1. Management of Incident in Cardiopulmonary Bypass
Pyo Won Park
Dept. Thoracic & Cardiovascular Surgery
Samsung Medical Center
Sungkyunkwan University School of Medicine

2. CPB Incident Rate per Case Number

3. Perfusion Survey of 1030 USA Hospital
Mejak BL, perfusion 2000;15:51

4. Mortality
Serious Injury

5. Australasian Perfusion Incident Survey

6. Iatrogenic Aortic dissection
Very low incidence ; %
High mortality; 20-40%
Location; ascending aortic cannulation,
aortic root cardioplegic cannulation
femoral & axillary cannulation
partial & cross clamp site
proximal amastomosis of CABG
aortotomy site
Risk factor; Aorta dilatation, atherosclerotic change,
previous CABG, old age, hypertension at
decannulation, femoral cannulation,
preoperative steroid, asian race

7. Aortic dissection at the time of cannulation
Diagnosis by perfusionist
unexpected high arterial line pressure
systemic hypotension
reduced venous return
Diagnosis by operator
difficult aortic cannulation
low back flow through aortic cannulae
aortic wall hematoma
descending aorta dissection in TEE

8. Aortic dissection at the time of cannulation
Management
Stop CPB
Clamp venous line
Maintain self cardiac function
Change arterial cannulae to proximal aorta
Restart CPB
Tear site repair
graft replacement under circulatory arrest
primary repair

9. Aortic dissection at the time of decannulation
Prevention
Secure purse string suture
Keep low BP (80-90mmHg) in high risk pts
at the time of decannulation
Management
Proximal ascending aorta & venous cannulation
Restart CPB
Tear site replacement with graft under arrest
Transapical aortic cannulation, if needed

10. Transapical Aortic Cannulation
Wada JTCS 2006;132:369-72
Figure 1. A 1-cm incision is made in the
apex of the left ventricle without
a purse-string suture.
Figure 2. A 7-mm cannula (Sarns Soft-flow
Extended Aortic cannula)
is passed through the apex.
Figure 3. The cannula is passed across the aortic
valve until positioned in the ascending
aorta under transesophageal
echocardiographic guidance.

11. Personal Experiences of Aortic Dissection
Early aortic dissection in intramural aortic cannulation in adult ASD Ascending Ao replacement
Root cannulae dissection in AVR during rewarming Ao reclamp, ascending Ao replacement
Iliac artery dissection in HTX in redo cardiac surgery Iliac artery repair after HTX

12. Massive air embolism
Critical complication due to residual neurologic damage and high mortality
Cause
sudden reduction in venous reservoir level
(ex. large AP collateral)
Inverson of left sided vent
Reversal of pump head
Air from cardiac chambers
Runaway pump head

13. Management of Massive Air Embolism
Stop CPB immediately
Clamping venous line
Steep Trendelenberg position
Remove aortic cannulae
Remove arterial filter
Deair arterial cannulae & pump line
Retrograde hypothermic SVC perfusion
Resume antegrade CPB
Finish cardiac procedure
Rewarming; up to 34°C, no overheating
Induce hypertension

14. Management of Massive Air Embolism
Retrograde Cerebral perfusion
Direct connect arterial line to SVC
Use arterio-venous shunt line
Flow; 1-2 L/min (adult)
Temp; °C
Duration; 1-4 min
Pressure; up to 40mmHg
Carotid compression
Confirm no air on aortic cannulation site

15. Management of Massive Air Embolism
Medication OR
Methyprednisolone 30mg/kg
Thiopental 20mg/kg
Mannitol 1gm/kg
ICU
Mannitol 0.5gm/kg Q 8hrs
Phenytoin 25mg Q 12hrs
Temperature control

16. Protamine reaction Type High risk group transient hypotension
severe pulmonary vasoconstriction
anaphylaxis
High risk group
fish allergy
prior protamine exposure
Insulin dependent diabetics
vasectomy

17. Prevention of Protamine reaction
Slow injection
Give 5-10mg test dose
Careful history taking
Extreme caution in high risk group
Vasectomy, previous exposure, fish allergy,
poor LV & RV dysfunction, Pul Ht
Keep CPB circuit intact during
protamine infusion

18. Management of Protamine Reaction
Administer fluid for hypotension
via arterial line
Give oxygen, steroid, epinephrine,
antihistamine for anaphylactic type
reaction
Vasopressor
Restart CPB
LVAD or ECMO, if needed

19. Electric Failure Prevention Extremely rare in mordern hospital
Usually failure of backup system (OR & CPB
console)
Prevention
Be familiar with operating facilities and
devices in case of emergency backup
Check flashlight and hand crank
Need battery operated emergency light
source, portable monitor, infusion pump,
suction

20. Management of Electric Failure
Source of light ; flashlight, laryngoscope
Venous line clamping to avoid exanguination
Manual systemic perfusion with hand crank
high speed(60-100rpm/min), extra manpower
Manual ventilation
Battery operated monitor, infusion pump,
suction device
CPB console battery; limted duration of support
30min for arterial pump, sucker, vent, light
50 min for only arterial pump

21. Oxygenator failure Diagnosis Dark colored blood exiting oxygenator
ABGA or in line blood gas sensor
Causes
Loss of gas supply ( failure of blender, leak or
obstruction of gas delivery system )
Inadequate anticoagulation ( after protamine
infusion, high incidence in aprotinin use )
Oxygenator leakage & malfunction
High transmembrane pressure gradient

22. Management of Oxygenator Failure
Notify surgeon & anesthesiologist
Seek qualified assistance
Turn off gas & water flow to oxygenator
Detach and attach oxygenator
Reconnect oxygenator lines
Recirculate oxygenator for deairing via
shunt line
Restart CPB

23. Parallel Replacement of Oxygenator
Routine shunt with 3/8 in tubing & 3/8 connector

24. Right coronary air embolism
Diagnosis
ST segment elevation
Decreased RV function
Flaccid & dilated RV
Ventricular arrythmia
Management
Restart CPB
High BP
Coronary artery massage
Coronary artery injection

25. Inadequate Blood flow Acute aortic dissection Low circulating volume
reduced priming volume
limited prebypass fluid infusion
Inadequate cannulae size
Malpositioned venous & arterial cannulae
During bypass
vasodilator infusion,
blood loss (pleural space, cell savor)

26. Management of Hypoperfusion
Add crystalloid/blood as needed
Watch line pressure at initiation to
insure proper cannulation
Scan venous line for air
Monitor venous O2 saturation
Reposition of IVC cannulae
Use vasodilator as needed

27. Other Problems Air lock False display of CPB pump output due
to incorrect setting of tubing size
(hyperperfusion or underperfusion)
Arterial line rupture
Aortic cannulae dislodgement
Drug error
ABO incompatible blood transfusion

28. Problem Solving & Prevention/Treatment protocol
Problem Identification
Development & treatment protocol
Evaluation of Protocol
Case evaluation
M & M report
Occurrence screen
Literature review
Equipment bulletins
Education
Drill

29. Prevention & Management of CPB Incident
Use of safety equipment
Human error account for 70-85%(2 perf)
Checklist for CPB
Written protocol for crisis management
Simulation; reusable training circuit
Mental rehearsal
Practice of skill
Communication between surgical teams
National survey & exchange experiences

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31. Thank you for your attention