This document discusses perfusion safety in cardioplegia delivery management. It covers:
1. The importance of safety in perfusion to protect patients' lives and avoid negative consequences.
2. Definitions of cardioplegia as the paralysis of the heart during cardiac surgery using chemicals or electricity.
3. Guidelines for safely managing cardioplegia delivery, including preparing accurate solutions, checking the cardioplegia circuit and roller pump calibration, and monitoring temperature, pressure, flow and volume during delivery.
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
Endomyocardial fibrosis (EMF) is a disease that is characterized by fibrosis of the apical endocardium of the right ventricle (RV), left ventricle (LV), or both.
The clinical manifestations are largely related to the consequences of restrictive ventricular filling, including left and right sided heart failure.
The heart failure is associated with atrioventricular-valve regurgitation.
Endomyocardial fibrosis is a major cause of illness and death in areas where it is endemic, and in its severest form carries a very poor prognosis, with an estimated survival of 2 years after diagnosis.
د/باسم السيد
Management of shocked patient
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
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of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
4. Safety is a committed respect
for human lives
in which we have
responsibility
(Reed, 1988)
5. Perfusion safety
• Absence of structural and functional damage after cardiopulmonary
bypass
• Protect life and talent and avoid negative social and economical
consequences
• Avoid feeling of personal guilt and maintain team’s reputation
6. Cardioplegia
paralysis of the heart, as may be done electively in
stopping the heart during cardiac surgery,
cardioplegia may be done using chemicals or
electrical stimulation
(The American Heritage, Medical Dictionary, 2007)
7. The problems had reported in case
management cardioplegia delivery
• Failure to add a sufficient amount of Potassium is the most common error
when preparing cardioplegia solutions
• The heating cooling unit may fail and cardioplegia may not be delivered at the
right temperature.
• A simple test is to feel the cardioplegia line during delivery. It should be at the
temperature during delivery and also a mist must form if giving cold
cardioplegia and if using metallic direct cardioplegia cannulae the handle must
cool.
(Patient Management & Perfusion Technique, The Regents of the University of Michigan, 2009)
9. Perfusion Safety…
I. Cardioplegia solutions
• Preparing cardioplegia solutions
• Cardioplegia solution label expired date
Check boxes are provided to indicate which solution has been prepared.
• Two perfusionist check when add the CPG into the solutions
• Blanks are also provided for the initials of the preparer as well as the time
and date of preparation.
10. Content of Cardioplegia Concentrate
• 20 ml (1 ampoule) of DBL Cardioplegia Concentrate
contains:
Magnesium chloride 16 mmol
Potassium chloride (KCl) 16 mmol
Procaine hydrochloride 1 mmol
12. Perfusion Safety…
II. Cardioplegia circuit
• Cardioplegia Roller Pump Calibration
– The cardioplegia roller pump should be calibrated prior to the initiation of
CPB.
• Refer to 4:1 Cardioplegia roller pump Calibration Chart below and
find the appropriate stroke volume for the prescribed 4:1
cardioplegia pump boot.
Cardioplegia Set 4:1 Cardioplegia Boot Diameters Stroke Volume/Revolution
MUF/4:1 CP Set 3/32” & 3/16” 10 ml
Non MUF 4:1 CP Set 3/32” & 3/16” 10 ml
14. III. Cardioplegia delivery technique
A. Flow
Antegrade cardioplegia
• aortic root to the coronary ostia
• flow 250-350 ml/min
conditions that influence the flow of cardioplegia delivery :
Low flow (below therapeutics dose) :
– Severe widespread coronary artery disease
– Small patient
– Intimal infusion
High flow (above therapeutics dose) :
– Large patient
– Aortic incompetence
– Crossclamp malposition
15. Cont…..
Retrogade cardioplegia
• Coronary sinus via a retrograde catheter
• Flow 200 ml/min
conditions that influence the flow of cardioplegia delivery :
Low flow (below therapeutics dose) :
Overinflated baloon
Too deep insertion of cannula into coronary sinus
Rotation of heart
High flow (above therapeutics dose):
Inadequate cardioplegia distribution (severe stenosis)
Leakage of blood around inadequately filled balloon
Ruptured coronary sinus
16. B. Pressure
Antegrade :
• Aortic root pressure : 50-90 mmHg
• High pressures (>100 mm Hg) cause difficulty with visualization and may lead
to myocardial edema.
• Low delivery pressures (<50 mm Hg) will result in inadequate myocardial
perfusion or left ventricular distention due to aortic valve incompetence
(Young JN, Choy IO. Aortic root pressure monitoring during antegrade cardioplegia administration.
Ann Thorac Surg 1996;62:1213–4)
17. Retrograde :
• Coronary sinus pressures : 28 - 50 ml.
• Keep coronary sinus pressures mid 30 mmHg as too low
pressures may compromise cardioplegia distribution, while too
high pressures may rupture the coronary sinus
18. • Additionally, delivery of retrograde cardioplegia takes longer compared
to antegrade delivery because of lower flow rates and pressures
employed to prevent the development of myocardial edema and
coronary sinus injury (antegrade cardioplegia is delivered at systemic
pressures).
• Because of this, many surgeons advocate initiating cardiac arrest with
a single dose of antegrade cardioplegia, followed by interval dosing of
retrograde cardioplegia.
19. C. Volume
• Induction dose : 20ml / kgBW for 4 minutes
• Maintenance dose : 10ml / kgBW for 2 minutes
20. Perfusion Safety…
D. Temperature
• Check the heat exchanger and the ice
• Cardioplegia solution temperature is controlled with a dual
cooler/heater unit.
• The cooler portion of the unit is set at 4oC for cold
cardioplegia delivery.
21. Giving Methods Cardioplegic Solutions
Crystalloid cardioplegia
• More likely to be used in pediatric where cross-clamp time of less than
1 hour
• Simple circuit and low cost
• Less oxygen carrying
• When given in large amounts of risk for hemodelution
22. Blood Cardioplegia
• advantage of blood cardioplegia is the blood oxygen carrying capacity greater
than crystaloid,
• Natural buffers hemoglobin
• Is a metabolic substrate carrier and free radical scavengers of natural
• oncotic also increase, preventing edema myocardia
• In some references mention that the blood kardioplegia more effective on long
cross-clamping conditions (> 1 hour)
• Need Potassium is higher than the cristaloid because it will mix with blood.
Usually the ratio is 4:1 (that is usually used in the protocol harkit)
23. Mechanism of myocardial protection with Cardioplegia
• Mechanical arrest (potassium-induced) will reduce oxygen consumption
• Hypothermia will reduce consumption
• Aerobic metabolism can be maintainted with oxygenated cardioplegia
24. Hot Shot
• Given just prior to the removal of the aortic cross clamp.
• "Hot Shot" is delivered retrograde at 150 - 200 ml/min at a
temperature of 32 - 37oC.
• Total dose of 30 ml/kg is ideally delivered over a 2 - 4
minute