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Problems in Cardiopulmonary Bypass 1 Introduction Perfusion Incident frequency Identify possible problems during CPB Outline remedial action 2 Incident Frequency Date Author Country 1980 Stoney US Incidence / Permanent accidents injury/death 1 / 300 1 / 1000 1981 Wheeldon UK 1 / 300 1 / 1500 1986 Kuruz US 1 / 100 1 / 1000 1997 Jenkins Australia 1 / 35 1 / 1300 2000 Mejak US 1 / 1400 1 / 130 3 Incident distribution Stoney Wheeldon Kuruz Jenkins Mejak DIC Elec failure Protamine reaction Heater/cooler problems DIC air embolism air embolism Oxy failure air embolism Protamine reaction Elec failure Oxy failure Elec / mech failure Protamine reaction/prob Ao dissection / cannula prob Mech failure Mech failure Drug error Oxy failure Oxy failure Oxy failure DIC air embolism DIC air embolism 4 Topics for Discussion Mediation of Patient’s immune system response Unusual syndromes Oxygenator problems Embolic events Protocol for Gross Air Embolism 5 Systemic Inflammatory response Platelet adhesion, activation of Factor XII Cascade activation : kallikrein kinin-bradykinin Fibrinolytic Complement - C3a + C5a leucocyte activation oxygen free radicals 6 Mediation of Inflammatory response 1. Biocompatible materials •Albumin in priming fluid •Heparin coating - ionic surface grafting covalent - benzalkonium heparin •Endothelial-like surfaces phosphorylcholine trillium - Carmeda 7 8 9 10 Mediation of Inflammatory response 2. Leucocyte depletion 3. Isolation of Cardiotomy suction 11 Anti-thrombin III deficiency In the absence of adequate circulating AT-III heparin has little or no effect retarding blood coagulation. Congenital AT-III deficiency Acute venous thrombosis DIC Liver cirrhosis 12 AT III - Diagnosis & action ACT still low after Heparin bolus Repeat bolus ( 30 - 40mg / Kg ) ACT still low – give 2 units FFP Recheck ACT On bypass add further FFP as reqd 13 Microaggregates - Cold agglutinins gp1 : Immunoglobulin M class directed against erythrocyte I antigen – wide thermal range 4 to 32C gp2 : narrow thermal range 0 - 10C Clotting / grainy appearance Interfere with cardioplegia distribution & myocardial protection. 14 Cold agglutinins – management strategy Rewarm pat to 320C Switch to warm blood cardioplegia Sample to haematology to determine thermal amplitude Pre-op plasmapheresis for patients with known agglutinins will remove most of the serum antibodies. 15 Malignant Hyperthermia Inherited disorder – rapid temp to 42°C in response to volatile anaesthetic agents Abnormal calcium metabolism myoplasmic ionic calcium Metabolic rate, resp + met acidosis, K+ , lactate + pyruvate, tachycardia, temp Massive muscle swelling, Pul oedema, DIC & acute renal failure 70% mortality 16 M.H. - remedial action Stop all volatile anaesthetic agents FiO2 to meet metabolic demand Administer Dantrolene sodium IV Correct acidosis + hyperkalaemia Use IV and surface cooling to control temp Give mannitol + frusemide to maintain urine output of at least 2ml/Kg/hr 17 Sickle Cell Disease Low O2 sat +/- hypothermia will cause sickle cells to clump + precipitate Disease : Pats with 50% Haemoglobin S cells will sickle @ 85% O2 sat Trait : Pats with 45% Haemoglobin S cells will sickle @ 40% O2 sat 18 Sickle Cell Disease – management strategy Disease : Divert venous blood to cell salvage / plasmapheresis to separate plasma and platelets Replace with RBC, FFP, colloid + crystalloid Trait : Keep O2 saturations high Avoid acidosis Avoid hypothermia Warm blood cardioplegia 19 Methaemoglobinaemia Severe cyanosis of arterial blood ( often appears chocolate brown rather than blue ) in spite of high pO2 Haem ion oxidised from ferrous (Fe 2+) to ferric (Fe 3+) state Hereditary deficiency in control enzymes Drug reaction – e.g. nitroglycerine, isosorbide dinitrate, sodium nitrate 20 Remedial Action Withdraw all possible causative agents Administer 1% methylene blue infusion 1 – 3mg/kg over 5 min Doses > 7mg/kg are toxic High dose Vitamin C and/or exchange transfusion in severe cases 21 Oxygenator Problems Physical attrition Gas exchange capability Inadequate anticoagulation Heparin resistance AT III deficiency Administration of Protamine ! 22 Sources of Emboli Particulate • Oxygenator - Polypropylene / polycarbonate • CPB circuit - PVC / silicone (spallation) • Patient - plaque calcium platelet / fibrin aggregates lipid globules muscle / connective tissue fragments 23 Sources of Emboli Gaseous • Cannulation • Venous air entrainment – (VAVD?) • Inadequate de-airing of the heart • Inappropriate vent suction • Centrifugal pump – retrograde flow • IABP deflation during aortotomy • Temperature Gradients • Catastrophic gross air embolism 24 Protection Against Embolic Events ( 1 ) Particulate 0.5 micron Pre-bypass filter 40 micron Arterial line filter 120 micron cardiotomy reservoir filter 25 Protection Against Embolic Events ( 2 ) Gaseous •Microemboli - arterial line filter + purge line - elimination of entrained venous air - vent line – one-way pressure relief valves •Macroemboli - oxygenator resevoir level sensor arterial line filter + purge line ultrasonic bubble detector in art line anti-siphon valve / software for centrifugal pumps - CO2 insufflation 26 Gross Air Embolism Incident Protocol Perfusion Surgical Anaesthetic Post operative care 27 Perfusion Discontinue bypass – clamp art + ven lines Identify origin of problem Reprime CPB circuit & art cannula Retrograde SVC perfusion 1-2 LPM Reinstitute bypass - temp (22 – 30o C) Systemic pressure FiO2 = 100% Off bypass @ 34o C 28 Surgical Clamp & remove aortic cannula Cannulate SVC or connect to SVC cannula Retrieve blood/air exiting aorta via vent When no more air is visible at aortotomy -- Re-cannulate aorta – reinstitute bypass Bleed air from coronary arteries Complete Surgical procedure 29 Anaesthetic Place patient in steep Trendelenberg position Compress carotid arteries Consider administering : Steroids Mannitol Antiplatelet agents 30 Post Bypass Management Ventilate patient on 100% oxygen Institute slight hyperventilation Rewarm to normothermia over 24hrs Place patient in reverse trendelenberg posn Avoid hyperglycaemia + hyponatraemia Consider Hyperbaric oxygen treatment 31 32