Isoflurane elimination via a bubble oxygenator during extracorporeal circulation

Desflurane pharmacokinetics during cardiopulmonary bypass

OBJECTIVE

To describe the washin and washout of desflurane when first administered during cardiopulmonary bypass (CPB) for cardiac surgery.

DESIGN

A single-arm prospective study.

SETTING

University-affiliated hospital operating room.

PARTICIPANTS

Ten adult patients presenting for cardiac surgery.

INTERVENTIONS

Consenting patients presenting for cardiac surgery received anesthesia with midazolam and fentanyl. Patients were cooled to 32 degrees C on CPB, then desflurane 6% was administered and blood samples drawn repeatedly from the arterial and venous bypass cannulae as well as from the membrane oxygenator inlet and exhaust from 2 to 32 minutes of desflurane administration. Just before rewarming, final (maximum) washin samples were taken. On rewarming, desflurane was discontinued, and blood and gas samples were taken 2 to 24 minutes thereafter.

MEASUREMENTS AND MAIN RESULTS

CPB time was 116 +/- 10 minutes, and ischemic time was 81 +/- 6 minutes. Mean pump flow was 4.49 +/- 0.03 L/min, and mean arterial pressure was 70.1 +/- 1 mmHg during the study period. Arterial washin of desflurane was initially rapid; arterial concentrations reached 50% of administered concentrations within 4 minutes, but then slowed, reaching 68% of inspired concentrations at 32 minutes (desflurane concentration 4.0% +/- 0.3%). Arterial washout of desflurane was more rapid; arterial concentrations fell to 18% of the maximum concentration reached within 4 minutes, and only 8% of the maximum arterial concentration was present in blood 20 minutes later.

CONCLUSION

Desflurane showed rapid initial washin and washout on CPB when administration was started at 32 degrees C and stopped at time of rewarming.

In vitro uptake and elimination of isoflurane by different membrane oxygenators

OBJECTIVE

This study was designed to investigate the effect of membrane oxygenator design and composition on the uptake and elimination of isoflurane.

DESIGN

Prospective, in vitro laboratory study.

SETTING

Bioengineering laboratory.

PARTICIPANTS

Three types of membrane oxygenator were tested: the SM-35 (polydimethylsiloxane in sheet form), the CML (polypropylene in sheet form), and the SAFE II (polypropylene in hollow-fiber form). The oxygenators were incorporated into a standard cardiopulmonary bypass circuit.

INTERVENTIONS

Isoflurane was added to the oxygenator input gas and measured in exhaust gas and in (bovine) blood leaving the oxygenator at 1, 2, 3, 5, 7, 10, 15, and 20 minutes. The isoflurane vaporizer was then turned off, and samples were obtained at the same time intervals. The experiment was performed at 28 degrees C and 37 degrees C.

MEASUREMENTS AND MAIN RESULTS

Uptake and elimination of isoflurane were slower via the SM-35 compared with the CML and the SAFE II (p < 0.01).

CONCLUSIONS

If isoflurane is administered during cardiopulmonary bypass, knowledge of the influence of oxygenator membrane composition on its pharmacokinetics is essential if patient awareness and unexpected cardiovascular depression are to be avoided.

Should the gas outlet port on membrane oxygenators be routinely scavenged during cardiopulmonary bypass?

Elimination of a volatile anesthetic agent administered prior to the start of bypass through the oxygenator has not been previously described. The purpose of this study was to determine the contamination risk from enflurane used before but not during cardiopulmonary bypass. Enflurane concentration was measured from the gas outlet port of a membrane oxygenator using infrared gas analysis in 11 cardiac surgical patients. The mean peak concentration at the gas outlet port in patients who had a final end-tidal concentration of < or = 0.3% was 0.08 +/- 0.04%, compared to 0.18 +/- 0.05% in patients with a final end-tidal concentration of more than 0.3%, P < 0.001. The elapsed time to reach peak concentration was 8.3 +/- 8.4 minutes, whereas the elapsed time from the peak concentration to 50% of the peak level was 63.1 +/- 25.1 minutes. At the time of peak enflurane release, a concentration of less than 2 ppm was measured at distances of 10 cm or less from the oxygenator gas outlet port in patients with an end-tidal enflurane of < or = 0.3%. In one patient with a final end-tidal enflurane of 1.1%, a contaminant level of 2 ppm could be measured at 95 cm from the oxygenator gas outlet port. This demonstrates that there is a potential risk of contamination from volatile anesthetics used immediately prior to extracorporeal circulation. Minimizing this risk may necessitate routine scavenging of the oxygenator, or simply avoiding increased concentrations of inhalation anesthesia before initiating cardiopulmonary bypass.

Blood/gas solubility coefficient and blood concentration of enflurane during normothermic and hypothermic cardiopulmonary bypass

The blood/gas solubility coefficient and blood concentration of enflurane were measured at intervals in 10 patients undergoing coronary artery revascularization with cardiopulmonary bypass (CPB) and moderate hypothermia. A constant end-tidal concentration of enflurane was maintained throughout the study. Blood/gas solubility coefficient was determined at 37 degrees C, which when combined with an initial single-step equilibration of the blood sample with air, permitted the accurate measurement of blood concentration. Blood/gas solubility coefficient and blood concentration both decreased significantly with the onset of CPB. During the period of hypothermia, blood/gas solubility as measured at 37 degrees C showed little change; however, there was a progressive, marked increase in blood concentration with a mean increase of 80% prior to rewarming. Therefore, the level of anesthesia provided by enflurane may lighten with the onset of CPB, and a deeper level will accompany any decrease in blood temperature. On rewarming, blood concentration levels rapidly returned to levels similar to those measured before cooling. The increased uptake and accumulation of volatile anesthetic agent that occurred as a result of the period of hypothermic CPB was rapidly cleared. The rapidity with which blood concentration responded to the changes occurring during CPB make it unlikely that there was any significant increase in myocardial depression in response to the raised blood concentration secondary to the hypothermia.