢ Watershed

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CVICU Case Presentation

Pt is a 67M, HTN, HLD, severe Aortic Stenosis; planned minimally

invasive AVRt via mini-thoracotomy. Complicated by ascending

dissection, necessitating sternotomy and ascending replacement.

Antifibrinolytic = TXA. Further complicated by severe coagulopathy

requiring multiple products and activated Factor VII; vasoplegia on

multiple pressors and methylene blue; delayed closure... Closed POD 1;

sedatives weaned late POD 1. Initial neuro exam with Myoclonus.

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CVICU Case Presentation

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CVICU Case

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Intracranial Hemorrhage

➢ NEUROSURGERY

➢ Surgical Interventions for ICH

➢ Ventriculostomy

➢ Craniotomy

➢ INITIAL Medical Management

➢ Coagulopathies

➢ Mycotic?

➢ Blood Pressure

➢ Temperature

➢ Glucose

16Top: Downloaded from hindawi.com, 2018Bottom: Allen, et al. AJNR, April 2013, Dowloaded 2018

Postperfusion Syndrome and Delirium

• “PUMP HEAD” and Postperfusion Syndrome

• Post-Operative Cognitive Decline

• Delirium – biggly real and hugely bad!

• Associated with longer pump run

• Hyperactive vs Hypoactive

• Temporary and Permanent

• Increased Mortality (12.5% vs 4.5% without)

• Readmits (47.6% vs 32.6% without)

• Concentration and Sleep

• Prevention is Key if possible

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Koster S et al. The Long-Term Cognitive and Functional Outcomes of Postoperative Delirium After Cardiac Surgery. Ann Thorac Surg. May 2009; 87(5):1469-1474

Effects of DHCA and Rewarming Rate

◆ Systemic effects of hypothermia

▪ Inflammatory

▪ Coagulopathy

▪ Metabollic

◆ Rewarming technique – SPEED MATTERS!!!

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Grigore AM et al. The rewarming rate and increased peak temperature alter neurological outcome after cardiac surgery. Anesth Analg, 2002;94:4-10Engelman et al. Rapid rewarming during cardiopulmonary bypass is associated with cerebral injury. Annals Thor Surg 2016 101(5):2026-2027

GAS GAS GAS!!! O2 & CO2

❖ Hyperoxia – Free Radicals

❖ Oxidative Injury

❖ Delirium? From Oxygen???

❖ CO2 can be PROTECTIVE?

❖ Brain?

❖ Yes

❖ No

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Svenarud P et al. Effect of CO2 Insufflation on the Number and Behavior of Air Microemboli in Open Heart Surgery. Circulation. 2004;109:1127-1132

Tranexamic Acid (TXA) and Seizures

➢ Antifibrinolytic – Replaced Aminocaproic Acid (EACA)

➢ Head to Head: TXA has more seizures, EACA worse renal complications

➢ Dose dependence

➢ Renal function at baseline

➢ Treatment

➢ Propofol, Benzodiazepenes

➢ Keppra long term???

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Lecker I, et al. Tanexamic acid-associated siezures: Causes and Treatment. Ann Neurology 2016; 79(1):18-26Murkin JM, Falter F, Granton J, Young B, Burt C, Chu M, et al. High-dose tranexamic acid is associated with nonischemic clinical seizures in cardiac surgical patients. AnesthAnalg. 2010;110:350–3

Cardiac Complications of CPB

◆ Ventricular Failure, dilation, failure to separate from pump

◆ Inflammatory Response

◆ Vasoplegia (inflammatory and pharmacological (ACEi))

◆ Intracardiac Thrombus and Pulmonary Thromboembolism

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Ventricular Failure / Failure to Separate from CPB

➢ Etiology:

➢ Left causes Right and Right causes Left

➢ Tamponade

➢ Pulmonary Embolism

➢ Often associated with prolonged CPB pump runs (significant

complement activation)

➢ Technically challenging cases

➢ Returning to pump (bleed, valve or graft repair)

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Ventricular Failure

❑ Monitoring and Recognition

❑ LV Failure

❑ Immediate evidence of inadequate perfusion

❑ Decreased MAP, narrowing Pulse Pressure (PP)

❑ RV Failure

❑ Rising CVP, narrowing PP, new Tricuspid Regurg

❑ Echocardiogram

❑ Ventricular dilation

❑ Ventricular wall motion abnormalities

❑ Septal wall

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RV Failure & Tamponade on Echo

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Downloaded from emDOCs.net, 2018 Downloaded from cardiachealth.org, 2018

Brief Overview of RV Failure Management

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Ferrari M. Future Challenges in Acute Right Heart Failure. GSL Cardiovasc Dis 2017; 1:102

Managing Acute Heart Failure

➢ KISS: CO = SV x HR

➢ Optimize Preload

➢ Thou Shalt Giveth, or Thou Shalt Taketh Away!!!

➢ Is there a “Happy CVP or PAD”???

➢ Optimize Afterload

➢ Pressors or Dilators (systemic and pulmonary)

➢ Afterload Effects on Ventricular Geometry

➢ Inotropy & Lusitropy

➢ Mechanical Support

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Mechanical Support

◆ Left or Right Ventricular Assist Devices (LVAD/RVAD)

◆ Heartmate II and III, Heartware, Impella, Tandem Heart

◆ Extracorporeal Membrane Oxygenator (ECMO)

◆ Veno-Arterial (VA), Veno-Veno (VV), RVAD

◆ Intra-Aortic Balloon Pump

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Vasoplegic Syndrome – Causes and Fixes

❖ Vasoplegic Syndrome: inflammatory response and associated with

overproduction of nitric oxide (NO)

❖ Pressors: Norepinephrine, Vasopressin (VANCS Trial)

❖ Methylene Blue: early = better

❖ Steroids – Not so much

❖ Angiotensin Converting Enzyme Inhibitors...

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Volume

Pressor

Rare Cardiac Thromboemboli from CPB

• Intracardiac Thrombosis (ICT) and

Pulmonary Thromboembolism

•Pathological mechanisms poorly

understood

•Commonalities in a case review study:

CHF (50%), Platelet Transfusion

(37.5%), CPB duration > 3 hrs

(37.5%), Aortic Injury (27.1%)

•Mortality 85.4% despite interventions

Williams, et al, Acute Intracardiac Thrombosis and Pulmonary Thromboembolism

After Cardiopulmonary Bypass: A Systematic Review of Reported Cases, Anesthesia &

Analgesia, 126, p425-434

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Pulmonary Sequelae of CBP

◆ Derecruitment

◆ Lungs “Down”

◆ Inadequate ventilation or PEEP on transfer

◆ Lobar Collapse or consolidation

◆ Volume overload

◆ Wet lungs

◆ Transfusions

◆ SIRS

◆ ARDS

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ARDS CXR & CT

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Downloaded from lumen.luc.edu, 2018

Pulmonary Edema & Lobar Collapse

32Downloaded from med-ed.virginia.edu, 2018 Downloaded from radiologypics.com, 2018

GI Complications of CPB - Bleed

◆ Early Upper GIB most common of all GI complications

◆ May be iatrogenic as complication of TEE

◆ Heparinization

◆ undiagnosed erosions, ulcerations, microbleed

◆ Rebound Heparinization

◆ Management (when to pull the consult trigger)

◆ Low Hanging Fruit: correct coags, rewarm, avoid

instrumentation

◆ Transfuse prn (anemia &/or thrombocytopenia);

DDaVP?

◆ EGD: cautery, local Epinephrine 33

Sciencesource.com, 2018

GI Complications of CPB - Ileus

34Slideshare.net, 2018

CVICU Case Presentation

Pt is a 71F with history of Aortic Stenosis, CAD, paroxysmal atrial fib,

asthma, COPD, HTN, HLD, GERD, Rheumatoid Arth, uncomplicated AVRt

with CABG x2 (LIMA-LAD, SVG-OM). Baseline EF 30% & normal RV.

IABP placed in OR for “sluggish” EF. Myoclonus on POD 1 (no clear

etiology and resolved). IABP d/c’d POD 4. From POD 4 – 7, off pressors,

bumex drip.

Worsening hemodynamics late POD 8 into 9, acidosis, refractory

tachycardia, increase pressor use, abd tender...

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Case Presentation

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GI Complications of CPB – Ischemic Bowel

◆ Causes: thrombi, hypoperfusion / low flow, pressors

◆ Exam: pain out of proportion

◆ Hemodynamics

◆ Worsening acidosis

◆ Airway pressures, Compartments

◆ Very High Mortality

◆ Management

◆ Almost exclusively surgical!

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Researchgate.net, 2018

GI Complications of CPB - ???

➢ Pt is 65F, history of CAD, NSTEMI, HTN, HLD, CKD 3, now POD 1 s/p

CABG x3; extubated, no drips. Persistent postop Nausea refractory to

Zofran & Reglan now w epigastric pains radiating to the back, dry

heaving, Febrile... SBP 92, tachycardic, tachypneic, UOP 20cc/kg/hr.

➢ Labs reveal a leukocytosis, resolving transaminitis and added-on

amylase is twice the upper limit of normal and lipase is four times the

upper limit of normal

➢ Acute Pancreatitis???

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GI Complications – Pancreatitis (rare)

❖ Etiology – usually ischemic; cholelithiasis, sludge or microlithiasis;

hypercalcemia, drug (amiodarone).

❖ Huge SIRS response and may cause MODS

❖ Diagnosis: exam, labs, US, CT, MR

❖ Treat based on etiology

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Alonso A., et al, Association of amiodarone use with acute pancreatitis in patients with atrial fibrillation: a nested case control study. JAMA Intern Med. 2015 Mar; 175(3): 449-450

Uptodate.com, 2018

GI Complications of CPB – Gall Bladder

◆ Acalculous Cholecystitis

◆ Ischemic is most likely culprit

◆ Exam and US/CT for the

diagnosis

◆ Perc Drain is most often

treatment (+/- Abx)

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GI Complications of CPB – Hepatic Injury

• Etiology: Ischemia and/or RV Failure

• Exam: Jaundiced

• Labs:

• Transient transaminitis

• Total Bilirubin lags and takes time to peak

• Management: unfortunately, supportive!

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CPB Influences on Blood

◆ Dilution / Bleeding / Vol expansion

◆ Crystalloid, colloid

◆ coagulopathies due to factor depletion

◆ Temperature influences - hypothermic coagulopathies

◆ decreased enzyme activities within the clotting cascade

◆ impairs platelet aggregation from reduction of Thrombaxane A3

◆ Acidosis: interferes with the production of complexes resulting in

reduction of factor Xa/Va activity. (50% reduction at pH 7.2)

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Meng ZH, et al, The effect of temperature and pH on the activity of Factor VIIa: implications for the efficacy of high-dose VIIa in hypothermic and acidotic patients. J Trauma. 2003; 55(5):886

CPB Influences on Blood

o Inflammatory Influences

o Complement activation – aka Antibody Triggered Response

o Multiple pathways

o Activation of C3a and C5a in the alternative pathway

o Mitigation of Lectin pathway with heparin coated tubing

o Hypothermia is now shown to increase pro-inflammatory cytokines

o Methylprednisilone??? (SIRS – Steroids In caRdiac Surgery)

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Pagowska-Klimek I., et al. Activation of the lectin pathway of complement by cardiopulmonary bypass contributes to the development of systemic inflammatory response syndrome after paediatric cardiac surgery. J Translational Immun 2016; 184(2):257-263Song DD, Effects of Normothermia Versus Hypothermia on Serum Complement Activation and Cytokine Production During Simulated Cardiopulmonary Bypass. Abstract, Dowloaded from digitalcommons.murraystate.edu, 2018Whitlock RP et al. Methylprednisilone in patients undergoing cardiopulmonary bypass (SIRS): a randomized, double blind, placebo-controlled trial. The Lancet. Oct 2015. 386(10000):1243-1253

CPB Influences on Blood

◆ Rebound heparinization

◆ AT III Deficiency

◆ Difficulty in achieving desired ACT

◆ Defined in CVICU as > 25 units/kg/hr

◆ Heparin Induced Thrombocytopenia

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Renal Sequelae from CPB

◆ Acute Kidney Injury is most likely due to Acute Tubular Necrosis

◆ Consequence of hypoperfusion: hypovolemia and/or hypotension, low

cardiac output state

◆ Renal Artery Vasoconstriction (with or without stenosis)

◆ Hypothermia

◆ Emboli / Atheroembolic Disease

◆ SIRS response

◆ Incidence of AKI is rising though mortality has decreased

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Thakar CV et al. Improved survival in acute kidney injury after cardiac surgery. Am J Kidney Dis. 2007;50(5):703

AKI / ATN Management

➢ Reverse insult

➢ Optimize hemodynamics and minimize nephrotoxic agents

➢ Tincture of Time

➢ Mechanically clear: dialysis

46Medrevise.co.uk

Vascular Misadventures of CPB

❖ Mediastinal Cannulation Sights, suture lines

❖ bleed, tamponade, arrhythmias/ECG changes

❖ Groin Misadventures – some may not be ours!!!

❖ Retroperitoneal Bleed

❖ Pseudoaneurysm

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67M with severe atherosclerotic disease “everywhere”, CAD, transferred with Impella CP in R groin for cardiogenic shock – which was removed.

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