Cardiopulmonary Bypass: The Frankenstein conundrum of Anaesthesia

Cardiopulmonary bypass, CPB or the heart-lung machine- that miraculous contraption that lets us casually stop the heart while pretending we (the Anaesthesiologists) are gods… As if we don’t have enough of a Zeus-complex already. It is a testament to the triumph of human ingenuity (and a lot of errors probably!) over basic common sense (as I often say, is not so common) because, really, who looked at a heart and thought, “I bet we could turn this off for a while and still have the patient survive”?

The story begins in the 1800s (yes! You heard right), when brave (and potentially foolish)—surgeons and engineers started tinkering with the idea of mechanically replacing heart and lung function. 

One of the earliest pioneers, Dr John Gibbon, is often credited with inventing the first successful CPB machine. Dr Gibbon’s inspiration? Watching a patient die in 1931 during pulmonary surgery(pulmonary embolectomy). He probably thought, “I could build something better than God’s creation!” And so, he tried. After 20 years of tinkering (and, probably, arguing with heretics who called him insane), Dr Gibbon debuted his machine in 1952. So, in May 1953, the Gibbon model 2 machine was used successfully during an ASD closure (atrial septal defect, basically a hole somewhere in the heart). Noticed the ‘successfully’ in my sentence, isn’t it? Well, we won’t go to the 1952 unsuccessful start.

Dr Gibbon famously said afterward, “The operation confirmed that the pump worked as planned,” though I bet there was an unspoken, “…and thank God it didn’t kill anyone!”

Of course, not everyone was on board. Surgeons were sceptical (iconoclasts as usual), perfusionists didn’t exist yet, and anaesthesiologists(as usual) were left muttering, “Wait, now I have to manage this mess, too?”.

Enter the Modern Era: Bigger Complex Machines

Fast-forward to today, and CPB is so common that even medical students know the basics (though they’ll still think the ‘Vent’ is to pump oxygen in. NB I also did, until I rotated to Cardiacs… And well, it was like the light at the end of the tunnel). It’s not just for adults anymore—neonatal cardiac surgeries are performed regularly, proving we’re not afraid to unplug and replug any human, no matter the size.

But let’s not romanticize it. Modern CPB still has its quirks. Consider the systemic inflammatory response (SIRS), cerebral microemboli, and that infamous “pumphead” fog (postperfusion syndrome) patients complain about post-op. You’d think after 70 years, we’d have solved that. But no, CPB is the anaesthesiologist's version of a malfunctioning coffee machine: vital, irritating, and occasionally life-threatening.

Oh, by the way, I forgot to mention- we inject sperm into your veins! Yes, you read right!

Protamine- that humble little protein extracted from fish sperm—yes, fish sperm, (some misogynists were probably thinking of informing their partners their sperm is worth gold) is the stuff of anaesthetic legend. You’d think a medication with such an unassuming origin story would be straightforward… Well, protamine is a drama king in disguise. It's like inviting your reliable but chaotic friend to a party (one of my two bromancers at Stellenbosch Uni would probably point out I am the protamine paradox for him! @Desigen!). So, the friend(Protamine) - they’ll help clean up (neutralize heparin), but not before knocking over a big vase (causing hypotension) and starting a fight for no reason at all (anaphylaxis, anyone?). Well, he is probably right.

NB. Luvnish and Desigen are two of the best people I have met till date, besides being my go-to Wikipedia for Anaesthesiology. Luvnish is like the Sheldon Cooper of our group- eidetic memory all the way, yet as cool as Robert Downey Jr. in Iron Man! Desigen is the Raj- quiet person in the corner…and then the alcohol kicks in! And me… I will leave it to your imagination! (My wife is the original ‘nectar’ in my life mind you! Mentioned here just so I can continue having my daily meals and a bed to sleep on!)

While cardiac surgeons bask in glory (ahemm… ), let’s not forget the real MVPs: perfusionists. The unsung heroes- Perfusionists micromanage oxygenators, blood gases, and flow rates like caffeinated jugglers, while we anaesthesiologists sit and have coffee during bypass! Yes, you heard right, we do nothing then (The adage that anaesthesiologists earn a lot for doing nothing is applicable during the bypass time!).

Perfusionists keep you alive all throughout bypass time! So, remember, if you ever need to go for any cardiac weird-thingy surgery- Thank your surgeon for sure but express your gratitude to the perfusionists and the nursing team.

To our Perfusionists at Steve Biko Hospital: the true maestros of the bypass machine orchestra, keeping the rhythm of life going while the rest of us pretend we’re in charge—thanks for making it look easy when it’s anything but!

To the Cardiac surgeons: masters of the scalpel and myocardium- Thank you for the thrilling hours of bypass where you steal the show (and blood flow in a way), who visualise a stopped heart not as a problem, but as an opportunity and for proving that fixing hearts isn’t just a profession—it’s an extreme sport. (Bonus points for keeping the rest of us entertained with your optimistic time estimates.)

My thought goes to one of the fastest and most efficient surgeons I have worked with till date, incidentally a female surgeon (Yes you male bigot and chauvinist!)- she can control the ‘theme’ of Theatre 10 just with her voice- the tone and decibel rating can signify stress, relief, motivational speech, double-check the ACT, love this team, good job everyone and occasionally, that look—the one that says, ‘Did you graduate from medical school or clown college you dumbo?’. Well, for me, she is great to work with (and I can feel the glare that will burn me down to the ground, from some of my peers!).

To end the surgeon ramble: one of the pioneers, Dr Michael DeBakey, a true surgical legend, famously said, “There are no such things as incurable, there are only things for which man has not found a cure.” If that’s not the perfect rallying cry for the genius of CPB, I don’t know what is.

Let’s be real: until someone invents a risk-free version of CPB, this beast of a machine isn’t going anywhere. As anaesthesiologists, we’ll be sitting at the head of the table, managing physiology like the gods we are (you can imagine the hyena cackle!), one eccentric bypass surgery at a time, one protamine paradox at a time.

To all the Anaesthesiology registrars who transform into Victor Frankenstein during that cardiac rotation, do not shout out ‘It lives’ when the heart starts beating again. You might lose that articulating ability when the exasperated surgeon finally decides to ‘sternotomy-wire’ your lips shut.