CONDUCT OF PERFUSION

NS. Ida Simanjuntak, S.Kep

Perfusionist,
National Cardiovascular Center Harapan Kita, Jakarta
 Overview

Conduct of perfusion begins hours

before the start of actual CPB
procedure
 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
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. Siapkan es batu
 Pre-Bypass checklist
• Patien data entered
• oxygenator holder in right place and secure
• pump sircuit tubing secure without kinks
• luer connectiont tight
• gas line connected
• gas line not leaking and obstructed
• gas supply operational, blenders and vaporizers working
• gas exhaust cap removed
• power cord secure
• back power available
• handcranks available
• backup light source available
• water lines connected
cont
• Water heater-cooler operable and warming
• oxygenator checked for leaks (before priming)
• occlusion set on roller pump
• arterial filter primed
• cardioplegiasystem primed and at proper temp
• drugs added to cardioplegia
• suckers and vent in proper
• vent valve in proper direction
• pressure tranducers calibrated
• level detector operable
• bubble detector operable
• pressure warning-turn off device operable
• temp probes connected
• oxygen analizer calibrated
• in-line sensor calibrated
• supply and backup components available

•
 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
• 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
• Clamp the venous tubing by occluder
• Venous saturation monitoring on
• On bypass
• Timer on
• Increase flow by open the venous tubing slowly until
full flow. Contionous Monitoring on CPB :
– Reservoir level
– pressure line
– blood pressure
– flow rate
– ECG
– venous oksigen saturation 65%-75%
• Surgion setting the canul of cardioplegia (antegrade -
retrograde)
• Coolling
• Surgion : plegic breffing - ok stop
• Surgion : solution breffing - ok stop
• Surgion : plegic breffing - ok stop
• Surgion : solution breffing - ok stop
• Surgion : ready to cross clamp ?
• Reply : ready
• Surgion : low flow, vent high clamp on
• Plegic on/ timer plegic on
• Cek blood gas, elektrolit and blood sugar after plegic
pass in 5 min (temp 28-30)
• Plegic on every pass in 10/15/20 min
• Surgion : low flow, vent high clamp off
• weaning - weaning
• of bypass
 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%
 Intermittent Monitoring During
CPB

• Urine output minimal 0,5-1 ml/kgBB/jam

• blood gas
• electrolit
• ACT > 480 sec
 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
 Causes of poor venous return
1. Kink in the venous line or cannula
2. Airlock in the venous line or canunla
3. Oxygenator or venous reservoir is not positioned low
enough
4. Non cardiac suction being used instead of pump suckers
5. Fluid rapidly moving to interstitial area, due to decreased
intravascular
6. Venous cannula placed too far dawn or up, and vena cava
not draining
7. Vent or cardioplegia line inadvertently open and draining
blood on field
8. Bleeding due to accidental laceration or puncture in back
of heart
9. Bleeding due to other causes such as a bleeding ulcer
The blood flow to various organs
while at rest or on bypass are :

BRAIN HEART KIDNEYS LIVER

15 % 4-5% 27% 29%
 Causes of no urine production

1. Kinked or disconected 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 vasopressors
4. Increase flows
5. Use mannitol or lasix
 Temperature
Temperature Cardiac indeks FIO2 Gas/blood flow ratio

37 C 2.4 L 80 1:1
34 C 2.2 L 70 8:1
30 C 2.0 L 65 7:1
28 C 1.8 L 60 6:1
22 C 1.6 L 50 5:1
 Weaning From CPB

• Termperature normal
• No artimia in ECG
• Blood gas and electrolit normal
• Ventilator on
 Initiating of bypass

1. Mean Arterial Pressure at least 90-100

2. PA 30/15 mmHg
3. CVP 5-15
 Daftar Pustaka
• Brodie,E, John. (1997). The Manual Of Clinical Perfusion.
Second ed. USA. Glendale Medical Corporation.
• Gravlee, P, Glenn. (2008). Cardiopulmonary bypass. Third
ed. USA. Lippincott.
• Hidayat, Kuswara. (2005). Penatalaksanaan CPB pada Tn.
AA dengan Coronary Artery Bypass Graft (CABG) di
ruang bedah RS Pusat Jantung Nasional Harapan Kita.
Jakarta