Arterial line filtration protects brain microcirculation during cardiopulmonary bypass in the pig.

Microemboli in the brain may inhibit brain function during cardiopulmonary bypass, and in a previous study in pigs of normothermic nonpulsatile bypass we reported a significant decrease in cerebral glucose consumption secondary to interruption of the capillary flow, possibly caused by microemboli. In the present study we measured the regional cerebral glucose consumption and the regional capillary diffusion capacity (that is, the number of perfused capillaries) in 10 different brain regions in two separate groups of animals with and without an arterial filter during normothermic cardiopulmonary bypass. Inclusion of a 40 micron arterial filter in the bypass circuit increased the regional brain glucose consumption 27% (median; range -12% to 145%) and regional capillary diffusion capacity increased 123% (median; range 36% to 829%). No change in brain histologic features, the cerebrovascular permeability to serum proteins, or cerebral water content was observed. The arterial filter probably protects the cerebral microcirculation and prevents the decrease in cerebral glucose consumption otherwise seen during bypass.

Brain damage following low flow cardiopulmonary bypass in pigs.

Reduction of pump flow during cardiopulmonary bypass (CPB) reduces the formation of microemboli and trauma to the blood components, reduces both rewarming of the heart and the noncoronary collateral flow, and improves surgical exposure. Recent studies indicate that a reduction in pump flow, even at normothermia, does not increase the incidence of postoperative cerebral dysfunction. We examined the cerebral consequences of 2 h of normothermic CPB in pigs carried out at pump flows of either 70 ml/kg per min or 50 ml/kg per min, and compared the results with those of a nonperfused control group. We measured the regional cerebral glucose metabolism and the regional capillary diffusion capacity simultaneously in ten different brain regions. Brain morphology, the blood-brain barrier permeability to serum proteins and the regional cerebral water content were also determined in the same animals. Glucose metabolism decreased significantly in both CPB groups (P < 0.001), and significant differences were found between the capillary diffusion capacities of the three groups (P < 0.05), with decreases in eight out of ten brain regions examined in the 50 ml/kg per min group. The results indicate that a reduction of pump flows from 70 ml/kg per min to 50 ml/kg per min is deleterious to the brain, and that a pump flow of 70 ml/kg per min itself has an injurious effect, when normothermic CPB is carried out for 2 h without the use of vasoactive drugs to maintain the blood pressure. Mean arterial blood pressure (MAP) rather than pump flow seemed to determine the adequacy of the cerebral perfusion.

Removal of halogenated anaesthetics from a closed circle system with a charcoal filter.

Halogenated anaesthetics may be removed from a closed circle system by means of a charcoal filter. With this technique dispersion to the atmosphere and a possibly destructive effect of the halogenated volatiles on the protective layer of ozone is avoided. Removal of halothane or isoflurane with a charcoal filter was studied in a closed circle system connected to an artificial lung. The concentration of anaesthetic (Ct) was recorded in relation to time by an anaesthetic gas monitor interposed between the system and the lung at ventilations of 3, 5, 7 or 9 l/min (v). Based on theoretical considerations, it was expected that Ct = Co.exp (-v/V.t), (V: volume of the system). Analysis of regression demonstrated that the results fitted well to an exponential decrease (R2 greater than 0.94) and the downslope increased with increasing rate of ventilation. However, the slopes deviated significantly from the theoretically predicted slopes, possibly because of adsorption to hoses and bags and unequal distribution of the volatiles in the system. Halothane was eliminated more slowly than isoflurane. This study demonstrates that halogenated volatiles are eliminated in an exponential way following charcoal filtration and the rate depends on the ventilation and type of volatile.

Hypocapnia prevents the decrease in regional cerebral metabolism during isoflurane-induced hypotension.

In neurologic surgery, induced hypotension is often used while the patient is hypocapnic. We investigated, by tissue biopsy methods and scintillation counting, the regional cerebral glucose utilization (rCMRglc) and blood flow (rCBF) in rats subjected to hypocapnia alone and in combination with hypotension. Anesthesia was maintained with 1.0% isoflurane in nitrous oxide/oxygen. Seven rats were maintained at PaCO2 of 40 mm Hg, six rats were ventilated to PaCO2 of 20 mm Hg, and six animals to PaCO2 of 20 mm Hg in combination with arterial hypotension of 50 mm Hg induced by isoflurane 2.5-3.5%. During hypocapnia, rCMRglc tended to increase in all regions, but the increase was statistically insignificant; rCBF was reduced uniformly by 40%. During combined hypocapnia/hypotension, rCMRglc was unaltered when compared to hypocapnia; compared to normocapnia, increases were seen in hippocampus and cerebellum. During hypocapnia/hypotension, rCBF was unaltered in cortical areas, while increases were seen in all subcortical areas compared to hypocapnia. Regional values of the ratio of rCBF/rCMRglc indicated that during hypocapnia and hypotension induced by isoflurane in nitrous oxide/oxygen, the individual brain areas were perfused according to their metabolic needs. It is suggested that hypocapnia may prevent the decrease in rCMRglc, which is usually observed during deep isoflurane anesthesia.

Regional cerebral blood flow and glucose utilization during hypocapnia and adenosine-induced hypotension in the rat.

Hypocapnia and induced hypotension have been claimed by some to cause cerebral hypoxia because of insufficient perfusion. Regional cerebral blood flow (rCBF) and regional cerebral glucose utilization (rCMRglc) were measured simultaneously in the same animal subjected to hypocapnia or hypocapnia combined with induced arterial hypotension. The rCMRglc was measured with (3H) deoxyglucose and the rCBF with (14C) iodoantipyrine with the use of tissue biopsy methods and scintillation counting. Nineteen male Wistar rats were anesthetized with halothane and artificially ventilated. Anesthesia was maintained with nitrous oxide/oxygen (70:30) and succinylcholine. Six rats were maintained at normocapnia, six rats were ventilated to a PaCO2 of 20 mmHg, and seven animals were ventilated to PaCO2 20 mmHg combined with arterial hypotension of 50 mmHg (mean blood pressure) induced by infusion of adenosine. Although hypocapnia alone did not cause a statistically significant decrease of rCBF except in hippocampus, hypocapnia combined with hypotension resulted in a significant reduction of rCBF in four of seven regions when compared with hypocapnia alone; rCMRglc values were unchanged during hypocapnia. However, the addition of hypotension induced by adenosine led to a significant decline of glucose utilization in five of seven brain regions. In the present study the authors observed no increase of regional glucose utilization and hence no signs of cerebral ischemia during hypocapnia alone or combined with hypotension induced by adenosine.

Brain histology, blood-brain barrier and brain water after normothermic and hypothermic cardiopulmonary bypass in pigs.

The effect of hypothermia during cardiopulmonary bypass (CPB) on cerebral histopathology, blood-brain barrier permeability to serum proteins and water content was evaluated. Pigs were subjected to non-pulsatile CPB for 2 h at either normothermia or hypothermia, and a group of anaesthetised pigs served as normothermic controls. The histopathology was assessed on paraffin embedded sections. The permeability of the cerebral vessels was studied by immunocytochemical demonstration of extravasated serum proteins. The cerebral water content was assessed by specific gravity measurements. The histological studies demonstrated hydropic degeneration of the brain parenchyma and perivascular swelling of the astrocytic endfeet throughout both white and gray matter in the normothermic CPB group. Similar changes were not encountered during hypothermic CPB, which suggests a beneficial effect of decreased temperatures on brain tissue during CPB. Neither normothermic nor hypothermic CPB induced significant changes in the cerebrovascular permeability or in the specific gravities.

Brain microvascular function during cardiopulmonary bypass.

Emboli in the brain microvasculature may inhibit brain activity during cardiopulmonary bypass. Such hypothetical blockade, if confirmed, may be responsible for the reduction of cerebral metabolic rate for glucose observed in animals subjected to cardiopulmonary bypass. In previous studies of cerebral blood flow during bypass, brain microcirculation was not evaluated. In the present study in animals (pigs), reduction of the number of perfused capillaries was estimated by measurements of the capillary diffusion capacity for hydrophilic tracers of low permeability. Capillary diffusion capacity, cerebral blood flow, and cerebral metabolic rate for glucose were measured simultaneously by the integral method, different tracers being used with different circulation times. In eight animals subjected to normothermic cardiopulmonary bypass, and seven subjected to hypothermic bypass, cerebral blood flow, cerebral metabolic rate for glucose, and capillary diffusion capacity decreased significantly: cerebral blood flow from 63 to 43 ml/100 gm/min in normothermia and to 34 ml/100 gm/min in hypothermia and cerebral metabolic rate for glucose from 43.0 to 23.0 mumol/100 gm/min in normothermia and to 14.1 mumol/100 gm/min in hypothermia. The capillary diffusion capacity declined markedly from 0.15 to 0.03 ml/100 gm/min in normothermia but only to 0.08 ml/100 gm/min in hypothermia. We conclude that the decrease of cerebral metabolic rate for glucose during normothermic cardiopulmonary bypass is caused by interruption of blood flow through a part of the capillary bed, possibly by microemboli, and that cerebral blood flow is an inadequate indicator of capillary blood flow. Further studies must clarify why normal microvascular function appears to be preserved during hypothermic cardiopulmonary bypass.

Prediction of cardiac risk in non-cardiac surgery.

This prospective study was carried out to develop a model for the prediction of cardiac risk in non-cardiac surgery. Detailed data were collected concerning the preoperative status of 2609 consecutive patients, who were followed closely during the postoperative course. Fatal or life-threatening cardiac complications occurred in 68 patients (2.6%). By utilizing logistic regression, a model for prediction of cardiac risk was developed. The model contained six significant preoperative predictor variables: Congestive heart failure (with 3 degrees of severity); ischaemic heart disease (with 2 degrees of severity); diabetes mellitus; serum creatinine above 0.13 mmol l-1; emergency operation; and the type of operation (two categories). With this model it seems possible to discriminate between patients with very different levels of cardiac risk.

The incidence of cardiac arrhythmias and arterial hypotension subsequent to standardized surgical stimuli in patients undergoing thoracotomy. With reference to enflurane and halothane.

A main factor which might cause cardiac arrhythmias and arterial hypotension during thoracic operations is surgical manipulation around the pericardium and the lung hilus. Halothane and enflurane were compared as to the occurrence of arrhythmias and hypotension caused by standardized surgical stimulation. Twenty-eight patients scheduled for thoracotomy were studied. The patients were selected in randomized order, and the anaesthetic agent in use was unknown to the surgeon. ECG, intra-arterial blood pressure and central venous pressure were recorded continuously. Six patients in the halothane group (n = 14) and nine patients in the enflurane group (n = 14) developed premature atrial contractions and nodal rhythm, while nine patients in the halothane group and five in the enflurane group developed a fall in systolic blood pressure of more than 20 mmHg (2.7 kPa). No statistically significant difference in the occurrence of cardiac arrhythmias and hypotension was found between the two anaesthetic groups.

Effect of epidural analgesia on muscle amino acid pattern after surgery.

Free amino acids in muscle were studied before and 96 hours after skin incision in 14 patients undergoing elective hip replacement and allocated to general anesthesia or epidural analgesia (T10-S5) effective before incision and maintained with intermittent 0.5% bupivacaine during the first 24 postoperative hours. The general anesthesia group (n = 8) showed the characteristic changes in muscle amino acids, with increase of branched chain amino acids and phenylalanine and decreased glutamine, arginine and lysine, as well as raised plasma levels of cortisol and glucose. The epidural group (n = 6), contrastingly, showed no significant changes in plasma cortisol and glucose and an attenuated postoperative response in all amino acids, without significant difference from the preoperative values. Differences in postoperative muscle amino acid concentrations between the epidural and the general anesthesia group were significant as regards glutamine, valine and asparagine. These results suggest that post-trauma changes in muscle amino acids are predominantly mediated by afferent neurogenic stimuli and the secondary increase in catabolic hormones.

Brain oedema and blood-brain barrier permeability in pulsatile and nonpulsatile cardiopulmonary bypass.

In pigs subjected to pulsatile or nonpulsatile cardiopulmonary bypass (CPB) at normothermia for 3 hours, evaluation was made of water content in brain tissue (specific gravity measurements), blood-brain permeability to serum proteins (immunocytochemical demonstration of extravasated proteins, using peroxidase-antiperoxidase technique) and histopathology (paraffin sections). The specific gravity in parietal cortex was higher after pulsatile than after nonpulsatile CPB or in control pigs, the change corresponding to a 6.3% water increase. The tissue water content was unchanged in the internal capsule, basal ganglia and nucleus accumbens after CPB. The vascular permeability to serum proteins was unchanged after nonpulsatile CPB, but after pulsatile CPB minute foci of extravasated serum proteins appeared. All the animals showed dark neurons in cortical and subcortical regions, but these could have been artefacts in immersion-fixed tissue. There were no other signs of ischaemic tissue damage. The study indicated that cortical oedema may follow pulsatile CPB, the cause being altered permeability of the blood-brain barrier to serum proteins.

Nonpulsatile cardiopulmonary bypass disrupts the flow-metabolism couple in the brain.

The effect of cardiopulmonary bypass on the relationship between brain glucose consumption and regional blood flow is unknown. We measured this relationship in pigs subjected to 3 hours of pulsatile or nonpulsatile cardiopulmonary bypass at normothermia and compared the results to the relationship established in a control group of pigs. A total of 10 regions were sampled in both hemispheres of the porcine brain. In control pigs, cerebral blood flow averaged 46 ml/100 gm and the glucose consumption, 21 mumol/100 gm/min. The ratio between blood flow and glucose consumption was close to 2 ml/mumol in all regions. In pulsatile cardiopulmonary bypass both the whole-brain average and the regional values declined, so that the ratio remained the same, about 2 ml/mumol. In nonpulsatile cardiopulmonary bypass regional blood flow remained normal; the average was 49 ml/100 gm/min, whereas the average glucose consumption declined to 16 mumol/100 gm. In regions with high blood flow rates, the ratio between blood flow and glucose consumption increased to about 3 ml/mumol, indicating perfusion in excess of metabolic demand. We conclude that nonpulsatile cardiopulmonary bypass at normothermia affects the metabolic flow regulation in the brain by interfering with the myogenic contractility of cerebral arterioles.

Pulsatile flow during cardiopulmonary bypass. Evaluation of a new pulsatile pump.

Pulsatile cardiopulmonary bypass (CPB) has been suggested to be superior to nonpulsatile CPB. This report concerns a newly developed pulsatile pump for clinical use. It is designed as a positive displacement pump, with blood allowed to collect in a valved cavity from which it is ejected by the reciprocating action of a piston. Using a uniform procedure of anaesthesia and surgery, 14 pigs were subjected to CPB at 37 degrees C for 3 hours. The pulsatile pump was used in seven pigs and a conventional roller pump in the other seven. The wave-form of the pulse during pulsatile CPB was similar to that recorded in the pigs before bypass. The values for rate of pressure change with respect to time (dp/dt) obtained in the aorta were close to the pre-CPB values. No difference was found between the two groups with respect to platelet count or haemolysis. The investigated pulsatile device appeared to be reliable and easy to handle, and the pulsation it produced closely resembled the physiologic pulse-wave form.

ATP-content in muscular interstitial fluid during pulsatile and non-pulsatile cardiopulmonary bypass in pigs.

The potential benefit of pulsatile flow during cardiopulmonary bypass (CPB) has been discussed extensively, but the debate is still unsettled. Release of intracellular ATP is a useful indicator of cellular damage; we have measured the ATP content in perfusates from muscles in pigs undergoing pulsatile or non-pulsatile CPB for 100 min at 37 degrees C. In 5 pigs the Polystan Pulsatile Pump was used and in 5 pigs a conventional roller pump. 11 pigs served as controls; 6 received heparin like the animals subjected to CPB, whereas the remaining 5 animals were not heparinized. ATP was measured by the firefly luminescence technique. At the start of the CPB or control period the ATP content was very low in all 4 groups. In the non-heparinized controls ATP continued to decrease, whereas in the other 3 groups ATP increased linearly during the 100 min of CPB or control period. It is concluded that, by this method, there was no significant difference between pulsatile and non-pulsatile CPB regarding damage to vascular endothelial or smooth muscle cells. However, heparinization per se caused a marked leakage of blood cells into the extravascular space even after the initial leakage from the cannulation had disappeared. This leakage was enhanced by non-pulsatile but not by pulsatile CPB.

The wide-range ejector flowmeter: calibrated gas evacuation comprising both high and low gas flows.

The wide-range ejector flowmeter is an active scavenging system applying calibrated gas removal directly to the anaesthetic circuit. The evacuation rate can be adjusted on the flowmeter under visual control using the calibration scale ranging from 200 ml X min-1 to 151 X min-1. The accuracy of the calibration was tested on three ejector flowmeters at 12 different presettings. The percentage deviation from presetting varied from + 18 to - 19.4 per cent. The ejector flowmeter enables the provision of consistent and accurately calibrated extraction of waste gases and is applicable within a wide range of fresh gas flows.

Haemodynamic effects of intravenous procaine as a supplement to general anaesthesia in patients with valvular heart disease.

The effect of intravenous procaine, 2 mg/kg/min, on the cardiovascular function of nine patients scheduled for cardiac valve replacement was studied under enflurane-pancuronium anaesthesia. Procaine infusion was started after intubation during steady-state anaesthesia, and continued until start of cardiopulmonary by-pass. Systemic vascular resistance decreased steadily from 198.2 +/- 28.7 to 133.0 +/- 17.2 kPa X s/l (P less than 0.05). A simultaneous decline in mean arterial pressure from 10.13 +/- 0.68 to 7.47 +/- 0.48 kPa was observed (P less than 0.01). Cardiac index, heart rate, central venous pressure, pulmonary arterial mean pressure and pulmonary capillary wedge pressure were all unaffected by procaine as well as by surgical stimulation. It is concluded that continuous procaine infusion as an adjuvant to general anaesthesia effectively abolishes the hypertensive and tachycardiac response to surgical stimulation. The limiting factor in the amount of infused procaine appears to be the hypotension caused by vasodilation, not myocardial depression or convulsions.

The closed co-axial analgesia system.

A twin-tube system for nitrous oxide analgesia in dental surgeries is described. The system is a non-polluting modification of the Mapleson A system, employing the principle of co-axial tubing introduced by Bain & Spoerel (1972). Active, continuous and calibrated gas removal takes place via the co-axial tubing by means of an ejector flowmeter. Investigation of the dynamic pressure excursions occurring at the nose-piece are fully compatible with normal breathing. Gas contamination of the dental environment can be reduced by at least 90%. The system described is safe and easy to handle. It is made of light-weight material and is adaptable to the equipment available. No rebreathing takes place when using a fresh gas inflow of 150 ml/kg body weight/min.

The ejector flowmeter as air/oxygen mixing device. An apparatus providing gas mixtures with adjustable oxygen content for high-flow humidification systems.

The ejector flowmeter is constructed for continuous removal of excess gas from anaesthetic circuits. This instrument can be used as an air/oxygen mixing device for high-flow humidification systems in wards where compressed air is not available. Pure oxygen is used as driving gas through the ejector. A nomogram has been constructed to show the relationship between oxygen driving pressure, inlet of air to the flowmeter, FIO2 and total outflow.