Sandeep Mewada Perfusionist Cardiopulmonarybypass

1. CBP is technique in which a machine
temporarily takes over the function of the heart
and lungs during surgery, maintaining the
circulation of blood & the oxygen contract of the
patient’s body.
The pump referred to as “heart” & Oxygenator
functions as lungs

2. Circuit :-
Chart review and selection of
equipment .
Before assembling the perfusion circuit
information from the patient’s chart is
obtained regarding the proposal surgical
procedure and relevant history.

3. 1
Oxygenator
2 Custom
tubing pack
3 ALF
4
Cardioplegia
delivery set
5 hamofilter 6 Cannulae
1 Aortic 2 Venous 3 CPG
4 Vent 5 Cardiotomy
sucker

4.  Conduction :-
The perfusionist is
responsible for the setup of CPB circuit &
priming of the HL –Machine & Oxygenator
the conduct of CPB & anticoagulation
activity drugs & write the records.

5. 1. Check all machines, HL –machine, all
pumps are in well working condition,
battery backup, spot light, oxygen supply
& cranks (handle).
2. TCM - check Water Levels (h20) both cold
& warm tubing are proper function is not &
ice making properly.
3. Also check JABP Machine according to
case.

6. 4. Holder – according to the type of oxygenator,
CPG system, arterial filter, cardioplegia device
holder & hemofliter holder.
5. Check oxygen source supply & blender also.
6. Clamps & available.
7. ACT tubes & machine.
8. All disposable items should be available.

7. 9. All drugs & fluid for priming.
10. Check the pressure transducers are
working properly.
11. Perfusion record chart is prepared for the
pts and Hct (hemotocrit) level predict.

8. 1. Assembly of HL machine & circuit:-
Disposable items available for
adult & pediatric preparations.
Assembly of circuit is done by
done by all sterile procedures, while pts is
being prepared by anesthetic & nurses.
 Oxygenator assembled with the circuit.
 Gas lines are connected.
 Water lines are connected to heat
exchanger, CPG System & check for any
leakage.

9.  CPB Circuit is primed with crystalloid,
Colloid & with heparin.

10. All outlets & venting parts & ancillary lines
from the oxygenator closed.
From above pump head 30 inch tubing keep
according to rate of falling 1 am/ min is
observed according to which is adjust the
compression of roller pump.

11. Lines are taken from surgeon side &
connected to venous inlet part & arterial filter
outlet, suckers & vent.
Sucker & vent are checked
CPG lines is flushed for de-airing.

12. AV loop is circulated fast to de-airing the
circuit properly
Lines are tapped from the surgical sides as
well as arterial filter is de-aired by tapping
the lines

14. 3-4 mg/kg, heparin is given , a period of 3
min is allowed to elapse after heparin
administration before cannulation ,is begun
while at others, ACT>300 is necessary for
cannulation.
Cardiotomy suckers, On when ACT is
reached at >250,400-480 sec ACT is
required for going bypass.

15.  Aortic cannulation is always performed first.
This help in managing blood loss during
cannulation & in case of hypotension allow
commencement of CPB with a single venous
cannula or “suker bypass”.
 During aortic cannulation, Perfusionist run the
aortic pump on surgeon’s calling to make air
free connection.
 After cannulation, check swing & resistance.

16. Line pressure checked, which is nearly
equal to perfusion pressure indicate
position of cannula is proper.

17. Retrograde autologous, priming is done after
aortic cannulation to reduce the prime volume
by maintain adequate reservoir volume.
To decrease hemodiludtion.

18.  This is depending on the surgical procedure.
Which types of cannulation is to be done.
1. Bicaval cannulation
2. Two stage cannulation
3. Single stage cannulation
 SVC Cannulation is always done first as this
involves less retraction of heart & hence less
chance of hypotension during cannualtion.

19.  IVC Cannulation :- On the posterior inferior RA wall.
 CPG Cannulation :- Depends on the surgical
procedure, CPG Cannulation is done.
1. Autograde CPG Cannulation :-
Placed to aortic root.
 P – 80- 120 mmHg.
 Flow – 200 -300 mmHg.
2. Ostial CPG :- Directly into the ostial by hand handling
into the coronary ostia.
2. P – It ostia RT coronary ostia flow

20.  Retrograde CPG – Cannula is inserted through
lower part of RA into the coronary sinuous.
 P –
 Flow-
 Vent placement – in some special cases, like
AVR if AR is present then surgeons uses LV
vent cannulation by RSPV to prevent cardiac
distension.
 ACT- when ACT>400-480 Sec.

21. CPB is initiated, after instructions from the
surgeon, by the perfusionist slowly
transfusing the pts with the CPB prime.
Arterial flow should be unobstructed & an
initial line pressure <100 mmHg.
Confirm oxygenator gases & CPB safely
alarms are switched on prior to the CPB.
Venous clamp is gradually released after
confirmation the arterial line is unobstructed,
the pts is blood is diverted into the reservior.

22. P – informs the surgeon, On full bypass,
Surgeon checks following
1. RA empty totally, with CVP<0 mmHg.
1. MPA should be soft.
 Then surgeon ready for aortic cross clamp
cooling of the pt,if required by the surgeon,
monitors, ECG at this stage, so that VF may
be noted & actions taken to prevent cardiac
distension.

23.  Once, aortic has been clamped(check L.P) the
required temperature has been achieved.
Cardioplegia has been administered if required
& steady state of perfusion has been attained
the first sample for blood gases & ACT is
checked.
 Perfusionist maintain perfusion pressure & all
ABG parameter, ACT with in normal limit.
 CPG is repeated every 25-30

24. Pt’s flow & Hypothermic management:-
pt’s blood flow depends on the C.I & Temp.
As a general rule flow should be reduce with
temp. (as metabolic required diminish) &
vice versa.

25. Hyothermia Temp. Flow index
(L/min)
Fi o2 Gas : Blood
flow
Normothermi
a
37 2.4 80% 1:1
Tepid (mild) 34 2.2 70% .8:1
Mod. 30 2.0 65% .7:1
Mod. 28 1.8 60% .6:1
Deep
hypothermia
22 1.6 50% .5:1

26.  Sys O2 consumption, V O2 is reduced by approx
.50% for every 7*C reduction in core temp.
below normothermia .
 At 30 *C - VO2 -50 %
 At 23 *C – VO2 -25%
 At 16 *C – VO2 -12.5%
 As relative, small decreases in temp.reduce
requirement for sys.O2 delivery, making reduce
in pump flow, DO2 sufficient to meet VO2.

27. 0
5
10
15
20
25
30
35
pO2(mmHG) 10 20 30
oxyhemoglobin(%
Saturation)

28. Ct & Rt shifts in O2- Hb dissociation curve
also occures with temp.changes during
CPB.
At lower temp. Hb has greater affinity for
binding O2, Consquently, O2 is also
released less readily & the dissociation
curve shift to the Ct. At high temp. converse
is true & curve shift to Rt.
Pump flow rate must be adjusted with due
consideration to temp. if metabolic
demands for O2 are to be matched by
delivery.

29. During CPB, Monitoring this parameters
Moitoring
continously intermittently

30. • Continously • Intermittently
1) ECG 1) ABG
2) Perfusion pressure/ line pressure
(MP 40-80mmHg)
2) pH/Base deficit
3) CVP 3) Hb/Hct
4) Arterial pump flow rates 4) K+ conc.
5) Suction pump flow rates 5) Urine output ( 0.5 -1.0 ml/kg/hr)
6) Core temp & Hypothermia 6) LA/PA Pressure
7) Venous reservoir level 7) Glucose/ACT

31. During CPB, good renal function is an
indication of the adequacy of perfusion .
pH, lactate conc.
SvO2 > 65% on bypass.
Mixed venous satuartion is an indicator of
matching of DO2 & VO2.

32. As margin between sys. O2 delivery &
demand narrow, O2 extraction increase &
SVO2 decrease.
O2 Delivery equals pump flow time CaO2 &
should be above 250 ml/min/m2 during
normothermic perfusion.
Metabolic acidosis ( base deficit) or eleveted
lactic acid level also indicate inadequate
perfusion.

33.  The pt’s should be rewarmed using the arterial
blood temp.& pt’s core temp.
 By maintaining the temp.gradient 4 -6 *C
 Rewarming the pt’s to 37*C more than 37*C
should not be exceeded.
 On rewarming , appropriate adjustments gas
flows & to the blood flow must be made
 Blood : Gas (1:1.5)

34. After intracardiac procedure, all cardiotomies
are closed & the heart is de-aired these
achieved by
Start HOTSPOT ( if requires depending on
surgical procedure,& surgeon.)
Patient in head down position. (tender burg
position)
Anesthetic starts ventiation (active filling )

35. Perfusionist by partially clamping the
venous line fills the heart .(passive filling)
Surgeon massages LV & de-airs the heart
through aortic root.

36. After complete de-airing, aortic is declamped
in head down position.
Aortic root vent is on slowly 1 ABh
repeated,according to ABG,correct blood
gas, metabolic abnormalities & Ca2+ &
Mg2+.

37. After aortic declamping, heart regains its
activity & contractility.
Perfusionist to restore the blood volume to
the heart by gradual occlusion of the venous
return.
Perfusionist now increasingly fill the heart
guided by the CVP & PA distolic pressure (
CVP 8 -12 mmHg)
Termination of CPB is achieved by complete
occlusion of venous line & STOP the arterial
pump.

38. Once, hemodynamic stability is established
after weaning off CPB.
Venous cannula is removed process of
reserving of heparin with protamine.
Prior to protamine administration,cardiotomy
suction is stopped to avoid clotting with in the
circuit.
When protamine started residual blood is
transfused to the pt’s by main taining safe
reservior volume by supporting B.P.