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Management of lung problems during Cardiac Surgery

Ospedale Papa Giovanni XXIII di Bergamo Dipartimento di Anestesia e Rianimazione : Direttore F.L.Lorini. Management of lung problems during Cardiac Surgery. Objectives. Size of the problem and Factors causing pulmonary dysfunction Definition of diseases Therapeutic implications.

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Management of lung problems during Cardiac Surgery

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  1. Ospedale Papa Giovanni XXIII di Bergamo Dipartimento di Anestesia e Rianimazione : DirettoreF.L.Lorini Management of lung problems during Cardiac Surgery

  2. Objectives • Size of the problem and Factors causing pulmonary dysfunction • Definition of diseases • Therapeutic implications

  3. Volume 25(11) November1999 pp 1831-1839 Early onset of acute pulmonary dysfunction after cardiovascular surgery: Risk factors and clinical outcome Rady, Mohamed Y. MD, PhD, FRCS, MRCP; Ryan, Thomas MB, MRCPI, FFARCSI; Starr, Norman J. MD A total of 3,122 patients were evaluated and 1,461 patients satisfied the entry criteria of the study. Early postoperative pulmonary dysfunction was present in 180 (12%) Conclusions: The incidence of early postoperative pulmonary dysfunction is uncommon; however, once developed, it is associated with increased morbidity and mortality after cardiovascular surgery.

  4. Is There a Pulmonary Problem? • Volume 25(11) November 1999 pp 1831-1839 Early onset of acute pulmonary dysfunction after cardiovascular surgery: Risk factors and clinical outcome • Rady, Mohamed Y. MD, PhD, FRCS, MRCP; Ryan, Thomas MB, MRCPI, FFARCSI; Starr, Norman J. MD • Advanced age • large body mass index • preoperative increased pulmonary arterial pressure • low stroke volume index, hypoalbuminemia • history of cerebral vascular disease • emergency surgery, and prolonged CPB time risk factors for early onset of severe pulmonary dysfunction after surgery. Postoperative systemic hemodynamics suggest that early postoperative pulmonary dysfunction can be a component of a generalized inflammatory reaction to cardiovascular surgery.

  5. Arachidonic acid metabolites Oxygen free radicals Endothelins Proteases PAF No 2. Complement activation 1. Ischemia/Reperfusion Endotoxin Proinflammatory cytokines Cellularactivation CPB Inflammatory response to CPB Tissue injury

  6. Ischemia/Reperfusion Representative light microscopic images of lung tissue Alveolar septal thickness (A) and alveolar surface area (B) before CPB and at the end of reperfusion after CPB with or without controlled PA perfusion. 7

  7. Is There a Pulmonary Problem? • Do we think about lung protection? • Ventilation – stop •  Perfusion – stop • 3% Total lung Bl. Flow (Bronchial Artery) LEAST PROTECTED ORGAN DURING CPB

  8. ALI-ARDS • PCWP < 18 mmHg • PaO2/FiO2 < 300 (ALI) • PaO2/FiO2 < 200 (ARDS) • Bilateral infiltrates on chest radiographs

  9. TRALI TRALI = Transfusion Related Acute Lung Injury • Acute onset • Within 6 hours after transfusion • ALI characteristics

  10. TRALI Causes: • Packed RBC, FFP, Platelets, granulocytes, cryoprecipitate, IV immunoglobulin ,bone marrow stem cells • No Association with washed red cells, albumin,clotting factor concentrates Pathogenesis is not clear : • Ab- mediated TRALI • Non Ab mediated TRALI • Two hits

  11. TRALI Journal of Intensive Care Medicine Volume 23 Number 2 March/April 2008 109-121

  12. TRALI • Resolution usually in 96h after transfusion • Mortality between 5-10% • Therapy is supportive

  13. TRALI RBC are the major cause of transfusion related side effects Ann Thorac Surg 2009;88:1410–8)

  14. TRALI Crit Care Med 2010 Vol. 38, No. 3

  15. Monitoring Vital Parametrs Swan -Ganz Echography RS function Chemistry Radiology

  16. Echography • Heart: • Biventricular funtion • ( RV failure) • Pulmonary hypertension • Valve function • Septal defects • Lung: • Effusion • Consolidation • PNX

  17. Right Ventricular Function Echography Baseline Recruitment Open lung PEEP Critical Care 2009, 13:R59

  18. Variation of RV function after CABG in 250 elective patients

  19. Lung-Heart interaction Afterload of RV increase for : • Compression of intralveolar vessel by positive pressure ventilation • Increasing of vasomotor tone • Reduction of vessel tree by reduction of lung parenchyma • Fluid overload ( prexisting and caused by fluid resuscitation) Acidemia Hypercania Hypoxia

  20. Ventilation Recruitment Lung protective ventilation Permissive hypercapnia

  21. Ventilation • TV ≤ 6 ml/Kg IBW (men weight in kg= 50+ 0.91 *(height in cm-152) (women weight in kg= 45.5+ 0.91 *(height in cm-152) • Plateu pressure ≤ 30 cmH20 • RF ≤ 35 b/min • PEEP

  22. PEEP • ALVEOLI,LOVs, EXPRESS ) there is an evidence of using high PEEP in patients with ARDS. May be harmful in patient with ALI • Titration of PEEP is not univocal • Less time to unassisted breath in ARDS patients JAMA, March 3, 2010—Vol 303, No. 9 Current Opinion in Critical Care 2010,16:39–44

  23. PEEP JAMA, March 3, 2010—Vol 303, No. 9

  24. PEEP JAMA, March 3, 2010—Vol 303, No. 9

  25. PEEP ALVEOLI –LOVS high PEEP • Sp02 between 88%-95%. • Po2 between 55 mmHg-80 mmHg. • Ventilation strategies included a protocol for reducing PEEP levels when plateau pressure exceeded 30-35 cmH2O or when mean arterial pressure decreased to less than 60 mmHg. • EXPRESS • In the higher PEEP group levels were set to maintain the plateau airway pressure between 28 cmH2O and 30 cm H2O. • When the plateau pressure was • less than 28 cm H2O despite a PEEP level producing a total PEEP of 20 cm H2O, PEEP was not increased further • When oxygenation targets were not met despite an FiO2 of 1 and a PEEP level producing a plateau of 30 cm H2O, PEEP was increased, provided the plateau pressure remained no greater than 32 cm H2O

  26. Recruitment Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006667

  27. Recruitment Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008

  28. Recruitment • Sure effect on oxygenation • Outstanding improving of oxygenation may indicate that PEEP is too low • Hypotension and desaturation are self-limited and without serious risk • Few side effect ( barotrauma 1%) • At the moment there is no evidence to use recruitment maneuvers as a routine, reserve it to patients with severe refractory hypoxemia

  29. Recruitment 28 days mortality ICU mortality Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006667

  30. Recruitment In Hospital Mortality There is no available evidence to determine whether recruitment manoeuvres alter mortality, duration of mechanical ventilation, or hospital stay. Further research is required to determine if recruitment in isolation increase oxygen partial pressure for a longer period of time and whether this has any impact on longerterm outcome. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006667

  31. Prone Position • Better recruitment of dorsal region • Heart on sternum • Better distribution of ventilation and ventilation /perfusion ratio • Improving on arterial saturation • Advantage in severe hypoxiemic ARDS ( P/F<100) Minerva Anestesiol. 2010 Jun;76(6):448-54 CHEST 2010; 137( 5 ): 1203 – 1216

  32. Prone Position In Gattinoni’s review were take in account 4 studies (Prono-Supine I e II, Mancebo 2006, Guerin 2003 ) Minerva Anestesiol. 2010 Jun;76(6):448-54

  33. Prone Position Alsaghir’s review take in account 5 studies with different timing and duration of supination Crit Care Med 2008 Vol. 36, No. 2

  34. ECMO V-V 1. In hypoxic respiratory failure due to any cause (primary or secondary) ECLS should be considered when the risk of mortality is 50% or greater, and is indicated when the risk of 80% or greater. a. 50% mortality risk can be identified by a PaO2/FiO2 < 150 on FiO2 > 90% and/or Murray score 2-3 b. 80% mortality risk can be identified by a PaO2/FiO2 < 80 on FiO2> 90% and Murray score 3-4 2. CO2 retention due to asthma or permissive hypercapnia with a PaCO2 > 80 or inability to achieve safe inflation pressures (Pplat ≤ 30 cm HO) is an indication for ECLS. 3. Severe air leak syndromes

  35. The Murray score grading system for ARDS (0-4) • PaO2/FIO2 FIO2 at 1 for at least 20 minutes. • PEEP in CMH2O • Lung Compliance in ml/CMH2O • Number of quadrants with infiltration seen on chest X-ray Score values • PaO2/FIO2: ≥ 300 = 0, 225–299 = 1, 175–224 = 2, 100– 174 = 3, <100 = 4 • CXR: normal = 0, 1 point per quadrant infiltrated. • PEEP: ≤ 5 = 0, 6–8 = 1, 9–11 = 2, 12–14 = 3, ≥ 15 = 4. • Compliance : ≥ 80 = 0, 60–79 = 1, 40–59 = 2, 20–39 = 3, and ≤ 19 = 4 36

  36. ECMO V-V Considered relative contraindication because of expected poor outcome: • Mechanical ventilation at high settings (FiO2 > .9, P-plat > 30) for 7 days or more 2. Major pharmacologic immunosuppression (absolute neutrophil count <400/ml3 3. CNS hemorrhage that is recent or expanding

  37. ECMO V-V • Criteri per ECMO VV: • PaO2/FiO2<100 con FiO2 100% • P (A-a)>600 mmHg • Murray Score > 3 • Not buffered hypercania pH < 7,2 • Respiratory condition with a reversible possibilty • Age < 65 y • No controindication to herapin CESAR Lancet Vol 374 Oct 17,2009

  38. CESAR Trial Lancet Vol 374 Oct 17,2009

  39. CESAR Trial Lancet Vol 374 Oct 17,2009

  40. Murray score Lancet Vol 374 Oct 17,2009 PaO2/FIO2: ≥ 300 = 0, 225–299 = 1, 175–224 = 2, 100– 174 = 3, <100 = 4 CXR: normal = 0, 1 point per quadrant infiltrated. PEEP: ≤ 5 = 0, 6–8 = 1, 9–11 = 2, 12–14 = 3, ≥ 15 = 4. Compliance (ml/cmH2O): ≥ 80 = 0, 60–79 = 1, 40–59 = 2, 20–39 = 3, and ≤ 19 = 4 Sum of the components divided for the number of the components used

  41. Steroids Ventilator free days at day 28 Mortality patients with steroids before 14 days Crit Care Med 2008 Vol. 36, No. 6

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