"LAMPS" stands for Laboratory data, Anesthesia/machine, Mean arterial pressure, Pump parameters, and Surgical considerations. The perfusionist evaluates these factors to determine if the patient is ready for separation from bypass.
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
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
Anaesthetic problems of open chest and pathophysiology of one lung ventilation aratimohan
Mechanics and physiology of lung isolation/ one-lung ventilaion,
Anaesthetic implications of one-lung ventilation and management strategies
West zones of the lung
Ventilation-perfusion mismatch, V-Q
Hypoxic pulmonary vasoconstriction
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive treatment medicine.
Similar to principles of cardiopulmonary bypass (20)
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. Principles of
Cardiopulmonary bypass
“Heart Lung Machine”
Ida Simanjuntak
Perfusionist Staff
National Cardiovascular Center Harapan Kita
Agustus 2012
4. Definition
Cardiopulmonary bypass(CPB) is a form
of extracorporeal circulation
It temporarily takes over the function of
the heart and lungs during surgery,
maintaining the circulation of blood and
the oxygen content of the body
5. Tujuan Umum Cardio Pulmonary By Pass
1. Mempertahankan sirkulasi dan respirasi yang adekuat
dengan mengalirkan darah ke suatu sirkuit
extracorporal yang berfungsi sebagai jantung dan
paru.
2. Menciptakan lapangan operasi yang bersih dari darah.
Dengan cara mengalirkan darah keluar jantung dan
menghisap darah yang masuk ke jantung, sehingga
dokter bedah dapat melakukan koreksi pembedahan/
operasi dengan bebas. ( Jon W. Austin, 1986).
8. Roller versus centrifugal pump
Roller pump Centrifugal pump
Description Nearly occlusive Non occlusive
After load independent After load sensitive
Advantages Low prime volume Portable, position insensitive
Low cost Safe positive and negative pressure
No potential for backflow Adapts to venous return
Shallow sine-wave pulse Superior for right or left heart bypass
Preferred for long-term bypass
Protects against massive air embolism
Disadvantages Excessive positive and negative pressure Large priming volume
Spallation Requires flow meter
Tubing rupture, hemolysis Potential passive backward flow
Potential for massive air embolism Higher cost
Necessary occlusion adjustments
10. Vena Cannulas
VENOUS CANNULAS AND CANNULATION
Three basic approaches for central venous cannulation
are used: bicaval, single atrial, or cavoatrial ("two stage")
At times, venous cannulation is accomplished via the
femoral or iliac vein. This either open or percutaneous
cannulation is used for emergency closed
cardiopulmonary assist, for support of particularly ill
patients,reoperations.
Single Canul /Two Stage Double Canul
( SVC, IVC Canul )
18. PRINCIPLES OF VENOUS DRAINAGE
Venous blood usually enters the circuit by gravity or
siphonage into a venous reservoir placed 40 to 70
cm below the level of the heart.
“AUGMENTED OR ASSISTED VENOUS RETURN”
20. CARDIOPLEGIA
Antegrade cardioplegia is delivered through a small
cannula in the aortic root or via handheld cannulas directly
into the coronary ostia when the aortic valve is exposed.
Pressure Antegrade
150-200 mmHg (Perfusion)
50-100 mmHg (Monitor)
Antegrade Cannula
21. Retrograde cardioplegia is delivered through a cuffed
catheter inserted blindly into the coronary sinus. Proper
placement of the retrograde catheter is critical, but not
difficult, and is verified by palpation, TEE, color of the
aspirated blood, or pressure waveform of a catheter
pressure sensor. Complications of retrograde
cardioplegia include rupture or perforation of the sinus,
hematoma, and rupture of the catheter cuff
Retrograde
Pressure Retrograde Cannula
100-150 mmHg (Perfusion)
30-50 mmHg (Monitor)
22.
23. (A) Aortic root vent,
which can also be
Vent Cannula
used to administer
cardioplegic solution
after the ascending
aorta is clamped.
(B) A catheter placed
in the right superior
pulmonary vein/left
atrial junction can be
passed through the
mitral valve into the
left ventricle.
(C) Direct venting of
the left ventricle at the
apex.
(D) Venting the main
pulmonary artery,
which decompresses
the left atrium
because pulmonary
veins lack valves.
24. Oxygenator
Oxygenation
Two types of oxygenators are in current use: the bubble
oxygenator and the more widely used mem- brane
oxygenator.
Both types usually have an integral heat exchanger to
control the temperature of the blood
Membrane oxygenator with integral venous reservoir
25. Oxygenator
Studies have shown that membrane oxygenators are less traumatic
to blood components (e.g., platelets) and cause less blood loss and
protein denaturization than bubble oxygenators (van Oeveren et al.
1985; Hill et al. 1985). Membrane oxygenators also provide sepa-
rate control of oxygen and carbon dioxide, which is more difficult to
obtain with bubble oxygenators. The indirect blood/gas interface
also reduces the occurrence of microemboli (Toner et al. 1997).
Furthermore, mem- brane oxygenators require lower priming
volumes and eliminate the need for defoaming devices or antifoam
agents. However, despite the current preference for membrane
oxygenators over bubble oxygenators, the effect of oxygenator type
on clinical outcome is not completely certain. Although there is
evidence that membrane oxygenators can reduce cerebral injury
dur- ing cardiopulmonary bypass (Toner et al. 1997
26. HEMOFILTRATION
Untukmengurangi
Hemodelusi
Filtrasi Cairan,
faktor inflamasi,
hiperkalemia atau
azotemia
Diintegrasikan
dengan sirkuit
secara hati2 dan
bebas Bubble
27.
28.
29. Pre-Bypass
1.Begins with the posting of the operating schedule
Perfusionist must assemble specific information about
the scheduled procedure
Specific information about the scheduled procedure :
Surgeon, patient’s data, diagnoses, procedure, time
of operation
2. .Review of the patient’s hospital chart
Information is recorded on the perfusion record
30. 3.Selection of the disposable equipment and perfusion circuit
using existing protocols
4.Assembly of the cardiopulmonary bypass circuit
5. Calculation of BSA, BV, cardiac indeks and blood flow
6. Size of cannulae
7. Drug dose l and laboratories
8. Predicted hemoglobin and hematocrits
9. Setting up the HLM & oxygenator
10. Priming the oxygenator
11. Initiating CPB
12. Saffety device on
13. Ice
31.
32. Dr Gibbon’s early heart/lung
machine
Gibbon JH et al. Arch Surg 1937; 34:
33. Priming
Filling the CPB circuit with blood or blood
substitutes after CO2 Flushing
Result in hemodilution
34. Hemodilution
Pt’s Blood Volume
Predicted Hct
Pre-CPB IV + CPB prime volume
Target: < 30% at BT below 30℃
< 25% when BT below 25℃
not below 20%
35. Hindari Hct intra CPB < 18 % Hct
Untuk memastikan Hct ketika inisiasi CPB:
Hctint = initial Hct on CPB
EBV = estimated patient blood volume
Hct = preoperative Hct
Jika diperlukan penambahan RBC maka bisa dikalkulasi dengan :
PBV = patient’s blood volume
ECCV = extracorporeal circuit volume
CPBHct = desired Hct on CPB
PtHct = patient’s pre CPB Hct
36. Initiating CPB
“Lines down” connects between table lines & pump
lines (in a sterile manner) Debubble
Surgeon : “Heparin in”
Anesthesiologist give heparin ACT check.
“Speed up (speedy)” fast circulating the priming
solutions, make sure no bubble exist.
“Stop” debubbling stopped, venous lines clamped.
Surgeons prepare to do cannulation
ACT > 300 sec Pump suckers on
38. Insert drugs and manitol
Resirculated of the priming solution
Oksigen on
Before cannulation of the aortic cannula, surgeon
will ask the perfusionist to roll forward, to fill in the
tubing with priming solution and to make sure no
bubble exist.
Reply : “Forward”..
After the aortic cannula is unclamp, surgeon :
“Open to you”.
Reply : “Open/Ok”, check the pressure fluctuation
on the pressure module of the pump.
Inform surgeon. Feel for pulsation the arterial line
tubing
ACT > 480 ready to on bypass
39.
40. Continous Monitoring During CPB
Reservoir level
Blood flow at proper rate/flow rate
Pressure line/arterial line pressure
Blood pressure/patient’s arterial pressure 50-90
mmHg
Oxigen saturation
Temperature appropriate
ECG
Venous oksigen saturation 65%-75%
41. Monitoring Blood pressure
MAP: in mild to moderate hypothermia
normal adult: 60-70 mmHg
adult with CAD, DM, and old age: > 60mmHg
infants: > 60mmHg
CVP: approximate 0 mmHg
42. Pump Flow Rate
In the normal body temperature
adult: 2.2~2.8 L /m2 . min
infant: 2.6~3.2 L /m2 . min
In hypothermia
adult: 1.6~2.2 L /m2 . min
Infant: 2.0~2.4 L /m2 . min
Adjust according MAP and SvO2
43. Monitoring pressure
Causes of aortic cannula high line pressure
1. Kink in arterial cannula or line
2. Cannula improperly positioned
3. Clamp too near cannula
4. Cannula to small
5. Arterial systemic blood pressure very high
6. Aortic disection
7. Blockage in arterial filter
46. Monitoring Devices
Monitoring secara
kontinue : SVO2,
Suhu vena, Hct
ACT > 480 sec
Cek ACT dan AGD
setiap 30 – 60 menit
jika stabil
47. Monitoring Blood Gas
Coagulation Status and Laboratory Data
Menggunakan ACT untuk evaluasi status
koagulasi
Hb 7,0 – 9,0 gr%
Ht 20 – 30 %
pO2 arterial AGD : 140-180 mmHg
pCO2 arterial AGD : 31 – 45 mmHg
BE (-2,5) – (+ 2,5)
48. Monitoring Urine Output
Urinary volume and renal function
Dipengaruhi waktu bypass dan gagal ginjal
sebelumnya
Volume urine 0,5-1 mL/kg/jam
Oligouria / normal + hiperkalemia,
hemoglobinemia, hemodilusi berlebihan =
indikasi diuretik
49. Causes of Urine Production
1. Kinked or disconnected Foley catheter or tubing
2. Catheter with tip obstructed by gel
3. Decreased blood pressure
4. Low pump flows
5. Fluid moving to interstitial space
Corrective Action
1. Straighten or connect tubing
2. Push on bladder
3. Give vasopressor
4. Increase flows
5. Use mannitol or lasix
50. Hypothermia
Advantages:
decrease metabolic rate, oxygen
requirement
decrease rate of degradative reactions,
increase tolerance to ischemia
reduces K+ necessary for cardiac arrest
inhibits intracellular Ca2+ accumulation
51. Hypothermia
Monitoring:
Core temperature: nasopharyngeal or
tympanic membrane probes reflect brain
temperature
Shell temperature: rectal probe or skeletal
muscle needle sensor reflect relatively
pooly perfused tissues of most of the
body’s mass
52. Temperature Cardiac Index FIO2 Gas/Blood Flow Ratio
37 C 2,4 L 0,80 1:1
34 C 2,2 L 0,70 0,8 : 1
30 C 2,0 L 0,65 0,7 : 1
28 C 1,8 L 0,60 0,6 : 1
22 C 1,6 L 0,50 0,5 : 1
53. Termination of CPB
Preparing for Separation (Rewarming)
Hipotermia sedang (25-30°C) digunakan untuk
memperlambat rewarming. Hipotermia berat (16-
25°C) + circulatory arrest : operasi defek
kongenital atau rekonstruksi arkus aorta
Kriteria rewarm : naso 37°C, bladder/rectal 35°C
atau jempol kaki 30°C
Rewarm yang inadekuat mengakibatkan penurunan
suhu pasien 2-3°C pasca CPB sampai tiba di ICU
mengigil, ↑VO2, gangguan irama jantung, ↑ PVR
54. Termination of CPB
LAMPS
Laboratory data
pH, pCO2 darah arteri
Acidosis depressant fungsi myocardial, gangguan obat inotropic
SvO2, Ht, ACT, konsentrasi heparin
Na, K, Ca,
HyperK >6 mEq/L (gangguan konduksi, AV blok)
HypoK (gangguan irama ventrikel dan atrial)
HypoCa akibat hemodilusi, albumin atau produk darah (+sitrat)
CaCl2 3-5 mg/kg (memperbaiki kontraksi miocardial dan PVR)
Glucosa darah insulin 10-20 unit iv + glukosa prn
55. Termination of CPB
Anastesia/Machine
Analgesia – supplemental opioid
Amnesia – benzodiazepine
Muscle relaxant – prn
Airway and functional oxygen delivery system
Anastesia machine on, Adequate oxygen supply
Breathing circuit intact, ETT connected
Ventilator functional, Ability to ventilate both lungs
confirmed
Vaporizers off (10 menit sebelum terminasi CPB) untuk
mengurangi efek depresi sirkulasi dan menghindari
depresi myocardial saat dilepas bypass
57. Termination of CPB
Patient/Pump
The Heart
Cardiac function – contractility, size
Rhythm, ventricular filling, air removed, vent
removed
The Lungs
Inflation/deflation, compliance
The Field
bleeding
Oxygenation – blood color
Movement – sign of inadequate anasthesia
58. Termination of CPB
Support
Pharmacologic
Inotropes
Vasodilators
Vasoconstrictiors
Antidysrhythmics
Electrical
Atrial/Ventricular Pacing
Mechanical
Intraaortic Balloon Counterpulsation
Left and/or right ventricular assist device
61. After Termination of CPB
Setelah kanul aorta dilepas, sisa perfusate bisa
diproses kedalam kantung intravena sterile untuk
kebutuhan transfusi nantinya. Atau dengan alat cell
salvage sehingga darah dicuci dahulu sebelum
ditransfusi
Pemberian protamine pada beberapa pasien
mengakibatkan penurunan hemodinamik sementara.
Perfusionis harus terus mengobservasi hemodinamik
pasien dan menjaga sirkuit CPB tetap dapat digunakan
62. Daftar Pustaka
http://www.cts.usc.edu/zglossary-heartlungmachine.html
http://www.surgeryencyclopedia.com/Fi-La/Heart-Lung-Machines.html
Lippincott Williams & Wilkins 2007 Cardiopulmonary Bypass :
Principles and Practice
Cardiopulmonary Bypass: Principles and Management: Edited by
Kenneth M. Taylor. 1998, Baltimore
On Bypass ,Advanced Perfusion Techniques Series: Current
Cardiac Surgery Mongero, Linda B.; Beck, James R. (Eds.) 2008,
XII, 576 p. 173 illus.
The cardiopulmonary bypass is a form of extracoporeal circulation. It takes over the cardiac and respiratory function temporarily during cardiac surgery, in order to making a silent heart for cardiac surgeon to perform complicating procedures.
This is the initial prototype of Gibbons CPB machine.
Priming means filling the bypass machine with fluid, preparing for the connection with the patient’s circulation. In the beginning period of cardiopulmonary bypass history, whole blood was used for priming. However, surgeons found that blood substitutes like crystalloid or colloid solutions made even better prognosis. The reasons we’ll discuss later. As the use of non-red blood cell solutions, the hematocrit of the patient falls down during the cardiopulmonary bypass. It’s called hemodilution.
When we use crystalloid and other solution as priming solution, hemodilution will be made. We should calculated the predicted hematocrit after the cardiopulmonary bypass. The formula is on the screen, the predicted hemotocrit is dividing the total amount of the patient’s original hemoglobin, which could be product of pre-bypass hematocrit and blood volume, with the total volume in the circuit The target hematocrit could less than 30% when body temperature is below 30 degree celsius, less than 25% when body temperature is below 25 degree celsius. Always remind that never let hematocirt below 20% because some study shows that severe impairment of the oxygen-carrying ability would appear in this low hematocrit.
Blood pressure during cardiopulmonary bypass should be controlled in order to maintain good tissue perfusion. The aim in the normal adult is over 50 mm mercury. As the patient with worse cardiovascular preserve, the aim should be elevated to 60. And the infant’s target should be over 30 mm mercury. The central venous pressure should approximate to zero, if not, there may be some problem with the venous cannulae drainage. If the blood pressure is inadequate, searching for the etiology and correct it. If hypotension, increase the flow rate to restore the adequate blood volume. After that, if the blood pressure is still low, try some vasoconstrictive agent to raise systemic vascular resistance. If hypertension, fentanyl may be given to correct the inadequate anesthetic level.
The pump’s flow rate during total cardiopulmonary bypass is the same word as the “cardiac output” in the ordinary time. In the normal body temperature, adult should have the flow rate between 2.2 to 2.8 liter per square-meter per minute. The infant has higher metabolic rate so the flow rate should be higher with the same body surface area. In hypothemic state, the flow may be lower, due to lower metabolic needs. The perfusionist would adjust the flow rate according to the patient’s blood pressure. Higher flow rate leads to higher blood pressure, but the blood cell damage also increases. And according to venous oxygen saturation, which reflects the tissue oxygen extraction ratio.
K ink in the venous line or cannula Airlock in the venous line Oxygenator or venous reservoir is not positioned low enough Noncardiac suction being used instead of pump suckers
Hypothermia would be induced during cardiopulmonary bypass surgery. It has several advantages. First, the cells’ metabolic rate and oxygen requirements would decrease in the hypothermic state. Second, cells’ degradation rate decreases and the tolerance of ischemia increases. Third, hypothermia also reduces potassium need for arresting heart and inhibits intracellular calcium accumulation.
At least two temperature probes should be set. One at nasopharyngeal or tympanic membrane measures the core temperature, which reflect the central, or brain temperature. The other is set at rectal or in the skeletal muscle, which reflects the temperature of peripheral body mass, called shell temperature.