CONDUCT OF CONDUCT OF PERFUSIONPERFUSION

October 16, 2003October 16, 2003

Brian Schwartz, CCPBrian Schwartz, CCP

PURPOSE OF CPBPURPOSE OF CPB

• PROVIDE SURGEONS WITH A MOTIONLESS AND BLOODLESS FIELD

• PROVIDE PROTECTION TO VITAL ORGAN SYSTEMS

Your ObjectivesYour 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

Conduct of Perfusion Conduct of Perfusion

• Purpose of CPB: support patient’s 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

Components of the CPB CircuitComponents of the CPB Circuit

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

Assembly Assembly

• The set up is dependent upon:• Procedure • Patient size• Surgeon’s preference• Perfusionist’s preference

CONDUCT OF PERFUSIONCONDUCT OF PERFUSION

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

THE PERFUSIONIST’S TIME LINETHE PERFUSIONIST’S TIME LINE

• GET A HANDLE ON THE SCHEDULE

• REVIEW PATIENT’S CHART

• SELECTION OF DISPOSABLE EQUIPMENT

• ASSEMBLE HLM

• PLUG IN POWER AND GAS LINES

• PLUG IN HEATER/COOLER (WATER TEST)

Time Line (cont)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

TIME LINE (CONTINUED)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

PRE-BYPASS CALCULATIONSPRE-BYPASS CALCULATIONS

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

PRE-BYPASS CALCULATIONSPRE-BYPASS CALCULATIONS

• HCT IF SEQUESTERING BLOOD– TRBC – { 500 cc x HCT } / TCBV – 500 cc

HEPARIN ADMINISTRATIONHEPARIN 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

HEPARIN ( CONTINUED )HEPARIN ( CONTINUED )

• HALF LIFE = 1-2 HOURS

• 3-5 MINUTES AFTER ADMINISTERING TAKE AN ACT…..MUST BE >480 SECONDS

• SOME PATIENTS MAY BE HEPARIN RESISTENT– THEY ARE ATIII DEFICIENT– GIVE FRESH FROZEN PLASMA

CANNULATIONCANNULATION

• SURGEONS NOW PLACE THE CANNULAE INTO THE HEART

• VENOUS CANNULAE– IN RIGHT ATRIUM WITH 2 STAGE – SINGLE STAGE IN THE IVC AND THE SVC

CANNULATION CANNULATION

• ARTERIAL CANNULAE– AORTA OR FEMORAL ARTERY

• RETROGRADE CARDIOPLEGIA

• ANTEGRADE CARDIOPLEGIA

• VENT

PURPOSE OF VENTPURPOSE OF VENT

• PLACED IN THE AORTIC ROOT OR IN THE LEFT VENTRICLE

• USED TO PREVENT DISTENTION OF THE HEART

• USE A ONE-WAY VALVE

INITIATION OF BYPASSINITIATION 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 !!!!!!!!

BYPASSBYPASS

• UNCLAMP VENOUS LINE AND INCREASE FLOW TO YOUR 2.4 INDEX

• IF YOU SENSE A HIGH LINE PRESSURE AS YOU INITIATE BYPASS…IMMEDIATELY TERMINATE BYPASS!!!!!!

CAUSES OF HIGH AORTIC LINE CAUSES OF HIGH AORTIC LINE PRESSUREPRESSURE

• 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

CAUSES OF POOR VENOUS CAUSES OF POOR VENOUS RETURNRETURN

• 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

CHATTERINGCHATTERING

• 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

SAFTEY CHECKS TO DO ON SAFTEY CHECKS TO DO ON BYPASSBYPASS

• FLOWING AT PROPER RATE• A-LINE PRESSURE IN NORMAL• OXYGEN IS ON AND THAT ARTERIAL BLOOD

IS RED….COMPARE A/V LINES• O2 SAT’S NORMAL• MAP BETWEEN 50-70 • TEMP’S• ACT>480• MAKE SURE ALL SAFETY DEVICES ARE ON

MONITORINGMONITORING

• 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

CHARTINGCHARTING

• VITAL SIGNS MUST BE TAKEN EVERY 15 MINUTES

• ACT’S 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– DON’T FORGET TO GET A WARM GAS BEFORE

TERMINATING BYPASS

NORMAL ARTERIAL GASNORMAL 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

NORMAL VENOUS GASNORMAL 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

Determine Oxygen ConsumptionDetermine Oxygen Consumption

• Oxygen content=1.34 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

CALCULATE AMOUNT OF CALCULATE AMOUNT OF BICARB TO GIVEBICARB TO GIVE

1. WT (KG) X BASE DEFICIT X .3

2. EQUATION #1 DIVIDED BY 2 = AMOUNT OF BICARB TO GIVE

EXAMPLE: 70 X 3 X .3 = 63

63 / 2 = 32 mEq

POST BYPASSPOST BYPASS

• MONITOR PATIENTS HEMODYNAMICS

• NEVER DISMANTLE PUMP UNTIL CHEST IS CLOSED

• PROTAMINE• MANY PATIENTS HAVE REACTION• TURN OFF PUMP SUCKERS• MONITOR PA AND MAP

PROTAMINE REACTIONSPROTAMINE 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

CLEAN-UPCLEAN-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