Professional Documents
Culture Documents
Off pump
On pump
Bypass system
• Removes & pumps blood.
Cardioplegia
• Stops beating of the heart
BYPASS SYSTEM
• Basic bypass system
– Blood drained from the venous system using
gravity through,
• Cannulas in SVC & IVC
• Single cannula in RA in to the venous reservoir.
• It is pumped into the membrane oxygenator .
• Returned to the systemic circulation via a cannula
usually placed in distal ascending aorta.
Basic CPB
Beyond the basics………
Basic components of CPB
• Venous cannula
• A venous reservoir
• An oxygenator
• A heat exchanger
• The main pump
• An arterial filter
• Aortic cannula
• Accessory pumps and devices
Basic components of CPB
Venous cannula & venous reservoir
Venous cannulas
• Made of flexible plastics
Size (According to )
• Pt size
• Anticipated flow rate
• Index of catheter: flow index
Bleeding Airlock
Reservoir is Non-cardiac
not positioned
low enough suction
• Blood gas
• Urine output : Urine output is monitored
using a freely draining urinary catheter.
• Electrolyte
Monitoring devices
• Anesthesia monitor
• Ventilator parameters
• CPB machine parameters and alarms
• Cardioplegia system alarms
• CVP pressure
• Pulse oxymetry
• Urine output
• Arterial line pressure monitor
Before Surgery – Pt Mx
• Routine preoperative care.
• NPO
• Antiseptic bath
• Autoclaved clothes
• High risk consent
• Various investigation reports should be attached to the
patient file.
• Articles needed in the surgery should be ready with the
client.
• Pre operative vitals monitoring and recording.
• Make sure that patient has no allergy to
heparin/shell fish.
Management of Pt
• Information from the patient's chart is
obtained regarding the proposed surgical
procedure and relevant history.
• Equipment is then selected appropriate to
surgical and patient needs.
• Blood grouping and matching done.
• Arranged for blood.
Before Sx - Management of Tubing
• CPB circuit must be primed with fluid and all
air expunged before connection to the
patient.
• The circuit is primed with a crystalloid solution
and sometimes with blood products .
• The patient must be fully anti-coagulated
with an anticoagulant such as heparin.
• The circuit may be briefly flushed with filtered
100% carbon dioxide to displace room air.
During surgery
• Patient is prepared.
• Circuits kept in a secure area with sealed ports
and vents to maintain sterility of the blood-
contacting surfaces.
• Sequence of circuit done in a consistent
manner.
• Heat exchanger and cardioplegia delivery
system are turned on and tested.
Preparation for bypass
• Full anticoagulation (heparin 300IU/kg)
• Bypass circuit primed with crystalloid, heparin
+/- mannitol just before aortic cannulation.
• Prepare and pressurize cardioplegia to
300mmHg.
Anticoagulation-heparin
• Heparin is given soon after the
chest is opened.
• After a control activated clotting
time(ACT) is obtained, a loading
dose of 300 IU/Kg heparin is
given through central venous
line.
During Surgery
• When the surgeon is ready to begin CPB, the
heart–lung machine console is positioned
near the operating table.
• Pump should be placed to minimize tubing
lengths to the cannulation sites to reduce
Prime volume
Pressure gradient (resistance to flow)
Blood trauma
Connection of patient to circuit
• After administration of systemic heparin
• Verify CPB circuit for any visible gas bubbles.
• Arterial and venous lines are clamped at the
pump and table.
• The surgeon or assistant divides the
arterial/venous recirculation loop.
• Upon instruction from the surgeon, CPB
begins by removing the clamp(s) on the
arterial line and activating the systemic pump
speed control.
• After removal of the arterial line clamp at the
field, the perfusionist should manually palpate
or observe pulsation on an arterial flow line
pressure monitor.
Establishing extracorporeal blood flow
• Full CPB flow can be established in most cases
within 30 seconds.
• Starts flow in the systemic pump before
releasing the venous line.
• As the volume of perfusate in the CPB
reservoir decreases, the venous line clamp or
occluder is released.
During bypass
• Turn off ventilator
• Propofol 6mg/kg/hr OR midazolam OR volatile
agent on bypass machine
• MAP maintained at 50-70mmHg by altering
SVR
• Pressure maintained with vasopressors and
vasodilators
• Hypothermia to 28-34˚C used
Performing the Correction
Coming off bypass
• Warm to 37˚C
• K+ 4.5-5.0
• HCT >20%
• Normal acid-base status
• HR 70-100/min (ideally SR)
• 100% O2
• Venous line progressively clamped
• Heart gradually fills.
• Start inotropes if inadequate cardiac output
• Protamine (3mg/kg)
• Restart volatile and opioid
• Removal of aortic cannula is the final step.
Protamine
• Once bypass is terminated, and
after removal of venous
cannula,protamine is given to
reverse heparin, usually during a
5-10 min period.
• The reversing dose is
approximately 1.3mg of
protamine for 100 U of heparin.
Bypass catastrophes
• Supply failure - pump stops working
• Inadequate anticoagulation - circuit clots
• Oxygenation failure - hypoxaemia and ischemia
• Disconnection, empty reservoir - RV distension,
increased PAP - cardiovascular collapse
• Gas emboli - into system circulation
• Aortic dissection - renal failure, bowel ischaemia,
paraplegia, cardiac tamponade, limb ischemia,
stroke
• Hemolysis
Other Complications