CONDUCT OF PERFUSION

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CONDUCT OF PERFUSION

• October 16, 2003
• Brian Schwartz, CCP

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PURPOSE OF CPB

• PROVIDE SURGEONS WITH A MOTIONLESS AND BLOODLESS
  FIELD
• PROVIDE PROTECTION TO VITAL ORGAN SYSTEMS

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Your Objectives

• Understand the components of the CPB circuit
• Understand the sequence for assembly of the
  circuit
• Able to calculate the predicted hemoglobin and
  hematocrit
• Understand the determinants of oxygen consumption

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Conduct of Perfusion

• Purpose of CPB support patients metabolic needs
  while providing a motionless, bloodless cardiac
  surgical field
• Parameters that must be met
• Proper flow rate
• Oxygen delivery
• Carbon dioxide removal
• Anticoagulation
• Temperature
• Blood pressure
• Blood recovery

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Components of the CPB Circuit

• Oxygenator
• Heat exchanger
• Venous reservoir
• Gas flow meter
• Variety of pumps
• Tubing
• Cannulae
• Hemoconcentrator
• Alarms
• Drugs

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Assembly

• The set up is dependent upon
• Procedure
• Patient size
• Surgeons preference
• Perfusionists preference

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CONDUCT OF PERFUSION

• WE ARE TALKING ABOUT OUR DUTIES AND
  RESPONSIBILTIES PRE-OP, INTRA-OP, AND
  POST-OPERATIVELY

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THE PERFUSIONISTS TIME LINE

• GET A HANDLE ON THE SCHEDULE
• REVIEW PATIENTS CHART
• SELECTION OF DISPOSABLE EQUIPMENT
• ASSEMBLE HLM
• PLUG IN POWER AND GAS LINES
• PLUG IN HEATER/COOLER (WATER TEST)

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Time Line (cont)

• CO2 flush the circuit
• Prime the circuit
• Test all occlusions
• Check list
• Perform all quality controls
• ALWAYS BE PROPARED TO GO ON CPB

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TIME LINE (CONTINUED)

• PRIME CIRCUIT
• PERFORM CHECK LIST
• ADMINISTRATION OF HEPARIN
• INITIATION OF CPB
• TERMINATION OF CPB
• ADMINISTRATION OF PROTAMINE
• BREAKDOWN AND CLEANUP OF HLM

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PRE-BYPASS CALCULATIONS

• PREDICTED HEMATOCRIT
• 70 X KG TBV
• TBV X HCT TRBC
• TBV PRIME ANES. DRIPS TCBV
• TRBC/RCBV DILUTIONAL HCT

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PRE-BYPASS CALCULATIONS

• HCT IF SEQUESTERING BLOOD
• TRBC 500 cc x HCT / TCBV 500 cc

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HEPARIN ADMINISTRATION

• DESCRIBED AS AN ANTICOAGULANT
• MUST FULLY ANTICOAGULATE PATIENT
• SITE OF ACTION ATlll AND INHIBITS FACTORS IX
  AND XI OF THE CLOTTING CASCADE
• GIVE 300-400 UNITS/KG
• IN RIGHT ATRIUM OR CENTRAL LINE

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HEPARIN ( CONTINUED )

• HALF LIFE 1-2 HOURS
• 3-5 MINUTES AFTER ADMINISTERING TAKE AN
  ACT..MUST BE gt480 SECONDS
• SOME PATIENTS MAY BE HEPARIN RESISTENT
• THEY ARE ATIII DEFICIENT
• GIVE FRESH FROZEN PLASMA

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CANNULATION

• SURGEONS NOW PLACE THE CANNULAE INTO THE HEART
• VENOUS CANNULAE
• IN RIGHT ATRIUM WITH 2 STAGE
• SINGLE STAGE IN THE IVC AND THE SVC

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CANNULATION

• ARTERIAL CANNULAE
• AORTA OR FEMORAL ARTERY
• RETROGRADE CARDIOPLEGIA
• ANTEGRADE CARDIOPLEGIA
• VENT

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PURPOSE OF VENT

• PLACED IN THE AORTIC ROOT OR IN THE LEFT
  VENTRICLE
• USED TO PREVENT DISTENTION OF THE HEART
• USE A ONE-WAY VALVE

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INITIATION OF BYPASS

• SURGEONS READY TO BEGIN CPB. THEY WILL TELL YOU
  TO GO ON
• ALWAYS REPEAT COMANDS BACK TO AVOID MISTAKES
• PUT 02 ON 100, SWEEP ON, REMOVE ARTERIAL CLAMP,
  SLOWLY TURN PUMP ON. CAREFULLY MONITOR ARTERIAL
  LINE PRESSURE !!!!!!!!

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BYPASS

• UNCLAMP VENOUS LINE AND INCREASE FLOW TO YOUR 2.4
  INDEX
• IF YOU SENSE A HIGH LINE PRESSURE AS YOU INITIATE
  BYPASSIMMEDIATELY TERMINATE BYPASS!!!!!!

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CAUSES OF HIGH AORTIC LINE PRESSURE

• KINK IN THE A-LINE
• CANNULAE IMPROPERLY POSTIONED
• CROSS-CLAMP TOO CLOSE TO CANNULAE
• ARTERIAL CANNULAE TOO SMALL
• SYSTEMIC PRESSURE TOO HIGH
• AORTIC DISECTION
• ARTERIAL FILTER OBSTRUCTED

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CAUSES OF POOR VENOUS RETURN

• KINK IN VENOUS LINE OR CANNULA
• AIRLOCK
• OXYGENATOR IS NOT POSITIONED LOW ENOUGH
• VENOUS CANNULA PLACED TO FAR DOWN INTO THE CAVA
• VENOUS CANNULA FALLS OUT

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CHATTERING

• A TERM USED IF THE HEART IS COMPLETELY EMPTY AND
  YOU SEE THE VENOUS LINE JUMPING AROURD
• CHATTERING IS CAUSED BY EXCESSIVE NEGATIVE
  PRESSURE IN THE VENOUS LINE CAUSING A SUCTION
  EFFECT.SIMPLY PLACE A CLAMP (PARTIALLY) ON THE
  VENOUS LINE TO REDUCE THE NEGATIVE PRESSURE

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SAFTEY CHECKS TO DO ON BYPASS

• FLOWING AT PROPER RATE
• A-LINE PRESSURE IN NORMAL
• OXYGEN IS ON AND THAT ARTERIAL BLOOD IS
  RED.COMPARE A/V LINES
• O2 SATS NORMAL
• MAP BETWEEN 50-70
• TEMPS
• ACTgt480
• MAKE SURE ALL SAFETY DEVICES ARE ON

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MONITORING

• EKG
• WHILE THE CROSS-CLAMP IS ON THERE SHOULD BE NO
  ACTIVITY
• WHEN CLAMP COMES OFF, BE ON THE LOOK OUT FOR ST
  ELEVATIONS, V-TACH, AND V-FIB
• PA PRESSURES
• CIRCUIT
• OPERATING TEAM
• KEEP COMMUNICATION OPEN
• TRAFFIC AROUND PUMP

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CHARTING

• VITAL SIGNS MUST BE TAKEN EVERY 15 MINUTES
• ACTS MUST BE TAKEN EVERY 30 MIN
• BLOOD GASES MUST BE TAKEN EVERY 30 MINUTES OR
  AFTER CHANGES HAVE BEEN MADE
• FIRST BLOOD GAS SHOULD BE TAKEN 5-10 MINUTES
  AFTER CPB
• DONT FORGET TO GET A WARM GAS BEFORE TERMINATING
  BYPASS

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NORMAL ARTERIAL GAS

• pH 7.35-7.45
• p02 Greater than 100
• 02 Sat 96-100
• K 3.5-5.3
• BICARB 22-28 MEQ/L
• BE -2.5 TO 2.5

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NORMAL VENOUS GAS

• pH 7.35-7.39
• P02 38-42
• 02 Sat 65-75
• pCO2 44-48mmHG
• Bicarb 22-28 mmHG
• BE -2.5 to 2.5

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Determine Oxygen Consumption

• Oxygen content1.34 x Hb x Sat .003xp2
• Oxygen Capacity 1.34 x Hb .003 x pO2
• Oxygen Saturation O2 content/ Capacity
• Oxygen Consumption aO2 content vO2 content x
  flow (L/min) X 10

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CALCULATE AMOUNT OF BICARB TO GIVE

• WT (KG) X BASE DEFICIT X .3
• EQUATION 1 DIVIDED BY 2 AMOUNT OF BICARB TO
  GIVE
• EXAMPLE 70 X 3 X .3 63
• 63 / 2 32 mEq

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POST BYPASS

• MONITOR PATIENTS HEMODYNAMICS
• NEVER DISMANTLE PUMP UNTIL CHEST IS CLOSED
• PROTAMINE
• MANY PATIENTS HAVE REACTION
• TURN OFF PUMP SUCKERS
• MONITOR PA AND MAP

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PROTAMINE REACTIONS

• TYPE I
• SYSTEMIC HYPOTENSION
• REDUCED SVR
• TYPE II
• ANAPHYLACTIC REACTION RESULTING IN HYPOTENSION,
  BRONCHOSPASM, AND EDEMA
• TYPE III
• CATASTROPHIC PULMONARY VASOCONSTRICTION WITH
  INCREASED PA PRESSURES, HYPOTENSION, DECREASED LA
  PRESSURES, AND DILATED RIGHT VENTRICLE

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CLEAN-UP

• SEND ALL BLOOD TO CELL SAVER
• DISMANTLE TUBING
• CLEAN UP PUMP FOR ANY BLOOD STAINS
• PAPER WORK
• SET UP BACK UP PUMP
• SET UP BACK UP CELL SAVER