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The Annals of Thoracic Surgery, Vol 55, 1093-1103, Copyright © 1993 by The Society of Thoracic Surgeons
M Aoki, F Nomura, ME Stromski, MK Tsuji, JC Fackler, PR Hickey, DH Holtzman and RA Jonas
The pH management that provides optimal organ protection during hypothermic
circulatory arrest is uncertain. Recent retrospective clinical data suggest
that the pH-stat strategy (maintenance of pH at 7.40 corrected to core
temperature) may improve brain protection during hypothermic
cardiopulmonary bypass with a period of circulatory arrest in infants. The
impact of alpha-stat (group A) and pH-stat (group P) strategies on recovery
of cerebral high-energy phosphates and intracellular pH measured by
magnetic resonance spectroscopy (A, n = 7; P, n = 5), organ blood flow
measured by microspheres, cerebral metabolic rate measured by oxygen and
glucose extraction (A, n = 7; P, n = 6), and cerebral edema was studied in
25 4-week-old piglets undergoing core cooling and 1 hour of circulatory
arrest at 15 degrees C. Group P had greater cerebral blood flow during core
cooling (54.3% +/- 4.7% versus 34.2% +/- 1.5% of normothermic baseline,
respectively; p = 0.001). The intracellular pH during core cooling showed
an alkaline shift in both groups but became more alkaline in group A than
in group P at the end of cooling (7.08 to 7.63 versus 7.09 to 7.41,
respectively; p = 0.013). Recovery of cerebral adenosine triphosphate (p =
0.046) and intracellular pH (p = 0.014) in the initial 30 minutes of
reperfusion was faster in group P. The cerebral intracellular pH became
more acidotic during early reperfusion in group A, whereas it showed
continuous recovery in group P. Brain water content postoperatively was
less in group P (0.8075) than in group A (0.8124) (p = 0.05). These results
suggest that compared with alpha-stat, the pH- stat strategy provides
better early brain recovery after deep hypothermic cardiopulmonary bypass
with circulatory arrest in the immature animal. Possible mechanisms include
improved brain cooling by increased blood flow to subcortical areas,
improved oxygen delivery, and reduction of reperfusion injury, as well as
an alkaline shift in intracellular pH with hypothermia in spite of a stable
blood pH.
ARTICLES
Effects of pH on brain energetics after hypothermic circulatory arrest
Department of Cardiovascular Surgery, Children's Hospital, Boston, Massachusetts.
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R. A. Jonas Invited Commentary Ann. Thorac. Surg., September 1, 2000; 70(3): 755 - 755. [Full Text] [PDF]
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S. M. Langley, P. J. Chai, S. E. Miller, J. R. Mault, J. J. Jaggers, S. S. Tsui, A. J. Lodge, A. Lefurgey, and R. M. Ungerleider Intermittent perfusion protects the brain during deep hypothermic circulatory arrest Ann. Thorac. Surg., July 1, 1999; 68(1): 4 - 12. [Abstract] [Full Text] [PDF]
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N. Oshikiri, T Watanabe, H Saitou, Y Iijima, T Minowa, K Inui, and Y Shimazaki Retrograde cerebral perfusion: experimental approach to brain oedema Perfusion, July 1, 1999; 14(4): 257 - 262. [PDF]
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R. A Jonas Optimal pH strategy for cardiopulmonary bypass in neonates, infants and children Perfusion, December 1, 1998; 13(6): 377 - 387. [PDF]
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A. J. du Plessis, R. A. Jonas, D. Wypij, P. R. Hickey, J. Riviello, D. L. Wessel, S. J. Roth, F. A. Burrows, G. Walter, D. M. Farrell, et al. PERIOPERATIVE EFFECTS OF ALPHA-STAT VERSUS pH-STAT STRATEGIES FOR DEEP HYPOTHERMIC CARDIOPULMONARY BYPASS IN INFANTS J. Thorac. Cardiovasc. Surg., December 1, 1997; 114(6): 991 - 1001. [Abstract] [Full Text]
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C. D. Kurth, J. M. Steven, S. C. Nicolson, and M. L. Jacobs Cerebral oxygenation during cardiopulmonary bypass in children J. Thorac. Cardiovasc. Surg., November 1, 1997; 114(5): 872 - 873. [Full Text]
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 A. J. du Plessis Topical Review: Cerebral Hemodynamics and Metabolism During Infant Cardiac Surgery. Mechanisms of Injury and Strategies for Protection J Child Neurol, August 1, 1997; 12(5): 285 - 300. [Abstract] [PDF]
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T. Shin'oka, D. Shum-Tim, R. A. Jonas, H. G. W. Lidov, P. C. Laussen, T. Miura, and A. d. Plessis HIGHER HEMATOCRIT IMPROVES CEREBRAL OUTCOME AFTER DEEP HYPOTHERMIC CIRCULATORY ARREST J. Thorac. Cardiovasc. Surg., December 1, 1996; 112(6): 1610 - 1621. [Abstract] [Full Text]
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T. Watanabe, Y. Iijima, K. Abe, H. Abe, H. Saito, Y. Naruke, and M. Washio RETROGRADE BRAIN PERFUSION BEYOND THE VENOUS VALVESHemodynamics and intracellular pH mapping J. Thorac. Cardiovasc. Surg., January 1, 1996; 111(1): 36 - 44. [Abstract] [Full Text]
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P. M. Kirshbom, L. R. Skaryak, L. R. DiBernardo, F. H. Kern, W. J. Greeley, J. W. Gaynor, and R. M. Ungerleider pH-STAT COOLING IMPROVES CEREBRAL METABOLIC RECOVERY AFTER CIRCULATORY ARREST IN A PIGLET MODEL OF AORTOPULMONARY COLLATERALS J. Thorac. Cardiovasc. Surg., January 1, 1996; 111(1): 147 - 157. [Abstract] [Full Text]
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L. A. Skaryak, P. J. Chai, F. H. Kern, W. J. Greeley, and R. M. Ungerleider BLOOD GAS MANAGEMENT AND DEGREE OF COOLING: EFFECTS ON CEREBRAL METABOLISM BEFORE AND AFTER CIRCULATORY ARREST J. Thorac. Cardiovasc. Surg., December 1, 1995; 110(6): 1649 - 1657. [Abstract] [Full Text]
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J. M. Murkin The Role of CPB Management in Neurobehavioral Outcomes After Cardiac Surgery Ann. Thorac. Surg., May 1, 1995; 59(5): 1308 - 1311. [Abstract] [Full Text]
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J. van der Linden Cerebral Hemodynamics After Low-Flow Versus No-Flow Procedures Ann. Thorac. Surg., May 1, 1995; 59(5): 1321 - 1325. [Abstract] [Full Text]
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L. A. Skaryak, P. M. Kirshbom, L. R. DiBernardo, F. H. Kern, W. J. Greeley, R. M. Ungerleider, J. W. Gaynor, and S. b. D. C. Sabiston Jr. Modified ultrafiltration improves cerebral metabolic recovery after circulatory arrest J. Thorac. Cardiovasc. Surg., April 1, 1995; 109(4): 744 - 752. [Abstract] [Full Text]
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R. A. Jonas Invited letter concerning: Cerebral blood flow, carbon dioxide, and pH J. Thorac. Cardiovasc. Surg., November 1, 1994; 108(5): 984 - 985. [Full Text]
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M. Aoki, R. A. Jonas, F. Nomura, M. E. Stromski, M. K. Tsuji, P. R. Hickey, and D. Holtzman Effects of cerebroplegic solutions during hypothermic circulatory arrest and short-term recovery J. Thorac. Cardiovasc. Surg., August 1, 1994; 108(2): 291 - 301. [Abstract] [Full Text]
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