Avoiding hyperoxemia at the start of cardiopulmonary bypass while optimizing gas flow and temperature

There seems to be a wide range of practice in relation to the optimum oxygen setting before, and at the start of, cardiopulmonary bypass. Even manufacturers of blood oxygenators vary in their suggestions for this phase of extracorporeal circulation. Most of these suggestions are based on peak performance, Association for the Advancement of Medical Instrumentation (AAMI) standards, experience, and legal considerations. Therefore, suggested gas:blood flow ratios will vary from no gas flow at the start of bypass, to a ratio setting of 1:1. On the other hand, suggested inspired oxygen concentrations will generally vary between 0.80 to 1.0 at the start of cardiopulmonary bypass. In regard to perfusate temperatures before going on bypass, there are no clearly defined standards other than those of clinical preference. The manufacturer of the oxygenator used in this study clearly states in the operating instructions that gas flow should be proportional to blood flow at the start of bypass, and gas flow should be turned off when there is no fluid flow through the oxygenator. The presence of hyperoxic perfusates and wide patient/perfusate temperature gradients at the start of bypass has been suspected in the appearance of gaseous microemboli during this critical period. Hyperoxemia during the bypass period is also implicated in the introduction of oxygen free radicals and nitric oxide into the hypoxic myocardium during cardioplegia delivery. Presented here are the results of a randomized clinical study involving 39 adult patients undergoing cardiopulmonary bypass for the surgical treatment of coronary artery disease. All patients were randomly selected into five groupings. The first group had 1 L of gas flow through the perfusate before bypass, and bypass was then started with an FIO2 of 0.80. The second two groups had no gas flow through the perfusate prior to bypass and a starting FIO2 of 0.21. Groups 4 and 5 had 1 L of gas flowing through the perfusate and a starting FIO2 of 0.21. Results indicate that gas flow through Normosol R/Albumin perfusates will prevent the acidosis that is found in this solution when the system is previously flushed with carbon dioxide. Also, suggested high FIO2 settings will produce hyperoxic perfusates at the start of cardiopulmonary bypass. However, the use of an FIO2 of 0.21 at the start of bypass will produce normoxemic conditions that are both safe and reliable for the conduct of initiating cardiopulmonary bypass.