Anaes · Cardiac anaesthesia
Weaning from bypass and low cardiac output
Also known as Weaning from bypass and low cardiac output · Unable to wean CPB · Low cardiac output syndrome
RRRAC weaning framework, TOE-guided optimisation, vasoplegia, RV failure, and escalation to IABP/ECMO when unable to wean from CPB.
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Red flags
- Repeated failed weans without a new diagnosis waste myocardium.
- Vasoplegia needs vasoconstrictors, not only inotropes.
- RV failure needs pulmonary vascular and ventilation strategy, not pure systemic vasoconstriction alone.
- Do not give protamine during an unstable failed wean.
- Dynamic obstruction (SAM) worsens with pure inotropes and empty LV.
Meet the patient
A 66-year-old is being weaned after a three-vessel CABG. As pump flow falls, the MAP drops to 50, the LV looks dilated and poorly thickening on TOE, and the surgeon calls it sluggish. The two questions that decide the next ten minutes: what is the phenotype on TOE, and is this a heart that needs drugs or a heart that needs a pump?[2]
Random adrenaline boluses without a diagnosis fail this patient. The hot case is won by structure — full flow, TOE on, RRRAC out loud.[2]
References4ShowHide
- [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery N Engl J Med, 2017.PMID 29130845
- [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists J Am Soc Echocardiogr, 2013.PMID 23998692
- [3]Levy JH, et al. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives J Thromb Haemost, 2023.PMID 37062523
- [4]Ratnani I et al. Vasoplegia: A Review. Methodist Debakey Cardiovasc J, 2023.PMID 37547893