A 50-year-old male who works as an aeronautical engineer presents sporting a bicuspid aortic valve and a “grande burrito” size (63 mm) ascending aorta. He is scheduled for both aortic valve replacement and ascending aortic replacement requiring deep hypothermic circulatory arrest (DHCA). Following initiation of cardiopulmonary bypass (CPB), the heater/cooler exchange jacket is dropped to 15°C, and after the patient reaches a nasopharyngeal temperature of 18°C, the rest of the operating room team is ready for DHCA. Are you? Hopefully, he’ll return to work for another 15 years after this operation, and his space shuttle will have a successful mission. To allow that, you’ll have to protect that great brain of his! Cover his head with ice bags, and prepare a brain cocktail with steroids, magnesium, and mannitol. Once circulation is arrested, ensure that the selective anterograde cerebral perfusion circuit flow is appropriate for his body size. Watch the clock; time is the enemy now, and the surgeon needs to be informed of the circulatory arrest time at regular intervals. Following complete rewarming of both core and shell temperatures, make sure that platelets, plasma, and red blood cells are available for transfusion if needed. With these maneuvers and a technically successful surgery, the patient has a great chance of going right back to being a rocket scientist!

Certain adult cardiac surgical procedures, primarily involving the ascending and descending aorta, aortic arch, and pulmonary vasculature require temporary interruption of cerebral blood flow to improve visualization and technical repair. This technique is referred to as DHCA (aka “circ arrest”) and is associated with high rates of neurologic compromise. Advanced age (older than 80 years) and DHCA times of >30 minutes are associated with higher rates of neurologic injury. The immediate energy-supply imbalance that occurs with “circ arrest” requires that the anesthesiologist consider the direct application of ice to the head (i.e., inducing an ice cream headache) and administration of a fancy drug cocktail in an attempt to preserve neurologic function. In addition, selective cerebral perfusion during DHCA has been observed to be of clinical benefit.