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Perfusion for the Non-Perfusionist

Perfusion for the Non-Perfusionist. Basics for the Extracorporeal Circuit Basics for Managing CPB during operation. Objectives. Perfusionist responsibilities CPB Equipment Components & cannulation. Mayo Clinic Rochester. The Mayo Clinic Cardiac surgery facts of interest.

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Perfusion for the Non-Perfusionist

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  1. Perfusion for the Non-Perfusionist Basics for the Extracorporeal Circuit Basics for Managing CPB during operation

  2. Objectives • Perfusionist responsibilities • CPB Equipment • Components & cannulation

  3. Mayo Clinic Rochester

  4. The Mayo ClinicCardiac surgery facts of interest • 2nd US News & World Report • 2,800+ annual cardiac surgeries • 10 surgeons, 16 anesthesiologists, 16 perfusionists, ATs, MTs, CRNAs and CSTs • 8-9 cardiac ORs, 8-16 procedures per day • Annually: 200 pediatric, 295 adult congenital, 50 VADs, 60 ECMOs,, and multiple DHCAs and re-operation procedures

  5. CPB / ECC Components

  6. TART oC TVEN oC O2 Content: PaO2 CO2 Content: PaCO2 pH, [HCO3-] SaO2 O2 Content: PvO2 CO2 Content: PvCO2 pH, [HCO3-] SvO2 Artificial Heart Artificial Lung +VO2 -VCO2 +/- Kcal/min The V-A ECLS Patient Interface -VO2 +VCO2 +/- Kcal/min TNP oC Patient Systemic Circulation Right Heart Left Heart +VO2 -VCO2 Patient Lungs

  7. CPB / ECC Components

  8. CPB / ECC Components • Artificial heart [blood propulsion devices] • Artificial lung [VCO2,VO2]; Internal HE, ALF • Artificial circulation [tubing, cannulae, connectors] • Accessories • Heat exchangers: kcal/min • Reservoirs: level detectors • Hemoconcentrator • Safety devices • Filters: Solution, blood, gas, particulate • In-line monitors [pressure, flow, temperature, BG, O2 Sat, %O2 gas] • One-way valves

  9. Circuit Design Issues: Cannulation

  10. Cannulation • The critical interface • Typically insert arterial first • double purse string • meticulous debubbling • Venous • single atrial • dual caval (for total CPBP) • Cardioplegia • Ventricular vent

  11. Dual Stage Single Cannulation • Most common approach • Single cannula • Traverses right atrium from right auricle • Basket in atrium • Tip in inferior cava

  12. Dual Caval Cannulation • Traditional approach • Individual cannulation of inferior and superior vena cava • Necessary for “total” bypass

  13. Partial vs. Total Bypass

  14. Ventricular Venting • Right superior pulmonary vein • Ventricular apex • Cardioplegia cannula • Pulmonary artery • Trans-septal

  15. Responsibilities: Perfusionist • Safe CPB • Avoid embolism • Myocardial and cerebral protection • Record keeping, communication • Flow, pressure (P), resistance • Velocity, shear, hemolysis • Acid-base status, pH, VCO2, [CO2], pCO2 • Oxygen transfer: VO2, [O2], pO2 • Heat transfer: kcal/min, temperature

  16. ICEBP

  17. Known Problems Associated with Cardiopulmonary Bypass Particulate or gaseous micro- or macro-embolization; Potential neurologic consequences Cannula misplacement; Excessive pressure drop or blood flow distribution patterns Biocompatibility issues; Cell destruction, hemolysis Oxygenator failure or wet-out; O2 and CO2 transfer limitations Inadequate heat transfer; Patient temperature after-drop in ICU

  18. “Orpheus” Cardiopulmonary BypassSimulation System

  19. “Orpheus” Cardiopulmonary Bypass Simulation System

  20. Summary • Basic components needed for safe CPB • Perfusionist’s role • Management of CPB is evidence-based and multi-disciplined • Patient management is guided by evidence- and consensus-based procedure guidelines

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