Studies of hypoxemic/reoxygenation injury: without aortic clamping. IX. Importance of avoiding perioperative hyperoxemia in the setting of previous cyanosis.

This study of an in vivo infantile piglet model of compensated hypoxemia tests the hypothesis that reoxygenation on hyperoxemic cardiopulmonary bypass produces oxygen-mediated myocardial injury that can be limited by normoxemic management of cardiopulmonary bypass and the interval after cardiopulmonary bypass. Twenty-five immature piglets (< 3 weeks old) were placed on 120 minutes of cardiopulmonary bypass and five piglets served as a biochemical control group without cardiopulmonary bypass. Five piglets underwent cardiopulmonary bypass without hypoxemia (cardiopulmonary bypass control). Twenty others became hypoxemic on cardiopulmonary bypass for 60 minutes by lowering oxygen tension to about 25 mm Hg. The study was terminated in five piglets at the end of hypoxemia, whereas 15 others were reoxygenated at an oxygen tension about 400 mm Hg or about 100 mm Hg for 60 minutes. Oxygen delivery was maintained during hypoxemia by increasing cardiopulmonary bypass flow and hematocrit level to avoid metabolic acidosis and lactate production. Myocardial function after cardiopulmonary bypass was evaluated from end-systolic elastance (conductance catheter) and Starling curve analysis. Myocardial conjugated diene production and creatine kinase leakage were assessed as biochemical markers of injury, and antioxidant reserve capacity was determined by measuring malondialdehyde after cardiopulmonary bypass in myocardium incubated in the oxidant, t-butylhydroperoxide. Cardiopulmonary bypass without hypoxemia caused no oxidant or functional damage. Conversely, reoxygenation at an oxygen tension about 400 mm Hg raised myocardial conjugated diene level and creatine kinase production (CD: 3.5 +/- 0.7 A233 nm/min/100 g, creatine kinase: 8.5 +/- 1.5 U/min/100 g, p < 0.05 vs cardiopulmonary bypass control), reduced antioxidant reserve capacity (malondialdehyde: 1115 +/- 60 nmol/g protein at 4.0 mmol t-butylhydroperoxide, p < 0.05 vs control), and produced severe postbypass dysfunction (end-systolic elastance recovered only 39% +/- 7%, p < 0.05 vs cardiopulmonary bypass control). Lowering oxygen tension to about 100 mm Hg during reoxygenation avoided conjugated diene production and creatine kinase release, retained normal antioxidant reserve, and improved functional recovery (80% +/- 11%, p < 0.05 vs oxygen tension about 400 mm Hg). These findings show that conventional hyperoxemic cardiopulmonary bypass causes unintended reoxygenation injury in hypoxemic immature hearts that may contribute to myocardial dysfunction after cardiopulmonary bypass and that normoxemic management may be used to surgical advantage.