PERFUSION

TECHNOLOGY
WEEK 7-SPDX
https://www.youtube.com/watch?v=72SUUCIn3lE
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 Table of contents

1 2 3
PHYSIOLOGY PERFUSIONIST EXTRACORPOREAL
MEMBRANE
OXYGENATION

4 5 6
CARDIOPULMONARY CONDUCT OF COMPLICATIONS
BYPASS CARDIOPULMONARY
BYPASS
 Introduction
The term "perfusion" is derived from the
French verb 'perfuse' meaning to 'pour
over or through'. Perfusionists employ
artificial blood pumps to propel open-
heart surgery patients' blood through
their body tissue, replacing the function
of the heart while the cardiac surgeon
operates.
 01
PHYSIOLOGY
Functions of the Heart
Generating blood pressure.
Contractions of the heart generate blood
1 pressure, which is responsible for moving
blood through the blood vessels.
Routing blood.

2 The heart separates the pulmonary and

systemic circulations and ensures better
oxygenation of the blood flowing to the
tissues.
Ensuring one-way blood flow.
3 The valves of the heart ensure a one-way
flow of blood through the heart and blood
vessels.
Regulating blood supply.
The rate and force of heart contractions
4 change to meet the metabolic needs of the
tissues, which vary depending on such
conditions as rest, exercise, and changes in
body position.
 ROUTE OF BLOOD FLOW
Deoxygenated
Superior & Right Right Pulmonary Pulmonary
Inferior Vena Atrium Ventricle trunk arteries
Cava

Oxygenated
Left Left Coronary
Pulmonary veins
Ventricle
Aorta arteries
Atrium
 02
WHAT IS A PERFUSIONIST?
perfusionist -responsible for the selection, setup, and
operation of a mechanical device commonly referred to
as the heart-lung machine.

Perfusionists can combine sterile tubing and artificial

organs to build an ECC to meet the needs of several
physician specialists to treat patients with specific
operable diseases.
 03
What is Extracorporeal membrane
oxygenation (ECMO)?

Extracorporeal Membrane
Oxygenation (ECMO) and
Extracorporeal Life Support
(ECLS), a broader term used
synonymously, both include
various modalities of
temporary mechanical
cardiopulmonary assistance
used to support patients with
severe heart and/or lung
failure which is unresponsive
to optimal conventional care.
The main objective is to provide
systemic perfusion and gas
exchange allowing the heart
and/or lungs to rest and recover
or to bridge a patient to a
different modality of support or to
transplantation. This technology
involves redirecting the blood
flow from the patient’s body
through cannulas and connecting
tubing to a gas exchange
membrane and then returning the
blood by means of a pump back
to the patient’s circulation.
 ADVANCES IN TECHNOLOGY

1 2 3 4

Dr. John Gibbon Kammermeyer Bartlett and Bartlett,

development of a revolutionized the Drinker Gazzaniga et al.
roller pump in the artificial lung with developed an reported the first
1930’s led to the the development approach to successful cardiac
first successful of synthesis of continuously ECMO run of 36 hours
extracorporeal assist silicone rubber titrate coagulation in a 2 year old infant
in 1953
with Heparin with cardiac failure
 04

CARDIOPULMONARY BYPASS
 Cardiopulmonary bypass (CPB)
provides a bloodless field for cardiac
surgery.

-technique that temporarily replaces

the function of the heart and lungs
while the heart is arrested to provide
a still and bloodless surgical field

It incorporates an extracorporeal circuit to provide physiological

support in which venous blood is drained to a reservoir,
oxygenated and sent back to the body using a pump.
Cardiopulmonary Bypass
-often referred to as heart-lung machine
-also called “the pump”
-operated by perfusionist
-a form of extracorporeal circulation
USES:
- machine pumps the blood using an
oxygenator, allows the RBC to pickup
oxygen as well as allowing carbon
dioxide levels to decrease.
-mimics the function of the heart and
lungs
-used to rewarm individuals suffering
from hypothermia
Components of CPB Machine

1. Cannula
2. Reservoir
3. Oxygenator
4. Temperature Control
5. Filter
6. Pump
 CPB circuit includes pumps, cannulae,
tubing, reservoir, oxygenator, heat
exchanger and arterial line filter. Modern
CPB machines have systems for monitoring
pressures, temperature, oxygen
saturation, haemoglobin, blood gases,
electrolytes as well as safety features such
as bubble detectors, oxygen sensor and
reservoir low-level detection alarm.
During CPB, venous blood is drained through
gravity into a reservoir. The pump moves
blood from the reservoir to the oxygenator
through a heat exchanger, before returning it
to the arterial circulation.

Additional components include suckers (to

remove blood from surgical field), vents (to
decompress the heart), haemofilters (for
ultrafiltration) and cardioplegia system
 PUMP
ROLLER PUMP
● Roller pump includes two rollers
positioned on a rotating arm, which
compress a length of tubing to produce
forward flow.
● This action can produce haemolysis and
tubing debris, the incidence of which
increases with time.
● Hence, the use of roller pumps for
longer procedures is discouraged.
CENTRIFUGAL PUMP
● Centrifugal pump consists of
impellers/stacked cones within housing.
● When rotated rapidly, negative pressure
is created at one inlet, and positive
pressure at the other, thus propelling the
blood forward. (less air embolism)
● Centrifugal pumps may improve platelet
preservation, renal function and
neurological outcomes in longer cases.
 CANNULAE
Cannulae connect the patient to the circuit and hence to the CPB
machine. They are made of polyvinylchloride (PVC) and are wire
reinforced to prevent obstruction due to kinking.

Venous cannulae: single-stage cannulae are used during most open-

heart surgeries, where two cannulae are inserted into the superior and
inferior vena cava and joined by a Y-piece.

Dual-stage cannulae are used for most closed-heart procedures, where a

single cannula is inserted into the right atrium. Drainage occurs through
gravity. Vacuum applied to the reservoir allows the use of smaller
cannulae and tubing, thus decreasing the circuit volume.
 CANNULAE
Venous cannula: removes oxygen depleted venous blood from patient’s
body

Arterial cannula: infuses oxygen rich blood into the arterial system
 OXYGENATOR
-designed to add oxygen to infused blood and
remove some carbon dioxide from the venous
blood

-serves as an artificial lungs

-Gas line is a component in the circuit that

delivers fresh gas to the oxygenator
 FILTER
-is a component in CPB machine and circuit that
removes microaggregates and particle matter
 TEMPERATURE CONTROL
-Heat exchangers are designed to remove or
add heat from the blood, thereby controlling the
patient’s body temperature

-during its flow in the CPB circuit the blood

cools and hence heat must be added to avoid
patient cooling
 TUBING
These are generally made of PVC, due to PVC's
durability and acceptable haemolysis rate.
Plasticisers like di(2-ethylhexyl) phthalate which
are added to impart flexibility are potentially
toxic and shown to leach from the tubing.
 RESERVOIR
They collect the blood drained from the heart. Open reservoirs
are more commonly used. They allow passive removal of
entrained venous air along with the option of applying
vacuum to assist drainage. They integrate a separate
cardiotomy, and defoaming circuit to process suctioned blood.
When they are used, a safe level of blood in the reservoir is
maintained to avoid air entry into the arterial circuit.

-In the extracorporeal circuit, blood from the vena cava is

drained through the RESERVOIR.
 CARDIOPLEGIA SYSTEM
Cardioplegia is a method of myocardial protection where the
heart is perfused with a solution to cause electromechanical arrest
which reduces myocardial oxygen consumption. The cardioplegia
cannula is inserted proximally while the aortic cannula is distal to
the clamp.

CPB circuit consists of systemic circuit for oxygenating blood and

reinfusing blood into a patient’s body and separate circuit for
infusing a solution into the heart itself to produce cardio plegia.

Therefore providing myocardial proterction to prevent the death

of the heart tissue
 05
CONDUCT OF
CARDIOPULMONARY BYPASS
 PRE-BYPASS
Calculations are performed to determine necessary blood
flow and if blood or other products are needed. The pump
can then be primed and the sizes of the cannulae
determined. Drug doses in the prime can also be
determined.
 PRIMING
The deairing of CPB circuit is done by
priming solutions, consisting of a mixture of
crystalloids and colloids.
Priming causes haemodilution which
improves flows during hypothermia.
Heparin 3–4 units/ml is added to the prime.
 INITIATION
During arterial cannulation, systolic pressure should be
90–100 mm Hg to reduce the risk of aortic dissection. The
aortic cannulation is done first to provide volume
resuscitation in case of hypotension associated with
venous cannulation. Once the aortic cannula is connected
to the tubing, line pressure is checked to rule out
dissection. After venous cannulation, venous clamp is
gradually released to establish full CPB and then
ventilation is discontinued.
 ANAESTHESIA AND MONITORING
ON CPB
Perfusion pressure is used as a surrogate marker of organ perfusion and
should be maintained between 50 and 70 mmHg. Hypertensive patients
and those at risk for stroke require higher flows and perfusion pressures to
maintain organ perfusion.

Blood level in the reservoir should be monitored to prevent air embolism.

Glucose is maintained between 120 and 180 mg/dL.

Anaesthesia can be maintained by inhalational route or total intravenous
anaesthesia can be given.
 TEMPERATURE MANAGEMENT
Hypothermia is frequently used during CPB for its presumed organ
protective effects. Blood viscosity increases with hypothermia and allows
maintenance of a higher perfusion pressure despite haemodilution.
However, hypothermia reversibly inhibits the clotting factors and platelets.

CPB can be used for the induction of total body hypothermia, a state in
which the body can be maintained for up to 45 minutes without perfusion
(blood flow). If blood flow is stopped at normal body temperature,
permanent brain damage normally occurs in three to four minutes — death
may follow shortly afterward.
 ULTRAFILTRATION
Ultrafiltration during and after CPB removes inflammatory
mediators and excess fluid thereby producing
haemoconcentration. Conventional ultrafiltration uses a
haemofilter inserted into the bypass circuit.

Hemofilters- contain semi permeable membranes that

permit passage of water and electrolytes out of blood.
 WEANING
Weaning is the process where extracorporeal support is
gradually withdrawn as the heart takes over the circulation.

-Process of transition from cardiopulmonary bypass to

normal, physiological circulation.

Nasopharyngeal temperature should not exceed 37°C,

although authors accept temperature range of 35.5°C–
36.5°C.
 06

COMPLICATIONS
 MECHANICAL COMPLICATION
Arterial cannulation can be associated with bleeding, cannula malposition
causing selective cerebral perfusion, plaque dislodgement and dissection.
Dissection presents as low arterial pressure, high arterial line pressure
(>300 mmHg), loss of venous return and bluish discolouration of the
vessel. It can be diagnosed with TOE.
Venous cannulation can be associated with bleeding, cannula
malposition/air lock causing an inadequate return, leading to cerebral and
splanchnic congestion. Massive air embolism is due to pumping from an
empty reservoir.
Other complications include oxygenator failure, pump malfunction, clotting
in the circuit, tubing rupture, gas supply failure and electrical failure due to
which hand cranking must be available at all times.
 SYSTEMIC COMPLICATIONS
• CPB causes qualitative and quantitative platelet dysfunction.

Inflammatory response and hypotension can cause acute kidney injury

(AKI). Risk factors are prolonged bypass time, sepsis and diabetes.

The spectrum of cerebral injury ranges from cognitive dysfunction to

stroke.

Subclinical myocardial injury can occur due to cross clamping of the

aorta in spite of cardioplegia.

Acute respiratory distress syndrome can be present due to the effects

of CPB.