Anesthetic management during cardiopulmonary bypass: a systematic review

Cardiopulmonary bypass (CPB) required for cardiac surgery presents unique challenges to the cardiac anesthesiologist responsible for providing the 3 most basic facets of any anesthetic: amnesia, analgesia, and muscle relaxation. Unique pathophysiologic changes during CPB result in pharmacokinetic alterations that impact the serum and tissue concentrations of IV and volatile anesthetics. Similarly, CPB causes pharmacodynamic alterations that impact anesthetic efficacy. The clinical significance of these alterations represents a "moving target" as practice evolves and the technology of CPB circuitry advances. In addition, perfusionists choose, modify, and maintain the CPB circuitry and membrane oxygenator. Thus, their significance may not be fully appreciated by the anesthesiologist. These issues have a profound impact on the anesthetic state of the patient. The delivery and maintenance of anesthesia during CPB present unique challenges. The perfusionist may be directly responsible for the delivery of anesthetic during CPB, a situation unique to the cardiac suite. In addition, monitors of anesthetic depth-assessment of clinical signs, hemodynamic indicators, the bispectral index monitor, end-tidal anesthetic concentration, or twitch monitoring-are often absent, unreliable, or directly impacted by the unique pathophysiology associated with CPB. The magnitude of these challenges is reflected in the higher incidence of intraoperative awareness during cardiac surgery. Further complicating matters are the lack of specific clinical guidelines and varying international policies regarding medical device specifications that add further layers of complexity and introduce practice variability both within institutions and among nations. We performed a systematic survey of the literature to identify where anesthetic practice during CPB is evidence based (or not), identify gaps in the literature to guide future investigations, and explore the implications of evolving surgical practice, perfusion techniques, and national policies that impact amnesia, analgesia, and muscle relaxation during CPB.