Cardiopulmonary Bypass in Adult Cardiac Surgery Clinical Practice Guidelines (2019)

European Association for Cardio-Thoracic Surgery (EACTS)/European Association of Cardiothoracic Anaesthesiology (EACTA)/European Board of Cardiovascular Perfusion (EBCP)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2019

Control of Mean Arterial Pressure (MAP) During CPB

It is recommended to adjust the MAP during CPB with arterial vasodilators (if MAP >80 mm Hg) or vasoconstrictors (if MAP < 50 mm Hg), after checking and adjusting the depth of anesthesia and assuming sufficiently targeted pump flow. Use of vasopressors to force MAP during CPB at values higher than 80 mm Hg is not recommended.

It is recommended that vasoplegic syndrome during CPB be treated with alpha1-adrenergic agonist vasopressors. For vasoplegic syndrome refractory to such agents, alternative drugs (vasopressin, terlipressin, or methylene blue) should be used, alone or in combination with alpha1-agonists. Hydroxocobalamin may be used to treat vasoplegic syndrome during CPB.

Pump Flow Management During CPB

It is recommended that the pump flow rate be determined before initiation of CPB on the basis of body surface area and planned temperature.

The adequacy of the pump flow rate during CPB should be checked in accordance with oxygenation and metabolic parameters (mixed venous oxygen saturation [SvO2], oxygen extraction ratio [O2ER], near-infrared spectroscopy [NIRS], carbon dioxide production [VCO2], lactates). The flow rate should be adjusted according to the arterial oxygen content to maintain a minimal threshold of oxygen delivery (DO2) under moderate hypothermia.

Pump flow rates may be settled on the basis of lean mass in obese patients.

Type of CPB Pump Flow

Pulsatile perfusion may reduce postoperative pulmonary and renal complications and should be considered in patients at high risk for adverse lung and renal outcomes.

Perioperative Hemodynamic Management

Goal-directed hemodynamic therapy (GDT) is recommended to reduce the postoperative complication rate and length of hospital stay.

Use of Assisted Venous Drainage

It is recommended that an approved venous reservoir be used for assisted venous drainage.

It is recommended that the venous line pressure be monitored when using assisted venous drainage. Excessive negative venous pressures are not recommended.

Transfusion Management During CPB

It is recommended that packed red blood cells (PRBCs) be transfused during CPB if hemoglobin (Hb) < 6.0 g/dL.

For hematocrit (Hct) values between 18% and 24%, PRBCs may be transfused based on an assessment of the adequacy of tissue oxygenation. PRBCs should not be transfused if Hct > 24%.

It is recommended that antithrombin concentrate be used instead of fresh frozen plasma (FFP) to treat antithrombin deficiency to improve heparin sensitivity. If antithrombin concentrate is unavailable, FFP should be considered.

FFP should not be used prophylactically during CPB to reduce perioperative blood loss.

Anesthesia and Pharmacologic Management

Volatile anesthetics should be considered during CPB. The oxygenator exhaust concentration of such an agent should be at least the same during CPB as before CPB (if used as sole anesthetic agent), except during rewarming, when it should be increased. Oxygenator exhaust concentrations should be monitored during CPB.

Doses of intravenous (IV) anesthetics and opioids, except remifentanil, should be at least the same during CPB as before CPB (if used as the sole anesthetic agent). After 20-30 minutes from the initiation of CPB, the remifentanil dose may be reduced by 30% at 32°C; hypothermia below 27°C requires immediate reduction by 60%.

Short-acting neuromuscular-blocking agents should be considered in cardiac anesthesia.

Routine use of prophylactic IV corticosteroids is not recommended during cardiac surgery.

Tight glycemic control may be considered during CPB.

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