Complications and safety during cpb

1. Safety during CPBSafety during CPB

2. Bypass safetyBypass safety
Concept of safety is subjective.Concept of safety is subjective.
Fatal perfusion accidents occurred 1/1800Fatal perfusion accidents occurred 1/1800
cases.(1981)cases.(1981)
Serious incident 1/130 procedures (1981)Serious incident 1/130 procedures (1981)
With better saftey features and perfusionWith better saftey features and perfusion
techniques standards has improvedtechniques standards has improved
considerably.considerably.

3. Organizational aspectsOrganizational aspects
Most important and fundamental aspect ofMost important and fundamental aspect of
cardiac surgery.cardiac surgery.
Describes the quality required of the unitDescribes the quality required of the unit
members and their responsibilities.members and their responsibilities.
Describes the components required for anDescribes the components required for an
open-heart unit.open-heart unit.
Emphasizes team work.Emphasizes team work.
Emphasizes co-operation,co-ordinationEmphasizes co-operation,co-ordination
and effective communication.and effective communication.

4. Perfusion department safetyPerfusion department safety
organizationorganization
Establishment of equipment records:Establishment of equipment records:
1.1. Identification and location of eachIdentification and location of each
individual device.individual device.
2.2. Record of maintenance and repair ofRecord of maintenance and repair of
each device.each device.
3.3. Establishment of routine preventiveEstablishment of routine preventive
maintenance protocols.maintenance protocols.
Faults bookFaults book

5. Perfusion protocolPerfusion protocol
Establish agreed protocols to be followed by allEstablish agreed protocols to be followed by all
perfusionistsperfusionists
1.1. Basis for selction of equipmentsBasis for selction of equipments
2.2. Pre-operative machine checksPre-operative machine checks
3.3. Priming solutions and techniquesPriming solutions and techniques
4.4. Case record which should includeCase record which should include
a) patient statisticsa) patient statistics
b) equipments usedb) equipments used
c) fluids and drugs used.c) fluids and drugs used.
d) measured parameters.d) measured parameters.
e) frequency of entries.e) frequency of entries.

6. Perfusion protocol contd.,Perfusion protocol contd.,
Pre-bypass check list.Pre-bypass check list.
Basic guideline for perfusionBasic guideline for perfusion
managementmanagement
1.1. Blood flowsBlood flows
2.2. Pressure limitsPressure limits
3.3. Fluid replacementsFluid replacements
4.4. Blood gas and electrolyte limitsBlood gas and electrolyte limits
5.5. Anticoagulation and temperature controlAnticoagulation and temperature control

7. Perfusion protocol contd.,Perfusion protocol contd.,
Procedures to be followed in the event ofProcedures to be followed in the event of
equipment failureequipment failure
1.1. Electrical powerElectrical power
2.2. Mechanical pump failureMechanical pump failure
3.3. Reservoir failureReservoir failure
4.4. Gas supply failureGas supply failure
5.5. Temperature controlTemperature control
6.6. Circuit ruptureCircuit rupture

8. Perfusion protocol contd.,Perfusion protocol contd.,
Team responsibility and communicationTeam responsibility and communication
1.1. Establish agreed areas of responsibilityEstablish agreed areas of responsibility
and systems of communicationand systems of communication
2.2. Establish a procedure in the event ofEstablish a procedure in the event of
failurefailure
Establish protocol for cleaning andEstablish protocol for cleaning and
decontamination of all non-disposabledecontamination of all non-disposable
equipments.equipments.

9. Patient specific safety protocolsPatient specific safety protocols
Identification of patientIdentification of patient
1.1. Patient statisticsPatient statistics
2.2. DiagnosisDiagnosis
3.3. Pre-operativePre-operative
haematology,biochemistry,drug theraphyhaematology,biochemistry,drug theraphy
4.4. Cardiac investigative resultsCardiac investigative results
5.5. Proposed opertationProposed opertation

10. Patient specific protocols contd.,Patient specific protocols contd.,
Selection of equipment according to protocolSelection of equipment according to protocol
Machine checksMachine checks
a)a) Availability of alternate systemsAvailability of alternate systems
b)b) Calibration checksCalibration checks
c)c) Occlusion checksOcclusion checks
Circuit componentsCircuit components
a)a) Sterility b) visual check for defectsSterility b) visual check for defects
c) Availability of alternativesc) Availability of alternatives

11. Protocol contd.,Protocol contd.,
Prime according to protocolPrime according to protocol
Double check all fluids and drugsDouble check all fluids and drugs
Institute case recordInstitute case record
Ensure record of identification data onEnsure record of identification data on
equipment and fluids usedequipment and fluids used
Follow protocols for cleaning andFollow protocols for cleaning and
decontamination.decontamination.

12. Accidents OR Mishaps In PerfusionAccidents OR Mishaps In Perfusion
OccasionalOccasional
OftenOften
TWO Categories:TWO Categories:
Human errorHuman error
Equipment failuresEquipment failuresTerumo conf.Dubai June 2002Terumo conf.Dubai June 2002

13. Human errorHuman error
Inadequate knowledgeInadequate knowledge
CarelessnessCarelessness
OverconfidenceOverconfidence
Poor investigationsPoor investigations
Poor communicationsPoor communications

14. Human errorHuman error
Critical situationCritical situation
Odd timesOdd times
Poor medical ethicsPoor medical ethics
interdepartmental politics or egointerdepartmental politics or ego
Untidiness or disorganized setupsUntidiness or disorganized setups

15. Non-human elementsNon-human elements
Mechanical defectsMechanical defects
Environmental factorsEnvironmental factors
Lighting conditionsLighting conditions

16. Human factors of accidentsHuman factors of accidents
Adventurous spiritAdventurous spirit
Inadequate trainingInadequate training
Negligence and irresponsibilitiesNegligence and irresponsibilities
FatigueFatigue
StressStress
ImpatienceImpatience
CarlessnessCarlessness
The ageing processThe ageing process

17. Equipment failuresEquipment failures
Equipment failures:Equipment failures:
Attention, resolve at the earliestAttention, resolve at the earliest
Failure attracts the attention of manyFailure attracts the attention of many
Too many opinionsToo many opinions
Confusion - Perfusionist - DiversionConfusion - Perfusionist - Diversion

18. Accidents only to medical field?Accidents only to medical field?
Common to any given speciality.Common to any given speciality.
More common in teaching institutionsMore common in teaching institutions
Interns and StudentsInterns and Students
Does not spare even the mostDoes not spare even the most
experienced and in the hands ofexperienced and in the hands of
observers.observers.

19. TO Err is humanTO Err is human
Acceptance gains knowledgeAcceptance gains knowledge
Denial fools selfDenial fools self
Knowledge gets ignoredKnowledge gets ignored

20. Reduced oxygenationReduced oxygenation
Most frequent incidentMost frequent incident
Gas delivery system may develop leak orGas delivery system may develop leak or
blockage.blockage.
Forgetting to turn on the gas before goingForgetting to turn on the gas before going
on cpbon cpb
Gas line not connected to oxygenator.Gas line not connected to oxygenator.
Defective oxygenatorDefective oxygenator
Blood flows more than the rated flowBlood flows more than the rated flow

21. Arterial line air embolismArterial line air embolism
Most sudden and distressing incidentMost sudden and distressing incident
during CPB.during CPB.
Mostly occurs due to non usage of safetyMostly occurs due to non usage of safety
devicesdevices
Level alarm is a usefull aid but not aLevel alarm is a usefull aid but not a
substitue for proper vigilance.substitue for proper vigilance.
The use of arterial filter and bubble traps.The use of arterial filter and bubble traps.

22. Other perfusion related causes ofOther perfusion related causes of
gross air embolismgross air embolism
Oxygenator related.Oxygenator related.
1.1. Break in the integrity of oxygenatorBreak in the integrity of oxygenator
connectionsconnections
2.2. Detachment of oxygenator from holderDetachment of oxygenator from holder
3.3. Non-venting of oxygenatorNon-venting of oxygenator
4.4. Clotted oxygenatorClotted oxygenator

23. Pump related causes of gross airPump related causes of gross air
embolismembolism
runaway arterial pump head.runaway arterial pump head.
Reversal of arterial pumpReversal of arterial pump
Occluded line proximal to arterial pumpOccluded line proximal to arterial pump
head.head.
Reversal of vent pumpReversal of vent pump
Ruptured pump boot due toRuptured pump boot due to
overocclussion.overocclussion.
Foreign bodies entering pump head.Foreign bodies entering pump head.

24. Cardiotomy reservoir relatedCardiotomy reservoir related
Production of positive pressure at theProduction of positive pressure at the
input to the reservoir.input to the reservoir.
Air forced back up an arterial filter purgeAir forced back up an arterial filter purge
lineline
Air forced back along vent system throughAir forced back along vent system through
a non-occlusive pumpa non-occlusive pump
Large amount of air entrained in theLarge amount of air entrained in the
cardiotomy reservoircardiotomy reservoir

25. Management of gross air embolismManagement of gross air embolism
Prevention is the best form management.Prevention is the best form management.
Guidelines and procedures should beGuidelines and procedures should be
setup and practiced by perfusionist.setup and practiced by perfusionist.
Stop arterial pump immediatley.Stop arterial pump immediatley.
Clamp venous line.Clamp venous line.
Place patient in a steep head downPlace patient in a steep head down
position.position.
Cannula removed and circuit purged of air.Cannula removed and circuit purged of air.

26. Management of air embolismManagement of air embolism
contd.,contd.,
Arterial line is connected to venousArterial line is connected to venous
cannula to facilitate retrograde perfusion.cannula to facilitate retrograde perfusion.
Start flow at 1 to 2lts/mt with flow directedStart flow at 1 to 2lts/mt with flow directed
up the SVC.up the SVC.
Try to cool the patient to 20 degrees.Try to cool the patient to 20 degrees.
Suction system is to retrieve blood fromSuction system is to retrieve blood from
aortotomy.aortotomy.
Anesthetist exerts pressure on carotids.Anesthetist exerts pressure on carotids.

27. Air embolism contd.,Air embolism contd.,
Retrograde perfusion is continued until theRetrograde perfusion is continued until the
arterial system is cleared of air.arterial system is cleared of air.
Standard bypass is resumed withStandard bypass is resumed with
hypothermia.hypothermia.
Air from the coronary system is alsoAir from the coronary system is also
removed by pharmocological elevation ofremoved by pharmocological elevation of
perfusion pressure.perfusion pressure.
Dexamethasone and thiopentone areDexamethasone and thiopentone are
administered.administered.

28. Contd.,Contd.,
Rewarming accomplished slowly to coreRewarming accomplished slowly to core
temp of 35 deg and bypass discontd.temp of 35 deg and bypass discontd.
Patient ventilated on 100% oxygenPatient ventilated on 100% oxygen
Deep barbiturate anesthesia may beDeep barbiturate anesthesia may be
useful.useful.
Hyperbaric treatment is useful with goodHyperbaric treatment is useful with good
results especially within 48 hrs of injury.results especially within 48 hrs of injury.
Mean arterial pressure at 100 to 130Mean arterial pressure at 100 to 130
mmhgmmhg

29. How to avoid accidents?How to avoid accidents?
Sound KnowledgeSound Knowledge
Regular updatesRegular updates
Regular Maintenance of equipments.Regular Maintenance of equipments.
Build up of trust and team spiritBuild up of trust and team spirit

30. How to avoid accidents? Contd.,How to avoid accidents? Contd.,
Follow the standards of perfusionFollow the standards of perfusion
Good data managementGood data management
Check list and double checkCheck list and double check
Reconfirmation of settingsReconfirmation of settings
Vigilant alwaysVigilant always
Never be overconfidentNever be overconfident

31. Contd.,Contd.,
Good communicationGood communication
Sharpness in sight, hearing andSharpness in sight, hearing and
reasoningreasoning
Engage all the saftey gadgets on theEngage all the saftey gadgets on the
HLMHLM
Widens the saftey windowWidens the saftey window
Machines have alarm, alertMachines have alarm, alert
and auto shut offand auto shut off

32. Contd.,Contd.,
Saftey gadgets gives relaxation to theSaftey gadgets gives relaxation to the
operating perfusionistoperating perfusionist
Keep the safe timing limitsKeep the safe timing limits
Develop good organising skillsDevelop good organising skills
Methodic approachMethodic approach

33. Standards to followStandards to follow
Document all the vital parameters,Document all the vital parameters,
history of the Patienthistory of the Patient
Appropriate the equipment selectionAppropriate the equipment selection
and the disposables as per the patientsand the disposables as per the patients
needneed
Never go with blind approachesNever go with blind approaches

34. DrugsDrugs
Always read the drug labelAlways read the drug label
Never follow the color or shape of theNever follow the color or shape of the
vial or containervial or container
May lead to increase in Morbidity andMay lead to increase in Morbidity and
mortalitymortality

35. Overcoming accidentsOvercoming accidents
LearningLearning
– An ongoing processAn ongoing process
– UniversalUniversal
– No age limitNo age limit
– Do not deny the opportunityDo not deny the opportunity
Dedicate your time and age forDedicate your time and age for
achievements.achievements.

36. Ultimate goalUltimate goal
Save the life inspite of all the oddSave the life inspite of all the odd
situationssituations
Prevent the re-occurrencePrevent the re-occurrence
Draft protocols and applicationsDraft protocols and applications
Be committed to the professionBe committed to the profession

37. Contd.,Contd.,
Do not work for rewards aloneDo not work for rewards alone
Earn the confidence of the teamEarn the confidence of the team
Knowledge, hard work and efficiencyKnowledge, hard work and efficiency
Earns a better livingEarns a better living

38. Sincereity, punctuality, honesty,Sincereity, punctuality, honesty,
vigilance, dedication, thoroughvigilance, dedication, thorough
knowledge and good communicationknowledge and good communication
Earns a good professionalEarns a good professional

39. Constant updateConstant update
Text booksText books
MediaMedia
CMECME
Conferences National, InternationalConferences National, International
Medical exhibitionsMedical exhibitions
Help to develop the management skillsHelp to develop the management skills
of the perfusionistof the perfusionist

40. Worldwide experience shows :Worldwide experience shows :
Human errors > 90%Human errors > 90%
Equipmental errors <10%Equipmental errors <10%

41. Perfusion management andPerfusion management and
perfusion systemsperfusion systems
inspite of advanced technologies,inspite of advanced technologies,
monitoring the adequacy of perfusion ismonitoring the adequacy of perfusion is
not reliable.not reliable.
Oxygen delivery to the vital organsOxygen delivery to the vital organs
depends on multi-faceted interaction ofdepends on multi-faceted interaction of
perfusion conditions.perfusion conditions.
There are no easily measured indicatorsThere are no easily measured indicators
of adequacy avilable to us in OTof adequacy avilable to us in OT

42. Perfusion systemsPerfusion systems
the CPB machine,patient and perfusionistthe CPB machine,patient and perfusionist
constitute a system.constitute a system.
Systems performance is a scienceSystems performance is a science
employed by diverse agencies such asemployed by diverse agencies such as
atomic energy commission and NASA.atomic energy commission and NASA.
From the perfusionist point of view it isFrom the perfusionist point of view it is
important that the fundamental priciples ofimportant that the fundamental priciples of
system performance are recoganised.system performance are recoganised.

43. Perfusion system contd.,Perfusion system contd.,
An FDA sponsored study identified fourAn FDA sponsored study identified four
broad areas as the cause ofbroad areas as the cause of
unsatisfactory perfusion.unsatisfactory perfusion.
1.1. Inadequacy of current perfusionInadequacy of current perfusion
management technique.management technique.
2.2. Pre-bypass pathalogical problems inPre-bypass pathalogical problems in
patientpatient
3.3. Bypass device inadequacy or failureBypass device inadequacy or failure
4.4. User error-accounts 80% of all errors.User error-accounts 80% of all errors.

44. Safety for the perfusionistSafety for the perfusionist
Awareness of safety factors related toAwareness of safety factors related to
hepatitis B infection and HIV hashepatitis B infection and HIV has
prompted concern among the team.prompted concern among the team.
Protection of health care staff is theProtection of health care staff is the
responsibility of management to help inresponsibility of management to help in
the vaccinationthe vaccination
Avoidance of skin, mucus membrane andAvoidance of skin, mucus membrane and
skin puncture contact with affected blood.skin puncture contact with affected blood.