بسم الله الرحمن الرحيم

By:By:

Mohamed R. El Tahan, , M.DLecturer of Anaesthesia & Surgical ICU

By:By:

Mohamed R. El Tahan, , M.DLecturer of Anaesthesia & Surgical ICU

To understand:

1.Pathophysiology of weaning from CBP.

2.Grouping of patients during weaning from CBP.

3.Preparation for weaning from CBP.

4.Discontinuation of CBP.

5.Difficult weaning from CBP.

☼ Weaning Off CBP isWeaning Off CBP is::☼ Weaning Off CBP isWeaning Off CBP is::

SouzaSouza && Elias Elias ((19971997), ), andand VegasVegas ( (20002000))

►► Simple process, that may occasionally prove very difficult or virtually impossible.

►► Period of potential stress for the heart.

►► Time of planned action among the cardiac operating team.

►► Critical time.

►► The time that the anaesthetist must be patient & well communicable with both the surgeons & the perfusionist.

IntroductionIntroduction

Cardiopulmonary Bypass

is associated with various insults to normal physiology.

Anticoagulatio

n.

Haemodilutio

n.

Hypothermi

a.Cardiac

Arrest.

▲ Cathecholamines.

Vasopressin

Release.

Electrolyte

Disturbances.

Platelet Activation.

Activation of

complement.

PathophysiologyPathophysiology

Moyers Moyers & & Tinker (Tinker (19891989))

Royster (Royster (19931993))

☻Following separation from CBP, ventricular function improves initially, but then begins to worsen & reaches a nadir between 4-6 hrs after surgery with full recovery occurring around 24 hrs post – operatively.

☻However, in patients with pre – operative ventricular dysfunction, the depression of ventricular function is more severe& recovery is longer.

Graphic illustration of myocardial performance

following CBP changes

Preop. CBP end Post CBP hours

PathophysiologyPathophysiology

■■ GroupGroup ((AA)):: MajorityMajorityMajorityMajority

No difficulties to remove from CPB. ± Slow infusion of inotropes/V.D.

■■ GroupGroup ((BB))::

Mild to Moderate dysfunction. Physiological (Starling’s law) or Pharmacological

(inotropes,vasoactive) support.

■■ GroupGroup ((CC))::

Poor or No cardiac action. Aggressive Pharmacological support or Prolonged Mechanical support.

SouzaSouza && Elias Elias ((19971997))

Grouping Of PatientsGrouping Of Patients

Preparation For WeaningPreparation For Weaning

☻Requirements of analgesic, narcotic and paralyzing drugs usually

increase during re warming and the necessary adjustments are made to avoid awareness or the increase of the oxygen demand

with avoidance of myocardial and circulatory depressant agents.

Hemmings Hemmings & & Thomas (Thomas (19931993))

► Temperature changes. ☻ CPB is accompanied by heat loss even when hypothermia is not employed.

☻ Re-warming should be initiated as early as necessary so that its completion coincides with completion of the surgical procedure or soon afterwards.

► Monitoring.☻Patient temperature is monitored in at least two sites such as:

☼ Nasopharyngeal. ☼ Esophageal. ☼ Rectal. ☼ Bladder. ☼ Tympanic.


► Goals. ☻☻ Nasopharyngeal ((36.5 –– 37 C C○○).).

☻☻ Rectal ((37 C C○○).).

☻☻ Bladder ((35 –– 37 C C○○).).

☻☻ Toe (>(>30 C C○○).).

► A larger than 4 C○ gradient between the nasopharyngeal and rectal temperatures is indicative of inadequate re – warming or increased vasoconstriction.

► This may predispose the patients to unstable cardiac, rhythm, shivering and increased SVR.


► After Drop Phenomenon. ♦ 2 – 3 C○ decrease in nasopharyngeal temperature during sternal

closure and transfer to ICU.

♦ This may be attributed to redistribution of heat within the body as the normal pulsatile blood flow opens up some relatively colder and constricted vascular beds.

♦ This may be corrected with:

☻A slow infusion of nitroprusside or other vasodilators may provide a more homogenous re warming.

☻ High CBP flow.

☻ Pulsatile flow.Hemmings Hemmings & & Thomas (Thomas (19931993))Williams Williams et alet al ( (19931993))


☻The recovery of the metabolic functions speeds the elimination of heparin with re–warming, so , activated clotting time (ACT) should repeated more frequently at normothermia and additional 100 u.Kg-1

of heparin may be needed to maintain ACT >480 seconds.


☻☻Regardless of the myocardial protection strategy and method used , even short periods of aortic cross – clamping can be followed by temporary functional depression.

☻☻Most hearts will benefit from a period of rest (reperfusion time) after releasing the aortic cross – clamp to replenish myocardial

ATP stores and washout metabolites from the coronary circulation.

☻☻Partial bypass may help to eliminate untoward pulmonary V.C.

☻☻An average of 15 to 20 minutes of supportive CPB will usually

provide a good recovery time for each hour of clamping time.

Moyers Moyers & & Tinker (Tinker (19891989))


HYPERKALEMIAHYPERKALEMIA

◙ Hyperkalemia during cardiac surgery may be caused by cardioplegia, haemolysis, acidosis, massive depolarization of muscle, and tissue cell death.

◙ After adoption of blood cardioplegia a higher potassium level is more commonly seen at the end of perfusion.

◙ High potassium level may be responsible for the presence of a heart block or bradycardia.

Hemmings Hemmings & & Thomas (Thomas (19931993))


POTASSIUM:POTASSIUM:

◙ Potassium has pronounced effects on cardiac conduction.




HYPERKALEMIAHYPERKALEMIA

● Mild hyperkalemia represented by a serum level of 6 mEq/L will not require special treatment and resolve spontaneously.

● Severe hyperkalemia represented by a serum level > 6 mEq/L:

▄ ▄ Treatment Treatment :: ■ Frusemide: [3,10,30,300 mg].

■ 1.0 gm glucose per kilogram and 1 unit of regular insulin per 4.0 gm of glucose administered.

■ CaCl2: [1 – 2 gm].

■ NaHCO3: [50 mEq].




HYPOKALEMIA HYPOKALEMIA

● Hypokalemia if present should be treated to avoid the risks of atrial and ventricular arrhythmias.

● Hypokalemia may be caused by haemodilution with non–potassium priming solutions, diuresis, or increased sympathetic tone during nonpulsatile perfusion.

● Hypokalemia predisposes to atrial arrhythmias, ventricular ectopy, and digitalis toxicity.

▄ ▄ TreatmenTreatment t :: ■ ■ KCL 5 –10 mEq.

CheungCheung && ChernowChernow ((19911991))


CALCIUM:CALCIUM:

◙ Ionized calcium levels usually decrease during CPB and appear to recover fast thereafter.

◙ Evidence suggests that calcium influx during ischemia – reperfusion contributes to myocardial dysfunction after CPB.


CALCIUM:CALCIUM:

CaClCaCl22:: ☻☻ Indications: Indications: ►Valvural surgery. ►Pediatric surgery. ☻☻ Time:Time: After reperfusion time or > 8 minutes.

☻☻ Dose:Dose: 10 – 15 mg.Kg -1.

☻☻ Advantages:Advantages: * ++ SVR. * Correction of ionized hypocalcaemia. * Correction of hyperkalemia. ☻☻ Drawbacks:Drawbacks: * Ischemic cellular injury. * Coronary artery spasm. * IMA graft spasm. * Post – operative pancreatitis. * Blunt the response to epinephrine & dobutamine.

Prielipp Prielipp && Butterworth ( Butterworth (19971997))


MAGNESIUM:MAGNESIUM:

◙◙ Magnesium, essential to the normal electro–mechanical function of myocardial cells, has an important role in protecting the myocardium against the damaging effects of intracellular accumulation of Ca++.

◙◙ Exogenous Mg++ has been considered in the management of cardiac dysrhythmias, myocardial infarction, and for improving myocardial performance after cardioplegic arrest.


MAGNESIUM:MAGNESIUM:

MgSoMgSo4 4 ::

☻☻ DoseDose: : 50 mg. Kg -1.

☻☻ AdvantagesAdvantages:: * Magnesium prevents hypomagnesaemia in 1st post –

operative day.

* less need for pacing, inotropes, & defibrillation during

separation from CPB.

* Magnesium inhibits platelet function.

* Magnesium has neuroprotective effects as proved by

reduced incidence of neurocognitive dysfunction in

post – CABG.

GathwalaGathwala ((20012001))

A.A. HAEMATOCRIT:

◙ Haemodilution is universally used as an adjunct to CBP.

◙ Haematocrit values from 20 to 25% are usual with most perfusion

protocols.

◙ By the end of re warming, depending on renal function and the use

of diuretics haematocrit may reach 24 to 30%.

◙ Hearts with severe preoperative myocardial dysfunction will perform

better immediately after termination of CPB with a haematocrit level above 34%.

◙ Red blood cells transfusion during re – warming may be necessary

to adjust the haematocrit prior to discontinuing perfusion.

MartineauMartineau ((19961996))

DO2=1.34xHb [gm.dl-1]xSaO2 x COP


B.B. Tissue oxygenation:

◙ A progressive disparity develops between arterial & mixed venous blood gases with regard to both acid-base status and oxygenation.

◙ Optimum ABGs will best reflect the adequacy of the oxygenator

performance.

◙ Mixed venous blood gases analysis is well correlated to the adequacy

of the tissues perfusion.

◙ Inadequate tissue perfusion & oxygenation is manifested by increased lactate production, decreased pH, decreased SvO2 and PvO2.

◙ A SvO2 of 75% and a minimum venous PvO2 of 35 mmHg are

satisfactory to start weaning from CPB.SouzaSouza && Elias Elias ((19971997))



C.C. Cardiac output:

◙◙ Assessment of cardiac function immediately prior to discontinuing perfusion is usually performed by:

☻☻Direct visualization: Simple visual observation of heart contraction and relaxation may provide valuable information on myocardial performance.

☻☻PAC.

☻☻TEE.

SouzaSouza && Elias Elias ((19971997))



C.C. Cardiac output:

I. Heart Rate & Rhythm:

► Weaning from CBP requires a heart rate of 70–100 bpm for adequate cardiac output to compensate for a lower stroke volume associated with myocardial dysfunction.

► Sinus rhythm is preferred for adequate atrial kick particularly in the presence of a non – compliant thick walled ventricle.



A- A- AsystoleAsystole / / Heart blockHeart block::

►► Frequently, temporarily A.V block is found at the end of CBP because of pre–existing heart block, K+ cardioplegia & ischemic insult during aortic cross–clamping.

(1.) Correction of hyperkalemia: � CaCl2: (1−2 g).

� Insulin (10 U ) ± Glucose (40 gm). � Fursemide: (1,3, 0, 100 mg).

� NaHCO3: (50 mEq).

(2.) Atropine (2-2.5 mg /70 Kg BWT). (3.) Temporary Epicardial Pacing: � Types: A−V sequential, Ventricular.

� Pacing Rate: 80– 100 Bpm.

(4.) Isoproterenol (0.01 − 0.1 μg.Kg-1.min-1 ).


C.C. Cardiac output: DO2=1.34xHb [gm.dl-1]xSaO2 x COP


B- B- Ventricular fibrillationVentricular fibrillation / / TachycardiaTachycardia::

(1) DC defibrillator: (10 - 40 Watt/Sec).

((2) ) Temperature: ++ to 37 Cº.

((3)) Electrolytes: K+ , MgSO4 [1 – 2 gm].

((4) ) ABGs: pH , PaO2 , PaCO2.

((5)) Haematocrit: > 30%.

((6) ) Check PAPA catheter position. .

((7) ) Satisfactory MAP [ ≥ 80 mmHg], PAOP & COP.

((8) ) Lidocaine: (1.5, 1, 0.5 mg.Kg-1 i.v).

((9) ) Amiodarone: ( 5 mg.Kg-1 i.v).

((10)) Bretylium: (5 – 10 mg.Kg-1 i.v followed with 1 –2 mg.min-1 i.v.i).




◙◙ Baraka et al (Baraka et al (20002000))

suggested that a bolus of 100 mg of lidocaine administered 2 minutes before release of the ACC can safely decrease the incidence of reperfusion ventricular fibrillation after weaning from CBP.

◙◙ Turkoz et alTurkoz et al ( (20022002))

concluded that a termination of persistent refractory VF, which can be difficult to treat, can be done by re – cross– clamping the ascending aorta while the patient is still on CBP, infusing 37 Cº buffered K+ cardioplegic solution into the coronary system,and, after having achieved flaccid standstill, pacing the heart by the ventricular mode.




B- B- Ventricular fibrillationVentricular fibrillation / / TachycardiaTachycardia::

C- Supra – ventricular arrythmias:C- Supra – ventricular arrythmias:

(1.) Temperature: ++ to 37 C○. (2.) Electrolytes: K+ , Mg++.

(3.) ABGs:. pH , PaCO2.

(4.) Haematocrit. (5.) Check CVP catheter position. (6.) Overdrive Pacing. (7.) Synchronized DC: (5−10 Watt/Sec). (8.) Adenosine: (6−12 mg).(9.) β-blockers: Esmolol / Propranalol.(10.) CCB: Diltiazem(5−25 mg i.v).(11.) Procainamide: (100 mg q. 5.00 min to effect OR 15 mg.Kg-1 ).




●● Preload is indirectly evaluated by ventricular filling pressures.

◙ Left ventricular preload is inferred from the left atrial mean pressure or pulmonary artery diastolic pressure.

◙ Right ventricular preload is inferred from the right atrial pressure.



II. Preload:

►During weaning preload is pump– dependent and can be adjusted by balancing blood volume between patient and oxygenator.

►If there is enough volume in the pump it will come off CPB.

►In the absence of sufficient volume, the perfusionist may administer additional blood, PRBCs, colloids or crystalloids.

►It is preferred to give blood and blood products through a peripheral line to avoid trauma to cells associated with the pump.



II. Preload:

● Left ventricular afterload is evaluated by the status of peripheral vascular resistance [SVR].

● Right ventricular afterload is evaluated by the status of pulmonary vascular resistance [PVR].

► Elevated peripheral resistance can be reduced by the administration of vasodilators.

► Decreased peripheral resistance will require a vasoconstrictor infusion [norepinephrine, phenylephrine] to restore a normal peripheral resistance.



III. Afterload:



III. Afterload:►►Elevated PVR can be reduced by:

▀ Correction and /or/ avoidance of the factors that increase PVR:1. Hypoxia. 2. Hypercarbia.3. Acidosis. 4. Sympathetic stimulation.5. Hypervolemia / Hypovolemia. 6. ++ ITP [eg . PEEP].7. Drugs: ■ Ketamine.

■ Nitrous Oxide.

▀ Administration of pulmonary vasodilators: [NO, PGEI, PDIs, Dobutamine, SNP, NTG].



IV. Contractility:

☻The usual situation is represented by a mild and very transient functional impairment shortly followed by resumption of effective cardiac action.

☻Most patients tolerate a relatively low B.P [SBP 60–80 mmHg] for 3–5 minutes and often it is a short time before the patient’s heart begins to function well without inotropes.

Vegas Vegas ((20002000))

►►The lungs should be re – expanded with 2 – 3 breaths to a peak pressure of 30 – 40 cmH2O with visual confirmation of bilateral lung expansion.

►►This may help removal of trapped air in the pulmonary veins.

►►Vaporizers are turned off 15 – 30 minutes prior to termination of CBP as agents may take a long time to clear from the pump circuit, particularly the oxygenator.



►► All pressure transducers are zeroed.

►►There is frequently discrepancy between the radial arterial pressure and the central aortic pressure, though the pressures gradually equilibrate over 10 – 30 minutes.

►►When a clinician is unsure of the blood pressure during separation from CPB, direct measurement of central aortic blood pressure, femoral arterial pressure, oscillometric, aortic line of the CPB circuit, and digital palpation is advised.



● Cardiac Chambers, air could be evaluated by TEE.

● Aorta.

● Saphenous graft.

● Head – down position.

● Carotid Artery Compression.

Miller (Miller (20002000))


Termination of CBPTermination of CBP

☻☻The venous line is partially occluded by the surgeon or perfusionist and the patient’s heart is allowed to fill.

☻☻Watch the filling pressures and observe the right heart filling.

☻☻Try not to overfill the heart, even if the systemic blood pressure appears low, as over distension impairs ventricular contractility and subendocardial blood flow which may predispose to mitral regurgitation.

Vegas (Vegas (20002000))

☻☻As the heart ejects blood flows through the aorta, the aortic pump flow is lowered by 0.5 –1.0 L.minute-1.

☻☻If the heart function is expected to be good, the venous line is clamped and the heart weaned from CPB quickly.



☻The venous line is completely clamped and the aortic pump head is turned off. * Rapid weaning: if good myocardial function. * Slow weaning: if poor myocardial function.

☻If needed, additional volume in increments of 50–100 cc to optimize

the preload with the aid of head – up position ± venodilators.

☻ Low preload may be due to:

a. Continued volume redistribution due to vasodilatation. b. Changes in ventricular diastolic compliance. c. Ongoing bleeding in the chest.

☻ Following CPB try to maintain an optimal SBP of 90–120 mmHg.

☻ Monitor adequacy of systemic perfusion by observing patient colour, urine output and absence of acidosis.



☻ Surgical control of major bleeding.

☻ Decanulation of venous cannulae.

☻ Decannulation of aortic cannula.

☻ Reversal of anticoagulation.

☻ Maintenance of circulating volume.

☻ Maintenance of adequate coagulation.

☻ Haemodynamic adjustment.

☻ Anaesthesia.

☻ Transfer to CVICU.

Miller (Miller (20002000))


60 year aged male patient underwent successful LCA bypass & Aortic valve replacement. Hypothermic CBPwas non – pulsatile & continued for 80 min.. Last cold

cardioplegia was given 20 min. ago.

NowNow,, it’s the time of weaning from CBP it’s the time of weaning from CBP,,

What do you want to ask me?What do you want to ask me?

1. Pre–operative myocardial function status.

2. What’s about the depth of anaesthesia?

3. What’s the value of his body temperature?

4. What’s the value of ACT, now?

5. What’s the Haematocrite value?

6. What’s the value of SaO2?

7. What’s the heart rate & rhythm?

8. What’s the value of RV and LV preload?

9. What’s about the myocard. contractility?

10.What’s the value of RV and LV afterload?

Cardiac F. FairFair

Anaesthesia ?

Temperature 3737 C C○○

ACT 390 390 sec.sec.

Hct. 2121%%

SaO2 9292%%

Heart RR & RR VFVF

Preload EmptyEmpty

Contractility WeakWeak

Afterload PVR + +PVR + +

1.1. I’m already prepared my I’m already prepared my drugsdrugs and they are and they are STAND – BYSTAND – BY..

2.2. I’ll ensure the adequate I’ll ensure the adequate depth of anaesthesiadepth of anaesthesia [ [ BY ?BY ?……. ].……. ].

3.3. Re – warmingRe – warming was started to the value of Nasopharyngeal was started to the value of Nasopharyngeal ((36.536.5––3737 C C○○) )

RectalRectal ((3737 C C○○).).

4.4. Additional Additional HeparinHeparin was considered to maintain was considered to maintain ACTACT > > 460460 seconds. seconds.

5.5. Re – perfusionRe – perfusion for for 2020 – – 2525 min.min.

5.5. Additional Lasix or PRBCs was given to maintain Additional Lasix or PRBCs was given to maintain HctHct value value 2020 toto 2525%%

6.6. Maintain adequate Maintain adequate tissue oxygenationtissue oxygenation ABGsABGs, , SvOSvO22 andand PvOPvO22..

7.7. VF protocol? VF protocol? ±± Electrolytes Electrolytes [ [ KK++, , CaCa++++, , MgMg++++ ]]..

8.8. I’ll consider additional I’ll consider additional filling of the empty heartfilling of the empty heart..

9.9. I’ll start my I’ll start my inotropic supportinotropic support after after 2/32/3 of the re – perfusion time. of the re – perfusion time.

10.10.I’ll start my I’ll start my V.DV.D to optimize the values of RV and LV afterload. to optimize the values of RV and LV afterload.

60 year aged male patient underwent successful LCA bypass & Aortic valve replacement. Hypothermic CBPwas non – pulsatile & continued for 80 min.. Last cold

cardioplegia was given 20 min. ago.

NowNow,, it’s the time of weaning from CBP it’s the time of weaning from CBP,,

What are your next steps?What are your next steps?

Difficult Weaning Off CBPDifficult Weaning Off CBP

☻☻Difficult Separation From CBP ( (DSBDSB)):

1. Systolic arterial pressure < 80 mmHg.

2. Diastolic pulmonary artery pressure >15 mmHg. During progressive separation from CPB without inotropic, mechanical support of cardiac function.

3. Haemodynamic instability resulting in the re-introduction of CBP.

4. The insertion of an intra – aortic balloon pump (IABP).

5. Patients with successful weaning from CPB but requiring a significant

amount of:Vasopressors (norepinephrine > 4 µg.min-1 or epinephrine > 2 µg.min-1).

Inotropic drugs (dobutamine > 2 µg.kg-1.min-1 or the use of amrinone and

milrinone) during the first 12 hours after surgery.

IABP, or both.BernardBernard et al (et al (20012001))

☻☻Factors of Difficult Weaning from CBP:1. Aortic cross clamp time > 120 minutes.2. Incomplete surgical repair: ► Valve replacement: a. small size. b. Failed prosthetic valve. c. Failed native repair.

► Incomplete revascularization: a. Graft failure [kink, debris, air]. b. Small vessels. c. Distal disease.

3. Inadequate myocardial protection: a. Non – systolic ECG. b. Prolonged ventricular fibrillation prior to aortic–cross clamp and un–clamping.

c. Warm myocardium: due to * LVH [incomplete cardioplegic protection]. * High grade coronary stenosis. * Choice of graft order. * Non – coronary collateral flow. * Poor LV venting.

4. Reperfusion injury.5. Ventricular distension [volume overload]. 6. Under–filled ventricles [inadequate preload].


VegasVegas ( (20002000))

☻☻The Consequences of Prolonged Weaning from CBP:

1. More prolonged pump time.

2. Potential systemic hypotension & organ damage.

3. Increase the need for multiple inotropes.

4. The use of mechanical assistance.

5. Potential need for blood products.



☻☻Predictors of The Needs of The Inotropic support:Pre–Operative:

1. Age > 60 years.2. Low LVEF < 0.4.3. Female sex.4. Cardiomegally.5. CHF.6. Recent M.I < 6 months.7. D.M.8. Three vessels coronary grafts.9. Redo surgery.10. Emergency surgery.

Intra–Operative:1. CBP time >150 minutes..2. Aortic cross clamp time >120 minutes..

Royster Royster ((19931993)), Rao , Rao ((19961996))& Butterworth& Butterworth ( (19981998))


☻☻Predictors of The Needs of The Vasopressor Support:

Pre – Operative:1. Low LVEF < 0.35 − 0.4.2. Advanced Age.3. D.M.4. Peripheral vascular disease.5. Drugs : eg : ACEIs, diuretics.6. Recent M.I < 6 months.

Intra – Operative:1. Normothermic CBP..2. Longer perfusion time.3. Hypothermic CPB -----------► -----------► Longer CPB time.

-----------► -----------► larger volume of cardioplegia.

ArgenzianoArgenziano((19981998)) & Christakis & Christakis ((19941994))


☻☻Management issues:

■ If the patient doing poorly, the simplest and fastest solution is to

Go Back on CBP

■ Try to differentiate wether the problem is:

● Technical [graft, valve or rhythm].

● Vasodilatation [low SVR].

● Myocardial dysfunction [either left, right, or biventricular].

■ There is no simple recipe of drugs to memorize instead the management of all patients should be individualized.


Go Back on CBP


☻☻Management issues:

■ Consider the following options: ☻ Further reperfusion on CBP.

☻ Haemodynamic manipulation with inotropes, vasopressors, afterload reducers.

☻ Improve preload, pacing, inotropy.

☻ Mechanical support: -----------► IABP.

-----------► LVAD.

-----------► RVAD.

-----------► IPBP.

-----------► BiVAD.

☻ Further surgical manipulation: redoing graft, replace valve, ? ASD/ PFO.

☻ Further investigations: ------►Laboratory [Haematocrit, K+, HCO3 ]. ------►TEE.



►►Clinical finding: a. Decrease SBP.

b. Decrease pulse pressure.

c. Decrease [SBP – MAP].

d. Decrease SvO2.

●● Management:

1. Decrease Afterload [SVR] -----------► systemic VD. 2. Adequate Preload. 3. Adequate H.R & Rhythm. 4. LV Support : ■ Dopamine, Epinephrine, Dobutamine. ■ Milirinone ± Epinephrine. ■ MAD [IABP, LVAD]. ■ Adequate metabolic milieu [K+, HCO3].

Left ventricular failureLeft ventricular failure



Dr.Mohammed R. El Tahan

►Clinical finding: a. Decrease COP and REF. b. Increase CVP > PADP / PAOP.

c. Decrease [CVP – MPAP] = zero.

●● Management:

1. Decrease Afterload [PVR] -----------► pulmonary VD. -----------► Avoid ++ PVR. 2. Adequate Preload. 3. Adequate H.R & Rhythm. 4. RV Support: ■ PDI [ Milirinone, Amrinone ]. ■ Norepinephrine ± NTG. ■ Nitirc oxide. ■ Isoproterenol. ■ PGE1. ■ MAD [IPBP, RVAD].

Right ventricular failureRight ventricular failure



The key to successful weaning is The key to successful weaning is

a lot of communicationa lot of communication,, a little a little

patiencepatience,, checking and reaching checking and reaching

the optimum haemodynamic the optimum haemodynamic

parameters and choosing the parameters and choosing the

best drugsbest drugs..

بسم الله الرحمن الرحيم

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