CARDIO PULMONARY BYPASS

1. CARDIO PULMONARY BYPASS MODERATOR:DR.POONAM MALHOTHRA PRESENTORS:DR.SENTHIL DR.PRABHU www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2. Cardiopulmonary Bypass “ provide a non beating bloodless heart with flow temporarily diverted to an extra-corporeal circuit that functionally replaces heart and lung ” “ boldest and most decisive feats of man’s mind ”

3. DEVELOPMENT OF HEART LUNG MACHINE GIBBON ERA 1930 October 3 Gibbon watches over a patient die of pulmonary embolism Birth of the idea Work at Thomas Jefferson Hospital, Philadelphia 1939 use of heparin 1939 CPB in cats and dogs W W - II interruption

4. 1945 GIBBON RESUMES WORK

5. BULL FINCH LAB MGH

6. JOHN GIBBON JR “Coupling extra corporeal circulation, oxygenation and cardiac surgery” 1952 first ASD closure died autopsy PDA 1953 May 6 2nd patient Cecelia Bavelok ,16/f ASD closure

7. JOHN GIBBON

8. CPB EQUIPMENT

9. FUNCTION OF CPB • Oxygenation and elimination ofco2 • Circulation of blood • Systemic cooling and re-warming • Diversion of blood from the heart

10. CPB CIRCUIT

11. CPB CIRCIUT

12. CPB CIRCUIT Venous canula reservoir pump heat exchanger oxygenator arterial filter aortic canula Vent cardiotomy suction gas blender saftey devices monitoring devices

13. OXYGENATORS Vertical screen Gibbon Rotating disc Kay Cross Stationary film Kirklin Bubble De Wall Lillehei Membrane Kolff, Neville

15. BUBBLE OXYGENATOR Blood drains into chamber Oxygen diffuses through diffusion plate -produce bubbles Small bubbles enhance O2 exchange Large bubbles enhance CO2 removal Easy to prime Inexpensive RISKS Air embolism > 2 hours protein denaturation platelet , complement activation Defoaming

16. MEMBRANE OXYGENATOR • Imitates natural lung • Gas exchange across thin membrane • 2 Types • Microporous • Nonporous

17. Membrane oxygenator MICROPOROUS Polypropelene Small pores impervious to blood 2 Types 1. Hollow Fiber 2. Parallel Plate/ Pleated Sheet

18. Membrane oxygenator Non Porous Methyl Silicone Rubber Increased priming volume ECMO

19. Membrane Oxygenator PCO2 controlled by gas flow PO2 controlled by fio2 Safer Less particulate and gaseous emboli Less reactive

20. BLOOD PUMPS Ideal Pump Flow Rate 7 Lts/ Min Pressure 500 Mm Hg Non Damaging No Turbulence Disposable Exact Calibration Manually Operable

21. BLOOD PUMPS • 4 Types • Roller Pump • Centrifugal Pump • Pulsatile Pump • Non Occlusive Roller Pump

22. ROLLER PUMP

23. Roller pump Since 1956 Positive Displacement Pump Most commonly used length of tubing inside curved raceway Predictable pump flow Preload/ Afterload independent Simple Can be used as vent

24. Roller pump • PROBLEMS • Mal occlusion • Tubing Fracture • Runaway pump • Spallation • Air Pumping • Cavitation

25. CENTRIFUGAL PUMPS Since 1976 Rotates and generates a vortex Magnetically coupled another magnet in pump head Non Occlusive Pre & After load Dependent

26. CENTRIFUGAL PUMPS Less blood trauma Do not over pressurize & disrupt No tubing wear No spallation No cavitation Decreased risk of air embolism

27. CENTRIFUGAL PUMPS DIS ADVANTAGES Lacks versatility in placement No vent / suction Adds to complexity Adds to cost Non Pulsatile Retrograde flow

28. VENOUS CANULATION and DRAINAGE CANULA chosen by Size and AGE& WEIGHT 1 STAGE 10 - 46 F 2 STAGE 36- 51 F Flow 1/3 SVC & 2/3 IVC CANULATION Bicaval Cavo atrial Single Atrial Peripheral

30. VENOUS DRAINAGE Gravity Siphon Assisted Vacuum Assisted ( VAVD) Regulated vacuum to closed hard shell reservoir Kinetic Assisted ( KAVD) centrifugal pump in venous line Roller pump between canula and reservoir

31. Advantages of AVD • Improved venous return • Lowering the priming volume. • Alternative venous cannulation sites • Almost impossible to have an air-lock in the venous line.

32. VAVD

33. ARTERIAL CANULAE Narrowest part of circuit High flow jet Pressure gradient > 100 mm hemolysis Choose smallest canula that will provide calculated flow rate with a gradient < 100 mm Hg COANDA EFFECT Jet stream adheres to boundary lower pressure on opposite wall carotid hypoperfusion

34. ARTERIAL CANULATION • Femoral Canulation • Redo Surgery • Aortic Surgery • Minimal Access Surgery • Severe Atherosclerosis of Asc Aorta

35. TUBING • Transparent • Resilient • Flexible • Non-kinking • Hardness • Toughness • Inertness • Smooth • Non-wettable • Heat Tolerance • Blood compatibility

36. TUBING Size of tube: Art- 3/8 th inch, Venous-1/2 inch, Suction-1/4th inch Latex Rubber Hemolysis PVC Stiffens Silicone Rubber Spallation

37. Heparin Bonded Circuits Increase hemocompatibility Reduced complement activation Decreased heparin requirement Lower blood loss Less transfusion requirement

38. TCM

39. Warm and cool patient temp range 4 - 42 c Nonsterile water in manifolds of tubing Water circulates in opposite direction to that of blood Heat exchangers @ venous reservoir, cardioplegia delivery

40. Venous Reservoir Hard shell Hard shell open to atmosphere risk of air embolism VAVD possible

41. Venous Reservoir Soft shell collapses on itself decreased risk of air embolism VAVD not possible

42. VENOUS RESERVOIR WITH INTEGRATED OXYGENATOR AND HEAT EXCHANGER

43. FILTERS Screen Filters Woven polyester or nylon Defined pore size Filter by interception Harder to deair

44. FILTERS Depth Filters Packed fibre/foam No defined pore size Filter by impaction and absorption Concern hemolysis,thrombocytopenia

45. MONITORING Inline blood gas monitoring HCT Line pressure Arterial flow meter Temperature monitoring Expired gas monitoring

47. www.anaesthesia.co.in anaesthesia.co.in@gmail.com