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J Thorac Cardiovasc Surg 1996;111:1267-1279
© 1996 Mosby, Inc.
CARDIOPULMONARY BYPASS, |
This work was supported by the Sir Jules Thorn Charitable Trust and the Research Endowments Trust of St. Thomas' Hospital.
Received for publication August 14, 1995; revisions requested Sept. 25, 1995; revisions received Oct. 25, 1995; Accepted for publication Oct. 27, 1995. Address for reprints: D. J. Chambers, PhD, Research Director, Cardiac Surgical Research, The Rayne Institute, St. Thomas' Hospital, London SE1 7EH, United Kingdom.
Abstract
Neuropsychologic impairment in patients undergoing cardiopulmonary bypass may be associated with cerebral blood flow changes arising from different management protocols for carbon dioxide tension during bypass. Seventy patients having coronary artery bypass grafting were randomized to either pH-stat or alpha-stat acid-base management during cardiopulmonary bypass with a membrane oxygenator. In each patient, cerebral blood flow (xenon 133 clearance), middle cerebral artery blood flow velocity (transcranial Doppler sonography), and cerebral oxygen metabolism (cerebral metabolic rate and cerebral extraction ratio) were measured during four phases of the operation: before bypass, during bypass (at hypothermia and at normothermia), and after bypass. A battery of neuropsychologic tests were also conducted before and 6 weeks after the operation. During hypothermic (28º C) bypass, cerebral blood flow was significantly (p < 0.001) greater in the pH-stat group (41 ml
100 gm-1min-1; 95% confidence interval 39 to 43 ml100 gm-1min-1) than in the alpha-stat group (24 ml100 gm-1min-1; confidence interval 22 to 26 ml100 gm-1min-1) at constant pressure and flow. Arterial carbon dioxide tensions were 41 mm Hg (40 to 41 mm Hg) and 26 mm Hg (25 to 27 mm Hg), respectively; pH was 7.36 (7.34 to 7.38) and 7.53 (7.51 to 7.55), respectively. Middle cerebral artery flow velocity was significantly (p < 0.05) reduced in the alpha-stat group to 87% (77% to 96%) of the prebypass value, whereas it was significantly (p < 0.05) increased (152%; 141% to 162%) in the pH-stat group. Cerebral extraction ratio for oxygen demonstrated relative cerebral hyperemia during hypothermic (28º C) bypass in both the pH-stat and alpha-stat groups (0.12 [0.11 to 0.14] and 0.25 [0.22 to 0.28], respectively); however, hyperemia was significantly more pronounced in the pH-stat group, indicating greater disruption in cerebral autoregulation. Neuropsychologic impairment criteria of deterioration in results of three or more tests revealed that a significantly (Fisher's exact test, p = 0.02) higher proportion of patients in the pH-stat group fared poorly than in the alpha-stat group at 6 weeks (17/35, 48.6% [32% to 65.1%], and 7/35, 20% [6.7% to 33.2.2%], respectively). In conclusion, patients receiving alpha-stat management had less disruption of cerebral autoregulation during cardiopulmonary bypass, accompanied by a reduced incidence of postoperative cerebral dysfunction. (J THORACCARDIOVASCSURG1996;111:1267-79)
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