Ascending thoracic aneurysm repair with CPB and circulatory arrest

1
Presented Aug 2002

• Ascending thoracic aneurysm repair with CPB and
  circulatory arrest
• (case presentation)
• Darko J. Vodopich MD
• Antonio Cooper MD
• MetroHealth Medical Center - CWRU
• Department of Anesthesiology

2
History

• CC 81 y.o. white male coming to ED after found
  in the bathroom. LOC, no amnesia. Responsive
  on arrival.
• C/o stroke like symptoms
• headache,
• confusion,
• left sided weakness,
• unable to turn the head to the left side

3
History cont.

• Allergy Ciprofloxacin, Levaquin
• PMHx
• HTN well controlled on Lisinopril and HCTZ
• Type 2 DM well controlled by diet/exercise
• Prostate cancer (on Megestrol)
• Occasional CP (no AMI in the past)
• COPD
• PVD

4
History cont.

• PSHx
• Inguinal hernia repair
• Umbilical hernia repair
• Past Anesthesia Hx
• GA
• No complications with GA

5
Physical

• HEENT PEERL, EOMI
• MP class 1, TMD 5 cm, Mouth opening 4 FB, good
  neck mobility, own dentition in a good shape
• Cor RRR, S1S2, no murmurs, no thrill, tones
  silent, distant on auscultation
• Pulmo decreased sounds bilaterally, no crackles
  or wheezing
• Extremities no gross abnormalities, left sided
  weakness
• Neurological AOx3, left sided focal signs
• ASA 5, Case type Emergency

6
Laboratory and studies report

• CBC WBC8.4, Hb11, Hct35, Plt207
• Na128, K3.6, HCO3-19, Cl98, BUN11,
  Creat0.6, Glu131
• Pt12.0, PTINR1.02, PTT42.9
• ECG NSR100 BPM, nonspecific S-T changes, no
  signs of acute ischaemia
• ECHO 19 July 2002 EF 74, no ischaemic changes
• Adenosine myocardial perfusion test 19 July
  2002 NSR, left axis anterior hemiblock, mild S-T
  changes. No evidence of ischaemia. Normal test.

7
Ultrasound done in Oberlin hospital
Ascending Thoracic Aorta
45 mm
Intimal flap
8
Ultrasound done in Oberlin hospital
Blood in dissection
Type A ascending aortic aneurysm
Aorta
9
Chronology

• Pt taken to OR 15.
• Difficulty cross matching the blood
• Anesthesia start time _at_ 2028 with a-line and 2
  large bore 16 G i.v. lines in place
• Smooth i.v. induction Fentanyl 100150200250
  mcg
• Midazolam 5mg, Vecuronium 10 mg.
• Easy ventilation and intubation ET 8, Grade 1
  view, atraumatic, secured _at_ 23 cm.
• Left IJ 9 F introducer placed, PAC introduced,
  good waves and wedge detected, secured _at_ 54 cm.
  Patient tolerated procedure well. No
  complications.
• Initial CI2.4, SVO275, CVP14, PAP24/14 mmHg

10
Intraoperative facts

• Maintenance of anesthesia before bypass
• Isoflurane 1.0, O2 2L, Air 2L.
• Fentanyl 0.05 mcg/kg/min
• Vecuronium 3mg/h
• Other drips
• Amicar
• Sodium nitroprusside
• NTG
• Neosynephrine
• BIS mid 40s
• BP titrated to a mean of 80s
• ABG _at_ the beginning surgery pH7.43, CO231.8,
  O2207, HCO321.1, BE-2.0, HCT30, Na123,
  K3.4, Glu160

11
Intraoperative during bypass

• 1st time 2nd time
  3rd time
• On pump 2212 0005 0240
• Off pump 2256 0148 0405
• Circulatory arrest _at_ 2235 BIS 00
• Temperature during arrest 18 C
• MAP 15-20s during circulatory arrest
• ABG on the pump pH7.40, CO235, O2336,
  HCO322, BE-2.1, HCT22, Na123, K3.8, Glu167

12
Intraoperative events

• Proximal aortic graft required resuturing
• Episode of hypotension/clotted pump filter
• Marked reduction in systolic function after
  weaning from bypass
• Unresponsive to iv epi/norepinephrine, but
  responsive to intracardiac Epinephrine 1 mg
• Blood gas revealed PaO245 mmHg
• Delayed reinstitution of CPB/clotted oxygenator

13
Intraoperative events (2)

• Persistent lactic acidosis on bypass
• Low urine output
• Weaned from bypass, with persistent hypoxemia
  and lactic acidosis, and hematuria
• Return to bypass for the 3rd time
• Weaned from the bypass after 1 hour and 25
  minutes
• Blood clot removed from right atrium
• Patient remained H/D unstable and expired _at_
  0530

14
Intraoperative facts

• Total surgery time 2028-0502 514 min
• Total bypass time 44min103min 85 min 232 min
• Total circulatory arrest time 27 minutes
• EBL 2000 ml
• PRBCs 6 units
• Platelets 6 packs
• Fluids 2200 ml
• Urinary output 120 ml (hemolyzed)
• Blood clot removed from right atrium
• Patient expired 0530 AM
• CAA identified in the blood

15
Cold agglutinins antibody (CAA)
16
Cold agglutinins antibody - CAA

• Common but usually unimportant - in serum of
  almost all healthy patients
• AHA caused WAB 185.000 caused CAA 1300,000
• Female/male 1.5/1.0
• Associated with
• Infectious mononucleosis (60)
• Lymphoreticular neoplasms
• Mycoplasma pnuemoniae
• IgM autoantibodies against RBC I-antigen

17
Cold agglutinins antibody - CAA

• Thermal amplitude - blood temperature below CAA
  react
• Higher thermal amplitude more malignant CAA (35
  Co)
• Routine screen by blood banks for CAA _at_ 37Co
• Significance of CAA is determined by
• Agglutination of RBC in 20 Co saline
• Agglutination of RBC in 30 Co albumin
• If tests are negative significant hemolysis is
  unlikely (Leach AB, Van Hasselt GL, Edwards
  JCCold agglutinins and deep hypothermia.
  Anesthesia 381401983)

18
CAA - physical exam and distribution

• PE may reveal
• nothing unusual
• pallor only, unless the patient is observed
  during or shortly after cold exposure.
• purplish discoloration of the ears, forehead, tip
  of the nose, and digits may then be observed.
• Distribution is provided by a study of 78
  patients with persistent cold agglutinins
• 31 lymphoma (40),
• 24 chronic, idiopathic CAD (31)
• 13 Waldenström syndrome (16)
• 6 chronic lymphocytic leukemia (CLL) (8) (Crisp,
  1982)

19
CAA - Ddx

• DDX
• Cryoglobulinemia
• Warm AIHA (Warm antibodymediated autoimmune
  hemolytic anemia )
• Neoplasms
• Drug-induced immune hemolytic anemia
• Heparin-induced thrombocytopenia/thrombosis
  syndrome (HITTS)
• Drug-induced hemolytic anemia
• Infections

20
Management of CAA and CPB.

• Depends on 1.titers, 2.thermal amplitude
• 1) During the bypass RBC agglutination can be
  determined by mixing the blood with cold
  cardioplegia
• 2) Dilute the blood sample to simulate the
  dilution with CPB and cool it down. (may not have
  the reaction)
• Many institutions avoid hypothermic CPB if CAA
  present
• Cold cardioplegia may produce agglutination in
  small heart blood vessels
• If hypothermia required despite CAA
• preoperative plasmapheresis to reduce titers
• limit hypothermia to temperature exceeding
  thermal amplitude
• use standard hemodilution techniques

21
Management of CAA and CPB.

• Cold cardioplegia with normothermic bypass and no
  plasmapheresis
• normothermic CPB
• cardioplegia 37 Co to washout CAA
• 4 C cold cardioplegia
• Malignant cold CAA
• Consider total washout technique - exchange
  patients blood with donors blood
• Heat all anesthetic gases, IV Fluids, blood, and
  plasma
• Keep room warm
• Use washed RBCs

22
Thanks for the attentionThe End