Introduction to Cardiopulmonary Bypass - tsda.org · Boot Camp Cardiac Faculty • John Alexander,...
Transcript of Introduction to Cardiopulmonary Bypass - tsda.org · Boot Camp Cardiac Faculty • John Alexander,...
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Introduction to
Cardiopulmonary Bypass
TSDA Boot Camp
July 26-29, 2012
Chapel Hill, NC
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Boot Camp Cardiac Faculty
• John Alexander, MD
• Brian Bethea , MD
Jim Fann, MD
• Dave Fullerton, MD
• Eugene Grossi, MD
• George Hicks, MD
• John Ikonomidis, MD
• William Jakobleff, MD
• Ahmet Kilic, MD
• Rick Lee, MD
• Frank Manetta, MD
• Walter Merrill, MD
• Nahush Mokadam, MD
• William Northrup, MD
• Richard Prager, MD
• Sara Shumway, MD
• Jennifer Walker, MD
• Pyongsoo Yoon, MD
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Boot Camp Cardiac Faculty Support
• Edward Darling, MS, CCP
• Daniel Coore, PhD
• Paul Ramphal, FRCS, DM
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Why CPB
• To facilitate a surgical intervention
• Provide a motionless field
• Provide a bloodless field
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Patient populations
• Coronary Artery
Disease (CAD)
• Valve Disease
• Congenital Heart
Defects
• Dissections
• Aneurysms
– aortic, ventricular,
giant cerebral
• Transplants
– heart, liver, lung,
trachea
• Other
– limb cancer,
hypothermic rescue
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Extracorporeal Circuit
• An artificial external blood pathway with
artificial organs
• 3.5 - 4 M2 of plastics and metals
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Tubing Characteristics
• Transparent
• Resilient
• Flexible
• Kink resistant
• Blood compatible
• Can be sterilized
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Tubing Size vs. Volume
• ID 1/4 inch = 9.65 ml/foot
• ID 3/8 inch = 21.71 ml/foot
• ID 1/2 inch = 38.61 ml/foot
• (8 foot venous line = 309 ml)
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Venous Tubing
• Minimum 10 mmHg pressure drop
• 1/4 inch = 0.9 lpm
• 3/8 inch = 4.0 lpm
• 1/2 inch = 7.0 lpm
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Arterial Tubing
• Velocities less than 200 cm/sec result in
acceptable hemolysis rates
• 1/4 inch = 3.4 lpm maximum flow
• 3/8 inch = 7.0 lpm maximum flow
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Cannulas
• Venous
– Drain blood from the
body
• 2 stage
• Bicaval
• Femoral
• Arterial
– Return blood to the
body
• Aortic
• Femoral
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Reservoir
• Allow for large fluid
shifts
• Open (Hard Shell)
• Closed (Bag)
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Arterial Blood Pump
• Roller
• Centrifugal
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Arterial Blood Pump
• Roller
• Centrifugal
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Arterial Blood Pump
• Roller
• Centrifugal
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Oxygenator
• Artificial Lung
• Micro-porous
– Hollow Fiber
– Flat Plate
• True Membrane
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Oxygenator
• Artificial Lung
• Micro-porous
– Hollow Fiber
– Flat Plate
• True Membrane
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Oxygenator
• Artificial Lung
• Micro-porous
– Hollow Fiber
– Flat Plate
• True Membrane
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Oxygenator
• Artificial Lung
• Micro-porous
– Hollow Fiber
– Flat Plate
• True Membrane
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Oxygenator
• Artificial Lung
• Micro-porous
– Hollow Fiber
– Flat Plate
• True Membrane
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Heat Exchanger
• Stainless steel,
aluminum, or plastic
• Induce hypothermia
• Return normothermia
• Hyperthermic Isolated
limb
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Heat Exchanger
• Stainless steel,
aluminum, or plastic
• Induce hypothermia
• Return normothermia
• Hyperthermic Isolated
limb
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Heat Exchanger
• Stainless steel,
aluminum, or plastic
• Induce hypothermia
• Return normothermia
• Hyperthermic Isolated
limb
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Heat Exchanger
• Stainless steel,
aluminum, or plastic
• Induce hypothermia
• Return normothermia
• Hyperthermic Isolated
limb
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Heat Exchanger
• Stainless steel,
aluminum, or plastic
• Induce hypothermia
• Return normothermia
• Hyperthermic Isolated
limb
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Filter
• Remove emboli
– 30-40 µ pore size
– Gaseous
– Particulate
• Remove leukocytes
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Cardioplegia
• Provides myocardial protection
• Motionless and bloodless surgical field
• Uses potassium to stop electrical impulses
and contractions
• Cools the heart to decrease oxygen demands
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Safety
• Low level alarm
• Air bubble detector
• Arterial line pressure
• Temperature monitor
• Venous oxygen saturation monitor
• FiO2 gas analyzer
• Battery back up power
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Safety
• Checklist
• Clear three-way communication between
the surgeon, anesthesiologist and
perfusionist
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Hemodynamics
Before CPB there is electrical
activity on the EKG,
pulsatile arterial blood
pressure,
and positive pressures from
blood present in the right side
of the
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Hemodynamics
On CPB, the hearts
electrical activity can be
suspended,
Therefore the arterial blood
pressure will be
nonpulsatile
And the right side of the
heart will be empty
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CPB Physiology
• Hemodilution
• Hypotension
• Hypothermia
• Blood gas control
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Hemodilution
• Decreased viscosity results in increased
tissue perfusion
• Routine procedures: Hematocrit > 21%
• Patient Age
• Jehovah Witness
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Hypotension
• CPB is “controlled shock”
• Sudden hemodilution with vasodilatation
• Fluid shift increases blood viscosity
• Hypothermia increases blood viscosity
• Released catecholamines = vasoconstriction
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Hypothermia
• Reduces metabolism and oxygen demand
• Allows less blood trauma
• Myocardial protection
• Systemic organ protection
• Provides a margin of safety in the event of
equipment failure
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Hypothermia
• Types Acceptable Circ. Arrest
• Mild 37° - 32°C < 5 min 32°
• Moderate 32° - 28° < 20 min 28 °
• Deep 28 ° - 18 ° < 45 min 18 °
• Profound < 18 ° < 60 min
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Hypothermia
• Outgassing
• Occurs at tissue level when cooling
• Occurs at heat exchanger when rewarming
• Maintain a 12°C gradient
• Cool at a rate of 1°C per minute
• Rewarm at a rate of 1°C per three minutes
• Protein denaturation occurs at 42°C
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Blood Gas Strategies
• pH stat maintain normal temperature
corrected values for pH and PaCO2
• As blood temperature decreases, CO2
becomes more soluble
• To maintain a constant pH and PaCO2,
CO2 must be added
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Blood Gas Strategies
• Alpha stat maintains a constant OH-/H+ ratio
• The fraction of unprotonated imidazole
groups (alpha) remains constant
• Total CO2 remains constant
• pH changes as temperature changes
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Seven Steps for CPB
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Step One for CPB
• Heparin
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Step Two for CPB
• Expose the heart
• Check BP and aorta
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Steps for Initiating CPB
• Cardiac Exposure
• Lines up to table
• Pericardial cradle/sutures
• HEPARIN (3mg/kg) ACT>400sec
• Prepare aorta
• Aortic cannulation sutures
– 2 Concentric 2-0 Ethibond stitches with sliders
– Outer suture with two pledgets
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Step Three for CPB
• Check ACT
• Cannulation of aorta
• Check if aortic cannula is safe
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Initiating CPB
• Aortic Cannulation
– #11 Blade and cannula insertion
– Snare both stitches securely and tie to cannula
– Remove all air
– Connect cannula to arterial line
– Ask for pulse pressure
– Ask for perfusion arterial line test
– Secure aortic cannula (skin stitch and/or towel
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Step Four for CPB
• Atrial (venous) Cannulation
• Remove venous clamp
• Command “On bypass”
• Turn lungs off
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Initiating CPB
• Venous Cannualtion
– Single Prolene or Ethibond stitch for RA appendage or
body followed by slider
– Make incision/dilate
– Insert cannula with hand over the IVC for accurate
positioning
• Secure cannula with slider and tie
• Connect ot venous line
• Initiate CPB
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Step Five for CPB
• Inspect the heart
• Place cardioplegia cannulae (retro/ante)
• Reduce pump flow/Clamp aorta
• Resume full flow/Check line pressure
• Start cardioplegia
• Set pt temperature with perfusionist
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Step Six for CPB
• Release cross-clamp after warm cardioplegia
• Remove all air from heart
• Begin respirations (start lungs)
• Check for be certain there is
– Good contractility
– No bleeding
– Stable heart rhythm
– Desired patient temperature
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Step Seven for CPB
• Wean slowly from CPB
• When stable:
• Clamp venous line and remove
• Remove vent/cardioplegia
• Begin Protamine assessing BP, CVP, BP
• Be alert for hemodynamic reactions
• Remove arterial cannula
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Weaning from CPB
• Check list before weaning
– No bleeding from inaccessible areas
– Body Temperature (36-37C)
– Stable heart rhythm
– Lung function normal in insp/expiration
– Good myocardial contractility
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Weaning from CPB
• Ask perfusionist if he/she is ready
• Reduce CPB to half flow observing preload,
afterload and contractility (TEE)
• If no RV/LV dilatation, ask perfusionist to come
off CPB
• Add volume to assess ventricular compliance
• Assess need for pharmacologic support depending
on preload after load and contractility
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Emergencies in CPB
• Massive Air Embolism
• Aortic Dissection with cannulation
• Clotted Oxygenator
• Severe Protamine Reaction
• Inadequate CPB flow
• Inadequate CPB oxygenation
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Massive Air Embolism
• Recognition
• Stop CPB
• Place pt in steep head-down position
• Remove aortic cannula from asc. Aorta
• Purge asc. aorta of air and refill arterial line
• Begin retrograde SVC perfusion (20C@1-2l/min for 2-3 min until air is cleared
• Return cannula to aorta for systemic cooling and ?pharmacologic brain protection
• Post-op-Hyperbaric O2 rx, hyperventilation, ?hypertension
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Aortic Dissection- Cannula induced
• Signs
– Sudden increase in arterial line pressure
– Profound drop in systemic pressure
– Decreased venous return to CPB
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Aortic Dissection-Cannula Induced
• Stop CPB
• Clamp arterial and venous lines
• Confirm diagnosis (visual or TEE evidence)
– Flaccid aorta, expanding hematoma, dissection flap
• Rule out kinked or obstructed art line
• Remove arterial cannula to alternate site
• Initiate cooling for DHCA and open aortic
repair/replacement
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Clotted Oxygenator
• Decreasing PaO2 with metabolic acidosis
– Check O2 supply/blender
– Rule out oxygenator thrombus
• Emergency oxygenator change-out may be
necessary
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Severe Protamine Reaction
• Anaphylactic reaction with pulm HTN, edema
and systemic hypotension
– 100%O2, IV fluids, steroids, antihistamines,
vasoconstrictors and bronchodilators
– Resume CPB if RV failure, severe pulm edema
present
– Epinephrine, vasopressin via LA line
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Inadequate CPB Flow
• Directly proportional to venous saturation/acid-base status
• Possible reasons:
– Inadequate CPB volume
– Aortic dissection
– Cannula problems (aortic or venous)
– Oxygenator thrombus
– Pump head malfunction
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References
• Cardiopulmonary Bypass-Principles and
Practice Gravlee GP 2nd Edit Lippincott
• Cardiopulmonary Bypass Mora CT 1995
Springer