1. Conduct of Perfusion Cooper University Hospital:
School of Perfusion 2014
Michael F. Hancock, CCP

2. Cardiopulmonary Bypass
Support and protect the patient’s organs during cardiac surgery
Delivering O2 and nutrients, removing CO2 and waste
Allow surgeon to operate on a motionless, bloodless heart
Cardioplegic arrest

3. Role of the Perfusionist
Setup and prepare the CPB circuit and room
Review patient’s specific case and prepare a treatment plan for CPB
Manage and maintain patient’s hemodynamics during the operation
Wean patient off CPB and transfer care to anesthesia
Clean up equipment and document case

4. Setting Up CPB Circuit Pump setup determined by: Build Pump
Operation type
Surgeon preference
Patient size
Perfusionist’s preference
Build Pump
Connect power, gas lines, heater cooler lines, vacuum suction
CO2 flush and Prime circuit

5. Room Setup View OR schedule for case information
Surgeon, type of case
Ensure all necessary equipment is in OR suite, setup, and QC’d
Pump, Cell-saver, platelet gel, ACT machine, Cerebral oximeter, vacuum, heater cooler, fibrillator, pacemaker
Select ancillary disposable equipment
Cell saver lines, platelet gel: syringes and field tips and canister, extra vent tubing

6. Room Setup Check on Blood Availability Order Cardioplegia- Rx #4552
Blood Bank- #2503
OR Schedule on Cooler door
Order Cardioplegia- Rx #4552
High Dose- 76 mEq and 36 mEq (most cases)
Low Dose- 46 mEq and 26 mEq (Rosenbloom CABG)
Draw up drugs
Inject Heparin into your Cell Saver
Draw up ACD for platelet gel
Put Heparin and Albumin in pump (if going on CPB)
Have all other drugs ready
Do your Pre-Bypass Checklist
BE READY TO GO ON BYPASS BY THE TIME THE PATIENT GETS IN THE ROOM!

7. Patient Preparation
See your patient in Holding Area and do your Charting
3 Consents
History and Physical
Surgical plan
Lab values
Send ABG and run ACT
Collect platelet gel blood and spin down

8. Patient Preparation
Pull cannulas depending on patient size, type of procedure, and surgeon preference
Calculate Estimated HCT on CPB
Calculation done to determine the estimated HCT after going on CPB and hemodiluting the patient from both the CPB circuit and anesthesia during the intraoperative period

9. Estimated HCT on CPB PT weight (kg) x 70 (70cc blood/kg) = TBV
TBV x HCT = TRBCV
TBV cc = TCBV
1800cc CPB Prime
1000cc anesthesia
TRBCV / TCBV = Estimated HCT on CPB
HCT / 3 = Hbg
TBV = Total Blood Volume
TRBCV = Total RBC Volume
Number of red blood cells circulating in body
TCBV = Total Circulating Blood Volume
Accounts for hemodilution caused by CPB and anesthesia

10. Estimated HCT
If Estimated HCT on CPB is < 7, then consult the surgeon and decide if putting donor blood in the prime is necessary
If Estimated HCT is high (> 9), talk to anesthesia to decide if sequestering whole blood is in order to preserve platelets for the end of the case

11. Patient in Room
Hook up SomaSensors for Cerebral Oximeter BEFORE intubation!
Anesthesia will intubate, go to sleep, and put lines in
Nurses will prep and drape
Connect Cell Saver Lines
Push the pump forward, hand off lines, then close shunt and clamp your lines out
Hook up temperature probe
Be ready to crash on CPB!
Always be in the room when surgeon makes Sternotomy!

12. Communication in OR Strong communication is HUGE in the OR
Always respond to surgeon’s commands quickly and loudly!!
Hesitation and soft speaking will annoy them greatly
Exude confidence and knowledge when you speak in the OR
DO NOT lie to anyone in the OR!
Mistakes happen, own up to them

13. Surgery Start If CABG If Mini-valve or Redo
Surgeon will take down Mammary (LIMA/RIMA)
PA/RNFA will take vein
If Mini-valve or Redo
Surgeon or PA/RNFA will expose groin for femoral cannulation

14. Heparin Administration
Surgeon will call for “Heparin IN”
Anesthesia will give units/kg of Heparin via Central Line in RA
Wait 3-4 minutes after administration and run an ACT
ACT > 480 seconds for CPB

15. Heparin
A polysaccharide anticoagulant extracted from mast cells of body tissue
2 Types: Defined by extraction location
Porcine intestinal mucosa (used at Cooper)
Lower mean molecular weight
More effectively inhibits Factor Xa
Less binding to platelets due to lower molecular weight
Linked with delayed bleeding post-op because Protamine doesn’t fully reverse the effect on Factor X
Bovine lung
Higher mean molecular weight
More effectively inhibits Factor IIa
Great affinity for binding to platelets
More effectively reversed by Protamine
A Polysaccharide that resides in Mast cells
Acidic in nature, combined with Sodium in medicine
Molecular Weight- 3, ,000 Daltons
Mean Molecular Mass = ~15,000 Daltons
Causes 10-20% decrease in SVR when given

16. Heparin Site of Action- Half-Life- 90 minutes
Binds to and potentiates AT-3 (Anti-Thrombin)
AT-3 binds to thrombin and inhibits the clotting cascade
If AT-3 deficient, must administer FFP to achieve an adequate ACT
Half-Life- 90 minutes
Metabolized by the Kidneys
Patient must be fully Heparinized for the surgeon to cannulate AND for us to go on CPB

17. Cannulation Surgeon will place cannulas into the heart
Depending on the type of case, cannula type and site will vary
Sternotomy (Open)-
Arterial cannula goes in first, into the ascending aorta
Venous cannula goes in next
MVR being done- 2 single stage cannulas
SVC (Short) IVC (Long)
All other cases- Dual Stage cannula
Inserted into the Right atrial appendage and the tip sits in the IVC

18. Cannulation Mini-valve-
Venous- inserted first due to anatomical position (Femoral vein is more posterior to femoral artery)
Size- usually 25 fr.
Small patients- 22 fr.
Sally’s Pneumonic- Anterior > Posterior
NAVL
Nerve, Artery, Vein, Lymphatic
Arterial- inserted second
Femoral Artery
Size- usually 21 fr.
Small- 17,19 fr.
Large- 23 fr.

19. Connecting to the HLM Once ACT is > 480s you may turn on the Sucker
Arterial cannula IN- surgeon may ask you to “roll up” or “slow flush” the arterial line
Transfuse volume to him slowly at ~300cc/min
Surgeon will say “OFF” and you clamp line
Once arterial line is connected you may ask to RAP
Once venous line is in you may ask to AAP
Need ACT of > 480s to RAP/AAP!!!

20. Retrograde Autologous Priming (RAP)
Confirm with surgeon and anesthesia that you may RAP
Only RAP when SBP is > 80 mm Hg
Open your purge line stopcock and allow blood to flow through the arterial cannula > arterial filter > purge line > resevoir
Stop RAP’ing when purge line is red-tinged blood
Send fluid up to your priming bags
Clamp recirc-resevoir line, open recirc line when spike bags are unclamped and send volume in the resevoir to bags
Let surgeon and anesthesia know you are done
RAP’ing helps combat hemodilution

21. Antegrade Autologous Priming (AAP)
Confirm with surgeon and anesthesia that you may AAP the venous line
Drop your venous sequester bag to the ground, if you are not venous sequestering whole blood
If you are sequestering, AAP into the resevoir and send fluid up to bags like RAP’ing
Open sequester bag clamps and let clear fluid come back into the bag until venous line is full of blood
Clamp off bag and hang it on pole
Only AAP when SBP is > 80 mm Hg
Let anesthesia and surgeon know when done

22. Retrograde and Plegia
Surgeon will insert retrograde cannula in the coronary sinus
He will hand you pressure line to flush and zero if he chooses
Surgeon will ask to “Run up plegia”
Unclamp and run up plegia at ~150 cc/min
“Trickle plegia”- run plegia up at 50 cc/min
Should be ready to go on CPB now

23. Initiate CPB Surgeon will say “Go On CPB” Make sure ACT > 480s
Say “Going on Bypass”
Turn sweep gas ON, CPB clock ON
Unclamp Arterial line first to ensure arterial pump is functional and forward flow is established
Look at arterial line pressure to prevent dissection
Open venous clamp and ensure adequate drainage
Apply vacuum once arterial flow is increased
Notice is blood in A-line is oxygenated (Bright Red)
Open purge line shunt
Come up to full flow, tell surgeon and anesthesia once there
Turn isoflurane ON
Do your sweep-
Look at volume status in resevoir, pump flow, line pressure, MAP, cerebral SATs, ECG, venous line, vacuum pressure

24. Issues Initiating CPB High arterial line pressure-
Immediately notify surgeon, come off CPB if necesary
Caused by:
Cannula being against aortic wall
Surgeon can pull back cannula
Cross-clamp too close to cannula
Surgeon can re-cross-clamp
Cannula too small
Flow at a lower index
SVR too high
Give a vasodilator
Can cause aortic dissection
Seen by huge drop in arterial line pressure after the initial increase
BP drop
Volume loss

25. Issues Initiating CPB Poor Venous Drainage- Causes:
Kink in venous line
Straighten tubing
Air or Air Lock
Apply VAVD (vacuum)
Venous cannula malpositioning (too far down IVC)
Reposition cannula
Venous cannula comes out
Put it back in
Cannula too small
Use VAVD

26. Issues Initiating CPB Venous Line Chatter-
Caused by excessive negative pressure draining the RA, heart is empty and walls are collapsing around the venous cannula (cavitation)
Fix-
Lower VAVD pressure
Partially clamp venous line to apply some positive pressure in the line
Make sure you’re not filling the heart, if you are, clamp is less

27. Monitoring on CPB Flow Rate- 2.4 index is ideal
Arterial Line Pressure at Pump mm Hg is ideal
Color distinction- bright red blood in A-line
VSat- 65% when normothermic, ~80 when hypothermic
ECG- while X-clamp ON- no activity
X-clamp off- look for arrhythmias (Vfib, Vtach)
MAP- ~60 mm Hg
PA Pressurs- filling pressures when coming off
Circuit- look at volume status and clotting
Cerebral SATs and VAVD pressure
ACTs
Temperature

28. Charting Vital signs must be taken every 15 minutes
ACTs must be taken every 30 minutes
Or 3 mins after giving extra Heparin to treat a low ACT
Blood gases must be taken every 30 minutes
Or after making changes to correct a blood gas
First ABG should be taken within the first 10 minutes on CPB
Final blood gas should be prior to coming off CPB to correct any issues before coming off
Document everything!
Make sure everything you document is accurate
Prioritize- treat your patient before writing down something, but don’t forget to write it down

29. Vent Insertion
When on CPB, surgeon will put his LV vent and/or Root vent in
LV vents are used to prevent LV distension by continuously venting the heart of blood
LV Vent Sites-
Right Superior Pulmonary Vein- most common
LV Apex
Root Vent- placed in the ascending aorta, usually Y’d to the antegrade cardioplegia cannula
He will tell you when to turn the vent on
Usually turn at cc/min
AI Protocol for Rosenbloom- patients with AI
LV vent turns at cc/min until he tells you to turn it up

30. Cross-Clamp Placement
5-10 minutes after initiation of CPB, surgeon will cross-clamp aorta and give plegia
“Flow Down” or Pump OFF”is the command
Lower your flow to 2L/min or push the ERC clamp button after reducing your RPMs
Take Vacuum off when you lower your flow
He wants pressure in the aorta minimal when he applies the cross-clamp on the ascending aorta
Hit XC clock ON
“Antegrade” or “Retrograde” ON will be the command to give cardioplegia
“Flow Back Up”- bring flow up to full flow
Reapply vacuum

31. Cardioplegia Delivery
Induction dose of cardioplegia will be 76 mEq
Unless Dr. Rosenbloom is doing a CABG and giving straight crystalloid at 46 mEq
Antegrade flows will be around 300 cc/min with a pressure of
Flow hard to close the aortic valve
Notice the pressure hit at higher flow then back down on flow ~300 cc/min
Usually induction dose is ~1000cc
Retrograde flows are around 150 cc/min with coronary sinus pressures of ~25-40 mm Hg

32. Maintenance Cardioplegia
Cardioplegia will be given in maintenance doses every 15 or 20 minutes
Bowen/Highbloom = 15 minutes
Rosenbloom = 20 minutes
They want to be reminded of those intervals
Ischemia time is the time between each plegia dose
Total ischemia time of the case is the length of the cross-clamp period
Maintenance doses are given at 36 mEq and dose is usually around 650 cc

33. Vein Graft and Ostial Plegia
Plegia may be delivered down vein grafts and directly into the coronary ostia
SVG Flows are around 100 cc/min each
Pressure ~ 200 mm Hg
Left Coronary Ostia- flows are cc/min
Pressure ~200 mm Hg
Right Coronary Ostia- flows are ~100 cc/min
Smaller vessel than the LCA
Ostial plegia is delivered when antegrade cardioplegia isn’t possible, usually for patients with AI

34. Rewarming Surgeon will notify us when to start rewarming Rewarming-
They want us to be warm in ~ 20 minutes
Turn FiO2 up
Rewarming-
Heater cooler temperature up to 38.5˚
Arterial blood temperature should stay at 37˚
Never exceed a warming gradient of 10˚ between arterial blood temp and core temp
Never exceed a warming gradient of 12˚between heater cooler temp and blood temp
Safe rewarming is 1˚ every 5 minutes
You will vasodilate and VSats will decrease as you warm
Patient is using more oxygen

35. CO2 to the Field
We deliver CO2 to the field to allow the surgeon to blow CO2 into the chest cavity as he closes the atrium or aortotomy during a valve case
Command is “Gas ON”
Turned on 2 L/min
Turn Sweep Gas UP while the CO2 is ON

36. Cross-Clamp Removal
Hot-shot of warm blood is given through cardioplegia system via retrograde cannula for valve cases
K+ bags are clamped, plegia bridge is opened allowing only warm blood to be delivered
“Warm Blood, No chemicals” or “Hot Shot” termed
Infused until heart starts beating or activity is restored
Usually ~ 350 cc

37. Cross-Clamp Removal
Surgeon will say “Head Down” or “Trendelenburg” which is your cue to get ready for clamp removal
Push your Mannitol in now
Surgeon will say “Flow Down” or “Pump OFF”
May have you fill the heart with blood first to expel any air
He will then take the cross-clamp off and tell you that “You’re OPEN” meaning aorta is open
Push your drugs in
Lidocaine, Magnesium, Mannitol (if not already in)
Warm blood OFF, gas OFF, sweep down, XC clock off, flow back up, vents up high if he asks for it

38. De-Airing the Heart
Surgeon will ask for anesthesia to look at the TEE to assess the air situation in the heart
He will say “De-air the heart”
You clamp your venous line and fill the heart until you see ejection on the arterial waveform
Don’t let BP get too high, use PA pressure to judge filling pressures
When all air is expelled through the vents, he will say all empty

39. Terminating CPB
Once warm, de-aired, normal sinus rhythm surgeon will tell anesthesia to ventilate and say “Come down and off”
We first fill the heart and see ejection, play the game until our BP, filling pressures, volume status, and flow are where we want them
Close purge line shunt first to prevent exsanguination
Eventually come off CPB when we know the patient can take over
Clamp Lines, turn off clock, announce off CPB time

40. Off CPB Transfuse volume as instructed Take venous line and transfuse
Turn off sucker when protamine is ½ in
Monitor patient’s hemodynamics and be ready to go back on bypass
Have Heparin ready at all times
Never break down pump until chest is closed and they are on skin closure
Spin down any cell-saver after draining the pump and give to anesthesia

41. Protamine Reactions Type I- Type II- Anaphylactic reaction
Systemic Hypotension due to reduced SVR
Type II- Anaphylactic reaction
Hypotension
Pulmonary Vasospasm (high PA pressures)
Edema
Type III- Catastrophic
Pulmonary Vasoconstriction (very high PAs)
Severe hypotension
Dilated RV
Death

42. Protamine Reactions Action taken- give vasoactive drugs
give inotropic drugs
give pulmonary vasodilators
give heparin, go back on CPB

43. Normal Arterial Blood Gas
pH – 7.45
pO on CPB (> 100 otherwise)
pCO
O2 SAT %
VSAT- 65% (normothermic) K
Bicarb BE

44. Normal Venous Blood Gas
pH – 7.45 pO
pCO
O2 SAT %
VSAT- 65% (normothermic) K
Bicarb BE

45. Determine Oxygen Consumption
Oxygen Content- (1.34 x Hbg x Sat) + (.0031 x pO2)
Oxygen Capacity- (1.34 x Hbg) + (.0031 x pO2)
Oxygen Saturation = O2 Content / O2 Capacity
Oxygen Consumption = (art. O2 content – ven. O2 content) x flow (L/min) x 10

46. Bicarb Administration Calculation
Weight (kg) x BE x 0.3
Give half of that amount
Example:
70 x 3 x 0.3 = 63 mEq
Give 32 mEq and repeat the gas