G. Baumgarten

Cardiopulmonary bypass in cardiac surgery

Cardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.ZusammenfassungDer kardiopulmonale Bypass („cardiopulmonary bypass“, CPB) ist ein Standardverfahren der Herzchirurgie. Neben den therapeutischen Perspektiven, die dieses Verfahren eröffnet, ist es selbst Ausgangspunkt für systemische und organspezifische Komplikationen. Typische Organkomplikationen sind Herzinsuffizienz, renale und pulmonale Dysfunktionen, Gerinnungsalterationen sowie neurologische und kognitive Einschränkungen. Die immunologische Reaktion auf die extrakorporale Zirkulation (EKZ) löst eine systemische Inflammation aus, die häufig die Definitionskriterien eines „systemic inflammatory response syndrome“ (SIRS) erfüllt. Die wesentlichen Ursachen hierfür sind der Kontakt des Bluts zur künstlichen Oberfläche der Herz-Lungen-Maschine (HLM), der mechanische Stress, der auf die Blutbestandteile einwirkt, und das beträchtliche operative Trauma. Eine Vielzahl an technischen Veränderungen der HLM zielt auf eine Reduktion der Inflammationsreaktion durch den CPB ab. Aus operationstechnischen Gründen kann heute bei einem Großteil des kardiochirurgischen Operationsspektrums noch nicht auf eine EKZ verzichtet werden. Es werden jedoch kontinuierlich Verfahren entwickelt, die das Ziel verfolgen, das operative Trauma und die negativen Auswirkungen des CPB zu reduzieren. Als positiv haben sich diesbezüglich verkleinerte Systeme mit biokompatiblen Oberflächen erwiesen. Alternative Verfahren wie die koronarchirurgische „Off-pump“-Chirurgie reduzieren CPB-assoziierte Organkomplikationen, werden jedoch aufgrund systemspezifischer Limitationen die konventionelle Bypasschirurgie nicht ersetzen können.AbstractCardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.

Kardiopulmonaler Bypass in der Herzchirurgie

Cardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.ZusammenfassungDer kardiopulmonale Bypass („cardiopulmonary bypass“, CPB) ist ein Standardverfahren der Herzchirurgie. Neben den therapeutischen Perspektiven, die dieses Verfahren eröffnet, ist es selbst Ausgangspunkt für systemische und organspezifische Komplikationen. Typische Organkomplikationen sind Herzinsuffizienz, renale und pulmonale Dysfunktionen, Gerinnungsalterationen sowie neurologische und kognitive Einschränkungen. Die immunologische Reaktion auf die extrakorporale Zirkulation (EKZ) löst eine systemische Inflammation aus, die häufig die Definitionskriterien eines „systemic inflammatory response syndrome“ (SIRS) erfüllt. Die wesentlichen Ursachen hierfür sind der Kontakt des Bluts zur künstlichen Oberfläche der Herz-Lungen-Maschine (HLM), der mechanische Stress, der auf die Blutbestandteile einwirkt, und das beträchtliche operative Trauma. Eine Vielzahl an technischen Veränderungen der HLM zielt auf eine Reduktion der Inflammationsreaktion durch den CPB ab. Aus operationstechnischen Gründen kann heute bei einem Großteil des kardiochirurgischen Operationsspektrums noch nicht auf eine EKZ verzichtet werden. Es werden jedoch kontinuierlich Verfahren entwickelt, die das Ziel verfolgen, das operative Trauma und die negativen Auswirkungen des CPB zu reduzieren. Als positiv haben sich diesbezüglich verkleinerte Systeme mit biokompatiblen Oberflächen erwiesen. Alternative Verfahren wie die koronarchirurgische „Off-pump“-Chirurgie reduzieren CPB-assoziierte Organkomplikationen, werden jedoch aufgrund systemspezifischer Limitationen die konventionelle Bypasschirurgie nicht ersetzen können.AbstractCardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.

Anästhesie bei Kindern und Jugendlichen nach angeborenen Herzfehlern

The incidence of congenital heart defects (CHD) has remained constant over many years; however, due to improved therapeutic options an increasing number of children and adolescents even with complex heart defects now reach adulthood. The increasing prevalence of adults with persisting or surgically corrected CHD as well as age-dependent non-cardiac comorbidities will increase the need for medical and non-cardiac surgical treatment in this population. Although elective medical care for these patients should be reserved for highly specialized centers, emergency treatment might become necessary in a non-specialized hospital setting as well. Due to the variety and complexity of CHD it is difficult to provide standardized guidelines for the anesthetic management. The treatment of patients with complex CHD requires a profound understanding of the underlying CHD and the current state of the hemodynamics by the anesthesiologist. Furthermore, typical comorbidities, such as chronic heart failure, altered coagulation and arrhythmia also have to be taken into account to ensure successful perioperative treatment. Especially in patients with shunt lesions or passive pulmonary blood flow the anesthetic management often substantially affects the hemodynamics and may be the starting point of severe decompensation. Awareness of anesthesia-induced changes of pulmonary and/or systemic vascular resistance as well as of preload alterations are the basis for successful anesthetic management. Finally, a multidisciplinary approach including cardiologists and radiologists in the planning is absolutely essential to achieve an optimal postoperative result for the patient.

Anesthesia in children and adolescents with congenital heart defects

The incidence of congenital heart defects (CHD) has remained constant over many years; however, due to improved therapeutic options an increasing number of children and adolescents even with complex heart defects now reach adulthood. The increasing prevalence of adults with persisting or surgically corrected CHD as well as age-dependent non-cardiac comorbidities will increase the need for medical and non-cardiac surgical treatment in this population. Although elective medical care for these patients should be reserved for highly specialized centers, emergency treatment might become necessary in a non-specialized hospital setting as well. Due to the variety and complexity of CHD it is difficult to provide standardized guidelines for the anesthetic management. The treatment of patients with complex CHD requires a profound understanding of the underlying CHD and the current state of the hemodynamics by the anesthesiologist. Furthermore, typical comorbidities, such as chronic heart failure, altered coagulation and arrhythmia also have to be taken into account to ensure successful perioperative treatment. Especially in patients with shunt lesions or passive pulmonary blood flow the anesthetic management often substantially affects the hemodynamics and may be the starting point of severe decompensation. Awareness of anesthesia-induced changes of pulmonary and/or systemic vascular resistance as well as of preload alterations are the basis for successful anesthetic management. Finally, a multidisciplinary approach including cardiologists and radiologists in the planning is absolutely essential to achieve an optimal postoperative result for the patient.

Anästhesie bei Kindern und Jugendlichen nach angeborenen Herzfehlern@@@Anesthesia in children and adolescents with congenital heart defects

The incidence of congenital heart defects (CHD) has remained constant over many years; however, due to improved therapeutic options an increasing number of children and adolescents even with complex heart defects now reach adulthood. The increasing prevalence of adults with persisting or surgically corrected CHD as well as age-dependent non-cardiac comorbidities will increase the need for medical and non-cardiac surgical treatment in this population. Although elective medical care for these patients should be reserved for highly specialized centers, emergency treatment might become necessary in a non-specialized hospital setting as well. Due to the variety and complexity of CHD it is difficult to provide standardized guidelines for the anesthetic management. The treatment of patients with complex CHD requires a profound understanding of the underlying CHD and the current state of the hemodynamics by the anesthesiologist. Furthermore, typical comorbidities, such as chronic heart failure, altered coagulation and arrhythmia also have to be taken into account to ensure successful perioperative treatment. Especially in patients with shunt lesions or passive pulmonary blood flow the anesthetic management often substantially affects the hemodynamics and may be the starting point of severe decompensation. Awareness of anesthesia-induced changes of pulmonary and/or systemic vascular resistance as well as of preload alterations are the basis for successful anesthetic management. Finally, a multidisciplinary approach including cardiologists and radiologists in the planning is absolutely essential to achieve an optimal postoperative result for the patient.

Kardiopulmonaler Bypass in der Herzchirurgie@@@Cardiopulmonary bypass in cardiac surgery

Cardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.ZusammenfassungDer kardiopulmonale Bypass („cardiopulmonary bypass“, CPB) ist ein Standardverfahren der Herzchirurgie. Neben den therapeutischen Perspektiven, die dieses Verfahren eröffnet, ist es selbst Ausgangspunkt für systemische und organspezifische Komplikationen. Typische Organkomplikationen sind Herzinsuffizienz, renale und pulmonale Dysfunktionen, Gerinnungsalterationen sowie neurologische und kognitive Einschränkungen. Die immunologische Reaktion auf die extrakorporale Zirkulation (EKZ) löst eine systemische Inflammation aus, die häufig die Definitionskriterien eines „systemic inflammatory response syndrome“ (SIRS) erfüllt. Die wesentlichen Ursachen hierfür sind der Kontakt des Bluts zur künstlichen Oberfläche der Herz-Lungen-Maschine (HLM), der mechanische Stress, der auf die Blutbestandteile einwirkt, und das beträchtliche operative Trauma. Eine Vielzahl an technischen Veränderungen der HLM zielt auf eine Reduktion der Inflammationsreaktion durch den CPB ab. Aus operationstechnischen Gründen kann heute bei einem Großteil des kardiochirurgischen Operationsspektrums noch nicht auf eine EKZ verzichtet werden. Es werden jedoch kontinuierlich Verfahren entwickelt, die das Ziel verfolgen, das operative Trauma und die negativen Auswirkungen des CPB zu reduzieren. Als positiv haben sich diesbezüglich verkleinerte Systeme mit biokompatiblen Oberflächen erwiesen. Alternative Verfahren wie die koronarchirurgische „Off-pump“-Chirurgie reduzieren CPB-assoziierte Organkomplikationen, werden jedoch aufgrund systemspezifischer Limitationen die konventionelle Bypasschirurgie nicht ersetzen können.AbstractCardiopulmonary bypass (CPB) is a standard procedure in cardiac surgery; however, apart from its therapeutic options a CPB might also initiate systemic and organ-specific complications, such as heart failure, renal and pulmonary dysfunction, impaired coagulation as well as neurological and cognitive dysfunction. The immunological response to the extracorporeal circulation generates systemic inflammation which often meets the definition of systemic inflammatory response syndrome (SIRS). The main inducers of SIRS are contact of blood with the artificial surfaces of the CPB, mechanical stress which affects the blood components and the extensive surgical trauma. Hence, a number of technical and surgical developments aim at reduction of the inflammatory response caused by the CPB. By reason of surgical demands, the majority of cardiothoracic procedures still depend on the use of CPB; however, there is an on-going development of new techniques trying to reduce the surgical trauma and the negative consequences of CPB. Here, minimized systems with biocompatible surfaces have been shown to be effective in attenuating the inflammatory response to CPB. Alternative procedures such as off-pump surgery may help to avoid CPB-associated complications but due to specific limitations will not replace conventional bypass surgery.