Conduct of perfusion
Download
1 / 32

CONDUCT OF PERFUSION - PowerPoint PPT Presentation


  • 93 Views
  • Uploaded on

CONDUCT OF PERFUSION. October 16, 2003 Brian Schwartz, CCP. PURPOSE OF CPB. PROVIDE SURGEONS WITH A MOTIONLESS AND BLOODLESS FIELD PROVIDE PROTECTION TO VITAL ORGAN SYSTEMS. Your Objectives. Understand the components of the CPB circuit Understand the sequence for assembly of the circuit

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' CONDUCT OF PERFUSION' - maite-christensen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Conduct of perfusion

CONDUCT OF PERFUSION

October 16, 2003

Brian Schwartz, CCP


Purpose of cpb
PURPOSE OF CPB

  • PROVIDE SURGEONS WITH A MOTIONLESS AND BLOODLESS FIELD

  • PROVIDE PROTECTION TO VITAL ORGAN SYSTEMS


Your objectives
Your Objectives

  • Understand the components of the CPB circuit

  • Understand the sequence for assembly of the circuit

  • Able to calculate the predicted hemoglobin and hematocrit

  • Understand the determinants of oxygen consumption


Conduct of perfusion1
Conduct of Perfusion

  • Purpose of CPB: support patient’s metabolic needs while providing a motionless, bloodless cardiac surgical field

    • Parameters that must be met:

      • Proper flow rate

      • Oxygen delivery

      • Carbon dioxide removal

      • Anticoagulation

      • Temperature

      • Blood pressure

      • Blood recovery


Components of the cpb circuit
Components of the CPB Circuit

  • Oxygenator

  • Heat exchanger

  • Venous reservoir

  • Gas flow meter

  • Variety of pumps

  • Tubing

  • Cannulae

  • Hemoconcentrator

  • Alarms

  • Drugs


Assembly
Assembly

  • The set up is dependent upon:

    • Procedure

    • Patient size

    • Surgeon’s preference

    • Perfusionist’s preference


Conduct of perfusion2
CONDUCT OF PERFUSION

  • WE ARE TALKING ABOUT OUR DUTIES AND RESPONSIBILTIES PRE-OP, INTRA-OP, AND POST-OPERATIVELY


The perfusionist s time line
THE PERFUSIONIST’S TIME LINE

  • GET A HANDLE ON THE SCHEDULE

  • REVIEW PATIENT’S CHART

  • SELECTION OF DISPOSABLE EQUIPMENT

  • ASSEMBLE HLM

  • PLUG IN POWER AND GAS LINES

  • PLUG IN HEATER/COOLER (WATER TEST)


Time line cont
Time Line (cont)

  • CO2 flush the circuit

  • Prime the circuit

  • Test all occlusions

  • Check list

  • Perform all quality controls

  • ALWAYS BE PROPARED TO GO ON CPB


Time line continued
TIME LINE (CONTINUED)

  • PRIME CIRCUIT

  • PERFORM CHECK LIST

  • ADMINISTRATION OF HEPARIN

  • INITIATION OF CPB

  • TERMINATION OF CPB

  • ADMINISTRATION OF PROTAMINE

  • BREAKDOWN AND CLEANUP OF HLM


Pre bypass calculations
PRE-BYPASS CALCULATIONS

  • PREDICTED HEMATOCRIT

    • 70 X KG = TBV

    • TBV X HCT = TRBC

    • TBV + PRIME + ANES. DRIPS = TCBV

    • TRBC/RCBV = DILUTIONAL HCT


Pre bypass calculations1
PRE-BYPASS CALCULATIONS

  • HCT IF SEQUESTERING BLOOD

    • TRBC – { 500 cc x HCT } / TCBV – 500 cc


Heparin administration
HEPARIN ADMINISTRATION

  • DESCRIBED AS AN ANTICOAGULANT

  • MUST FULLY ANTICOAGULATE PATIENT

  • SITE OF ACTION: ATlll AND INHIBITS FACTORS IX AND XI OF THE CLOTTING CASCADE

  • GIVE 300-400 UNITS/KG

    • IN RIGHT ATRIUM OR CENTRAL LINE


Heparin continued
HEPARIN ( CONTINUED )

  • HALF LIFE = 1-2 HOURS

  • 3-5 MINUTES AFTER ADMINISTERING TAKE AN ACT…..MUST BE >480 SECONDS

  • SOME PATIENTS MAY BE HEPARIN RESISTENT

    • THEY ARE ATIII DEFICIENT

    • GIVE FRESH FROZEN PLASMA


Cannulation
CANNULATION

  • SURGEONS NOW PLACE THE CANNULAE INTO THE HEART

  • VENOUS CANNULAE

    • IN RIGHT ATRIUM WITH 2 STAGE

    • SINGLE STAGE IN THE IVC AND THE SVC


Cannulation1
CANNULATION

  • ARTERIAL CANNULAE

    • AORTA OR FEMORAL ARTERY

  • RETROGRADE CARDIOPLEGIA

  • ANTEGRADE CARDIOPLEGIA

  • VENT


Purpose of vent
PURPOSE OF VENT

  • PLACED IN THE AORTIC ROOT OR IN THE LEFT VENTRICLE

  • USED TO PREVENT DISTENTION OF THE HEART

  • USE A ONE-WAY VALVE


Initiation of bypass
INITIATION OF BYPASS

  • SURGEONS READY TO BEGIN CPB. THEY WILL TELL YOU TO “GO ON”

    • ALWAYS REPEAT COMANDS BACK TO AVOID MISTAKES

  • PUT 02 ON 100%, SWEEP ON, REMOVE ARTERIAL CLAMP, SLOWLY TURN PUMP ON. CAREFULLY MONITOR ARTERIAL LINE PRESSURE !!!!!!!!


Bypass
BYPASS

  • UNCLAMP VENOUS LINE AND INCREASE FLOW TO YOUR 2.4 INDEX

  • IF YOU SENSE A HIGH LINE PRESSURE AS YOU INITIATE BYPASS…IMMEDIATELY TERMINATE BYPASS!!!!!!


Causes of high aortic line pressure
CAUSES OF HIGH AORTIC LINE PRESSURE

  • KINK IN THE A-LINE

  • CANNULAE IMPROPERLY POSTIONED

  • CROSS-CLAMP TOO CLOSE TO CANNULAE

  • ARTERIAL CANNULAE TOO SMALL

  • SYSTEMIC PRESSURE TOO HIGH

  • AORTIC DISECTION

  • ARTERIAL FILTER OBSTRUCTED


Causes of poor venous return
CAUSES OF POOR VENOUS RETURN

  • KINK IN VENOUS LINE OR CANNULA

  • AIRLOCK

  • OXYGENATOR IS NOT POSITIONED LOW ENOUGH

  • VENOUS CANNULA PLACED TO FAR DOWN INTO THE CAVA

  • VENOUS CANNULA FALLS OUT


Chattering
CHATTERING

  • A TERM USED IF THE HEART IS COMPLETELY EMPTY AND YOU SEE THE VENOUS LINE JUMPING AROURD

  • CHATTERING IS CAUSED BY EXCESSIVE NEGATIVE PRESSURE IN THE VENOUS LINE CAUSING A SUCTION EFFECT….SIMPLY PLACE A CLAMP (PARTIALLY) ON THE VENOUS LINE TO REDUCE THE NEGATIVE PRESSURE


Saftey checks to do on bypass
SAFTEY CHECKS TO DO ON BYPASS

  • FLOWING AT PROPER RATE

  • A-LINE PRESSURE IN NORMAL

  • OXYGEN IS ON AND THAT ARTERIAL BLOOD IS RED….COMPARE A/V LINES

  • O2 SAT’S NORMAL

  • MAP BETWEEN 50-70

  • TEMP’S

  • ACT>480

  • MAKE SURE ALL SAFETY DEVICES ARE ON


Monitoring
MONITORING

  • EKG

    • WHILE THE CROSS-CLAMP IS ON THERE SHOULD BE NO ACTIVITY

    • WHEN CLAMP COMES OFF, BE ON THE LOOK OUT FOR ST ELEVATIONS, V-TACH, AND V-FIB

  • PA PRESSURES

  • CIRCUIT

  • OPERATING TEAM

  • KEEP COMMUNICATION OPEN

  • TRAFFIC AROUND PUMP


Charting
CHARTING

  • VITAL SIGNS MUST BE TAKEN EVERY 15 MINUTES

  • ACT’S MUST BE TAKEN EVERY 30 MIN

  • BLOOD GASES MUST BE TAKEN EVERY 30 MINUTES OR AFTER CHANGES HAVE BEEN MADE

    • FIRST BLOOD GAS SHOULD BE TAKEN 5-10 MINUTES AFTER CPB

    • DON’T FORGET TO GET A WARM GAS BEFORE TERMINATING BYPASS


Normal arterial gas
NORMAL ARTERIAL GAS

  • pH: 7.35-7.45

  • p02: Greater than 100

  • 02 Sat: 96-100%

  • K+: 3.5-5.3

  • BICARB: 22-28 MEQ/L

  • BE: -2.5 TO + 2.5


Normal venous gas
NORMAL VENOUS GAS

  • pH: 7.35-7.39

  • P02: 38-42

  • 02 Sat: 65-75%

  • pCO2: 44-48mmHG

  • Bicarb: 22-28 mmHG

  • BE: -2.5 to +2.5


Determine oxygen consumption
Determine Oxygen Consumption

  • Oxygen content=1.34 x Hb x Sat + .003xp2

  • Oxygen Capacity =1.34 x Hb + .003 x pO2

  • Oxygen Saturation = O2 content/ Capacity

  • Oxygen Consumption= aO2 content – vO2 content x flow (L/min) X 10


Calculate amount of bicarb to give
CALCULATE AMOUNT OF BICARB TO GIVE

  • WT (KG) X BASE DEFICIT X .3

  • EQUATION #1 DIVIDED BY 2 = AMOUNT OF BICARB TO GIVE

    EXAMPLE: 70 X 3 X .3 = 63

    63 / 2 = 32 mEq


Post bypass
POST BYPASS

  • MONITOR PATIENTS HEMODYNAMICS

  • NEVER DISMANTLE PUMP UNTIL CHEST IS CLOSED

  • PROTAMINE

    • MANY PATIENTS HAVE REACTION

    • TURN OFF PUMP SUCKERS

    • MONITOR PA AND MAP


Protamine reactions
PROTAMINE REACTIONS

  • TYPE I

    • SYSTEMIC HYPOTENSION

    • REDUCED SVR

  • TYPE II

    • ANAPHYLACTIC REACTION RESULTING IN HYPOTENSION, BRONCHOSPASM, AND EDEMA

  • TYPE III

    • CATASTROPHIC PULMONARY VASOCONSTRICTION WITH INCREASED PA PRESSURES, HYPOTENSION, DECREASED LA PRESSURES, AND DILATED RIGHT VENTRICLE


Clean up
CLEAN-UP

  • SEND ALL BLOOD TO CELL SAVER

  • DISMANTLE TUBING

  • CLEAN UP PUMP FOR ANY BLOOD STAINS

  • PAPER WORK

  • SET UP BACK UP PUMP

  • SET UP BACK UP CELL SAVER


ad