Cardiopulmonary bypass can cause various effects including hyperglycemia, hypoglycemia, hematologic effects from platelet activation and inflammation, stress responses, cardiac effects from ischemia, potential for brain injury, lung injury from inflammation and mechanical effects, and renal effects from vasoconstriction. Hypothermia provides some protection during bypass by reducing metabolic rate and oxygen demand. Deep hypothermic circulatory arrest and hypothermic low-flow bypass are techniques used, with low-flow bypass showing potential benefits in reducing neural dysfunction. Anticoagulation with heparin and reversal with protamine is used but can cause bleeding complications.
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
This topic contains definition, meaning, classification, pathophysiology, clinical menifestations, metabolic and general changes, management of obstetrical shock
Journal of Gastroenterology, Liver & Pancreatic diseases is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Gastroenterology, Liver & Pancreas.
The journal aims to promote latest information and provide a forum for doctors, researchers, physicians, and healthcare professionals to find most recent advances in the areas of Gastroenterology, Liver & Pancreas. Journal of Gastroenterology, Liver & Pancreatic diseases accepts research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Gastroenterology, Liver & Pancreas.
Journal of Gastroenterology, Liver & Pancreatic diseases strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Effects of Cardiopulmonary Bypass
Ns. Ida Simanjuntak, S.Kep
Perfusionist Staff
National Cardiovascular Center Harapan Kita
Jakarta
2. Effects of Cardiopulmonary
Bypass
Glucose metabolism
Hyperglycemia usually accompanies the stress response
associated with CPB.
A more common complication of paediatric CPB is
hypoglycemia. This is largely because of the decreased
glycogen stores and reduced hepatic potential for
gluconeogenesis.
In patients with CHD, hepatic perfusion may be impaired further,
which leads to compromised liver function. Neurologic
consequences of hypoglycemia are aggravated by hypothermia
and other factors that may modify cerebral perfusion. Glucose
monitoring during CPB and rapid correction with dextrose is
essential for decreasing morbidity resulting from paediatric heart
surgery.
3. Effects of Cardiopulmonary
Bypass
Haematologic effects
Paediatric patients develop a more exaggerated response to
CPB. The inflammatory response is inversely proportional to the
patient’s age. Interleukin (IL)–8 and IL-6 production have been
linked to this inflammatory reaction, with their expression linked
to the duration of CPB.
The synthetic surfaces of the bypass circuit have been
associated with activation of inflammatory mediators. These
include activation of the complement system, including plasma-
activated complement 3 (C3a). A potent stimulator of platelet
aggregation, C3a causes histamine release from mast cells and
basophils, increases vascular permeability, and stimulates
WBCs to release oxygen free radicals and lysosomal enzymes.
Elevated levels of C3a have been linked to the duration of CPB.
4. Effects of Cardiopulmonary
Bypass
Haematologic effects
Contact of blood with the bypass machine surface
activates platelets and causes an increase in thrombus
formation. If not corrected, activation of coagulation and
fibrinolytic pathways can lead to excessive bleeding.
Expression of binding proteins on endothelial surfaces
leads to extravascular migration of neutrophils and
subsequent tissue injury.
Activated neutrophils obstruct the capillaries, thus limiting
reperfusion of ischemic tissue (i.e. no-reflow
phenomenon).
5. Effects of Cardiopulmonary
Bypass
Stress response
Low perfusion, hypothermia, and exposure of the blood
to the tubing and surface of the pump cause release of
hormones and other substances, including
catecholamines, cortisol, growth hormone,
prostaglandins, complement, glucose, insulin, and
endorphins.
Other factors involved in secreting these substances
include the type of anesthetic used and decreased renal
and hepatic function leading to decreased clearance from
the kidneys and liver.
The lung normally is responsible for metabolizing and
clearing many of these hormones, particularly
catecholamines.
6. Effects of Cardiopulmonary
Bypass
Cardiac effects
Studies on immature animal hearts have demonstrated
conflicting data with regard to the relative sensitivity of
the neonatal heart to ischemia compared to the adult
heart.
Reasons for better tolerance to ischemia in the neonatal heart
include
the increased glycolytic capability of the immature myocardium and
better preservation of high-energy phosphates because of decreased
levels of 5'-nucleotidase, which catalyzes the breakdown of adenosine
monophosphate (AMP) to adenosine.
Conversely, accumulation of lactic acid as a result of
anaerobic metabolism has been hypothesized as a cause
of ischemic intolerance in the neonatal heart.
7. Effects of Cardiopulmonary
Bypass
Central nervous system effects
Neurologic injury after routine CPB is uncommon in
neonates, but the risk is increased when deep
hypothermic circulatory arrest (DHCA) is required.
Although permanent injury is less common, evidence of
some neurologic injury is observed in as many as 25% of
infants who have undergone DHCA.
Neurologic morbidity includes seizures, strokes,
changes in tone and mental status, motor disorders,
abnormal cognitive functioning, and postpump
choreoathetosis. Areas most vulnerable for ischemic
injury include the neocortex, hippocampus, and striatum.
8. Effects of Cardiopulmonary
Bypass
Central nervous system effects
Another potential mechanism of brain injury involves
binding of glutamate to the N-methyl-D-aspartate
receptor (NMDAR). This binding increases the amount of
intracellular calcium and subsequently activates
proteases, phospholipases, and deoxyribonucleases
(DNAases) and promotes generation of free radicals. The
net result of these processes is cell injury, cell death, or
both.
Microemboli can be detected in patients on CPB. The
long-term effect of these emboli is not well defined.
9. Effects of Cardiopulmonary
Bypass
Pulmonary effects
Lung injury is mediated in one of two ways. Leukocyte
and complement activation cause an inflammatory
response, or a mechanical effect leads to surfactant loss
and atelectasis. These types of dysfunction cause a
reduction in static and dynamic compliance, reduced
functional residual capacity, and an increased alveolar-
arterial (A-a) gradient.
Hemodilution reduces oncotic pressure and causes
extravasation of fluid into the lung parenchyma.
CPB activates complement and leukocyte degranulation,
causing capillary membrane injury and platelet activation,
both of which eventually lead to increased pulmonary
vascular resistance.
10. Effects of Cardiopulmonary
Bypass
Renal effects
CPB leads to production of renin, angiotensin,
catecholamines, and antidiuretic hormone. In turn, these
substances cause renal vasoconstriction and reduced
renal blood flow.
Risk factors for postoperative renal dysfunction include
preoperative renal disease, contrast-related renal injury,
and profound post-CPB reduction in cardiac output.
In the period following CPB, 8% of patients have acute
renal insufficiency as indicated by oliguria and increased
creatinine levels.
After spontaneous urine output, diuretics are effective at
inducing diuresis and reversing renal cortical ischemia
associated with CPB, but their use does not alter the time
to recovery of renal function.
11. Use of Hypothermia
Effect on Metabolic Rate
In a patient undergoing CPB, hypothermia helps protect
against injury caused by the compromised substrate supply
to tissues resulting from reduced flow.
This protection occurs because of a reduction in metabolic
rate and decreased oxygen consumption.
The metabolic rate is determined by enzymatic activity, which
in turn depends on temperature.
The decrease in metabolic rate is not the only factor involved
in hypothermic protection. The actual safe period of
hypothermic CPB is longer than the period predicted by a
sole reduction in metabolic activity.
12. Use of Hypothermia
Effect on pH
The effect of hypothermia on pH is mediated by its effect
on the ionization constant of water and, therefore, its
effect on the ionized-to-nonionized ratio of metabolic
substrates.
In ischemia, the intracellular pH decreases because of
the accumulation of hydrogen ions. In turn, the
accumulation of hydrogen ions causes a decrease in the
ratio of ionized-to-nonionized metabolic substrates.
Nonionized substrates can cross the cellular membrane
and are lost. Hypothermia affects this by decreasing the
metabolic rate, then by increasing the ionized-to-
nonionized ratio.
In addition, the transformation of a semiliquid cellular
membrane to a semisolid membrane is postulated to
decrease calcium influx.
13. Use of Hypothermia
Effect on Central Nervous System
The effect of hypothermia on the nervous
system is multifactorial. In addition to
decreasing the metabolic rate, hypothermia has
been demonstrated to decrease the release of
glutamate, which is involved in CNS injury
during CPB.
A negative effect of hypothermia on brain
function is the loss of autoregulation at extreme
temperatures, which makes the blood flow
highly dependent on extracorporal perfusion.
14. Techniques of Hypothermia
Currently, two surgical techniques are
used in congenital heart surgery,
namely,
Deep hypothermic circulatory arrest
(DHCA)
Hypothermic low-flow bypass (HLFB)
15. Deep Hypothermic
Circulatory Arrest
DHCA provides excellent surgical exposure by
eliminating the need for multiple cannulas within
the surgical field and by providing a motionless
and bloodless field.
Surgical technique
Initiate the cooling phase prior to institution of
CPB by simple cooling of the operating room
environment.
After systemic heparinization and cannulation,
initiate CPB.
Monitor body temperature via esophageal,
tympanic, and rectal routes.
16. Deep Hypothermic
Circulatory Arrest
Mechanical Problems
Obstruction of the inferior vena cava (IVC) by a
misplaced IVC cannula can lead to increased venous
pressure, which causes ascites and decreased perfusion
pressure in mesenteric, hepatic, and vascular beds.
Monitor infants with ascites for GI tract, renal, and hepatic
functioning.
Misplacement of the cannula in the superior vena cava
(SVC) can result in increased venous pressure in the
cerebral venous system. Subsequent cerebral edema
results from inadequate venous drainage and a
consequent reduction in cerebral blood flow, potentially
resulting in ischemia.
17. Deep Hypothermic
Circulatory Arrest
Mechanical Problems
Arterial cannula misplacement also can occur. If the
cannula inadvertently slips beyond the takeoff of the right
innominate artery, preferential perfusion to the left side of
the brain can be observed.
Presence of any anomalous systemic-to-pulmonary shunts
can lead to shunting of blood away from the systemic
circulation, through the pulmonary circuit, and then
through the venous cannula to the CPB machine.
Thus, the systemic perfusion is shunted away from the
body in a futile circuit back to the CPB machine. Anatomic
lesions where such shunting can occur include an
unrecognized patent ductus arteriosus and large
aortopulmonary collaterals as found in pulmonary atresia.
18. Deep Hypothermic
Circulatory Arrest
Inflammatory response
Activation of the inflammatory pathway leads to serious
complications, morbidity, and mortality. Several
strategies have been used to modify the inflammatory
response. These include:
Use of heparin-coated CPB circuit to reduce the
inflammatory response
Modifying the blood cardioplegia solution has been
investigated as a means of reducing inflammatory-
mediated myocardial injury after intracardiac repair.
Since neutrophils may mediate the local inflammatory
response in the heart, a leukocyte-depleted blood
cardioplegia (LDBC) has been postulated as a means for
improving myocardial protection during CPB.
Modified ultrafiltration.
19. Anticoagulation for
Cardiopulmonary Bypass
Anticoagulation and heparin reversal
Paediatric and neonatal patients undergoing CPB for
cardiac surgery are prone to coagulopathy in the early
postoperative period.
Contributing factors include
hemodilution,
immaturity of the coagulation system,
depletion of platelets and other hemostatic proteins, and
the complex nature of the operations performed, which
often include multiple suture sites and, therefore, an
increased number of potential bleeding sites.
20. Anticoagulation for
Cardiopulmonary Bypass
Anticoagulation
To avoid forming thrombi in the CPB machine, heparin is
administered prior to cannulation. Heparin is chosen
because it is a fast-acting anticoagulant and its action
can be inhibited rapidly by protamine.
Heparin activates antithrombin III, which inhibits thrombin
activity.
Heparin can be stored in the vascular endothelium and
smooth muscle, contributing to heparin rebound, which is
observed after discontinuation of CPB and heparin
reversal.
Clearance of heparin also is determined by hepatic and
renal function.
21. Anticoagulation for
Cardiopulmonary Bypass
Anticoagulation
Typically, a loading dose of 200-300 U/kg of heparin is
given and then heparin activity is monitored by
measuring activated clotting time (ACT) and heparin
levels.
Physicians at some centers administer 300 U/kg, check
to see if this leads to an ACT of 450-480 seconds, then
administer supplemental heparin based on subsequent
ACT levels.
The use of only one of these monitoring methods may
not reflect the full degree of anticoagulation.
ACT levels can be affected by factors unrelated to
heparin concentration, including the patient's hematocrit
and temperature.
22. Anticoagulation for
Cardiopulmonary Bypass
Heparin reversal
Protamine binds to heparin and releases antithrombin III.
One method of administering protamine is to administer
1-1.3 mg for each 100 U of heparin administered. This
method does not take into account the half-life of heparin
or its clearance from circulation.
Other methods include ACT-heparin dose-response
curves, direct measurement of heparin levels, and use of
the heparin-protamine titration.
23. Anticoagulation for
Cardiopulmonary Bypass
Adverse effects of protamine
Release of histamine, which can lead to a decrease in
systemic vascular resistance
True anaphylaxis, which is mediated by antiprotamine
immunoglobulin E (IgE) and observed primarily in
patients with prior exposure to protamine (e.g. neutral
protamine Hagedorn [NPH] insulin) and in patients with
fish allergy
Thromboxane release, which leads to pulmonary
vasoconstriction and bronchoconstriction
24. Anticoagulation for
Cardiopulmonary Bypass
Strategy to counteract post-CPB bleeding
Bleeding after CPB is not unusual.
Identify any sources of obvious surgical bleeding since
this is the most common cause of post-CPB bleeding.
Assess the adequacy of the protamine dose.
If the dose appears to be sufficient, the next most common
cause of bleeding is platelet dysfunction, and platelet
infusion is warranted, even if the platelet count is within
reference range. Often, platelets are dysfunctional after
CPB in infants and children.
Administration of aprotinin can decrease blood transfusion
requirements in patients undergoing repeat surgeries and
in patients who are cyanotic.
Desmopressin has antifibrinolytic activity and acts as a
kallikrein inhibitor. Mild hypersensitivity reactions and
anaphylactic reactions are reported.
25. Hypothermic Low-Flow
Cardiopulmonary Bypass
The finding that DHCA was associated with neurologic
morbidity has led researchers to investigate the use of
HLFB.
This technique allows continuous low-flow perfusion to
the organs during the operation, which may lead to an
increase in oxygen supply, better nutrient supply, and
better achievement of homogeneous hypothermia during
bypass.
Recent trials comparing the 2 methods have reported
lower rates of neural dysfunction in the group of patients
undergoing HLFB.