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Cardiopulmonary Bypass
Cardiopulmonary Bypass

Edited by
Sunit Ghosh
Florian Falter
David J. Cook
CAMBRID GE UNIVERSIT Y PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore,
São Paulo, Delhi, Dubai, Tokyo

Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by
Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521721998

© S. Ghosh, F. Falter and D. J. Cook 2009

This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.

First published 2009

Printed in the United Kingdom at the University Press, Cambridge

A catalog record for this publication is available from the
British Library

ISBN 978-0-521-72199-8 Paperback

Additional resources for this publication at
www.cambridge.org/9780521721998

Cambridge University Press has no responsibility for the persistence or
accuracy of URLs for external or third-party Internet websites referred
to in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide
accurate and up-to-date information which is in accord with accepted
standards and practice at the time of publication. Although case histories
are drawn from actual cases, every effort has been made to disguise the
identities of the individuals involved. Nevertheless, the authors, editors
and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in
this publication. Readers are strongly advised to pay careful attention to
information provided by the manufacturer of any drugs or equipment
that they plan to use.
Contents
List of contributors vii
Preface ix



1. Equipment and monitoring 1 9. Mechanical circulatory
support 106
Victoria Chilton and Andrew Klein
Kirsty Dempster and Steven Tsui
2. Circuit setup and safety
checks 23 10. Deep hypothermic
circulatory arrest 125
Simon Colah and Steve Gray
Joe Arrowsmith and Charles W. Hogue
3. Priming solutions for
cardiopulmonary bypass 11. Organ damage during
circuits 36 cardiopulmonary bypass 140
George Hallward and Roger Hall Andrew Snell and Barbora Parizkova
4. Anticoagulation, coagulopathies, 12. Cerebral morbidity in adult
blood transfusion and cardiac surgery 153
conservation 41 David Cook
Liza Enriquez and Linda
13. Acute kidney injury (AKI) 167
Shore-Lesserson
Robert C. Albright
5. Conduct of cardiopulmonary
14. Extracorporeal membrane
bypass 54
oxygenation 176
Betsy Evans, Helen Dunningham and
Ashish A. Bartakke and Giles J. Peek
John Wallwork
15. Cardiopulmonary bypass in
6. Metabolic management during
non-cardiac procedures 187
cardiopulmonary bypass 70
Sukumaran Nair
Kevin Collins and G. Burkhard
Mackensen
7. Myocardial protection and
cardioplegia 80
Index 199
Constantine Athanasuleas and Gerald
D. Buckberg
8. Weaning from cardiopulmonary
bypass 92
James Keogh, Susanna Price and Brian
Keogh




v
Contributors

Helen Dunningham BSc CCP
Robert C. Albright Jr DO
Senior Clinical Perfusion Scientist, Cam-
Assistant Professor of Medicine, Division
of Nephrology and Hypertension, Mayo bridge Perfusion Services, Cambridge, UK
Clinic, Rochester, Minnesota, USA
Liza Enriquez MD
Joe Arrowsmith MD FRCP FRCA Fellow, Department of Anesthesiology,
Consultant Cardiothoracic Anaesthetist, Montefiore Medical Center, Albert Einstein
Papworth Hospital, Cambridge, UK College of Medicine, New York, USA
Constantine Athanasuleas MD Betsy Evans MA MRCS
Division of Cardiothoracic Surgery, Univer- Registrar in Cardiothoracic Surgery, Pap-
sity of Alabama, Birmingham, Alabama, USA worth Hospital, Cambridge, UK
Ashish A Bartakke MD (Anaesthesia),
Steve Gray MBBS FRCA
MBBS
Consultant Cardiothoracic Anaesthetist,
ECMO Research Fellow, Glenfield Hospital,
Papworth Hospital, Cambridge, UK
Leicester, UK
Roger Hall MBChB FANZCA FRCA
Gerald D. Buckberg MD
Consultant Cardiothoracic Anaesthetist,
Distinguished Professor of Surgery, Dep-
Papworth Hospital, Cambridge, UK
artment of Cardiothoracic Surgery, David
Geffen School of Medicine at UCLA, Los George Hallward MBBS MRCP FRCA
Angeles, California, USA
Clinical Fellow in Cardiothoracic Anaes-
thesia, Papworth Hospital, Cambridge, UK
Victoria Chilton BSc CCP
Senior Clinical Perfusion Scientist, Alder
Charles W. Hogue MD
Hey Children™s Hospital, Liverpool, UK
Associate Professor of Anesthesiology and
Critical Care Medicine, The Johns Hopkins
Simon Colah MSc FCP CCP
Medical Institutions and The Johns Hopkins
Senior Clinical Perfusion Scientist, Cam-
Hospital, Baltimore, Maryland, USA
bridge Perfusion Services, Cambridge, UK
Brian Keogh MBBS FRCA
Kevin Collins BSN CCP LP
Consultant Anaesthetist, Royal Brompton &
Staff Perfusionist, Duke University Medical
Harefield NHS Trust, UK
Center, Durham, North Carolina, USA
James Keogh MBChB FRCA
David Cook MD
Clinical Fellow in Paediatric Cardiothoracic
Associate Professor, Department of Anesthe-
Anaesthesia, Royal Brompton & Harefield
siology, Mayo Clinic, Rochester, Minnesota,
NHS Trust, UK
USA
Andrew Klein MBBS FRCA
Kirsty Dempster CCP
Consultant Cardiothoracic Anaesthetist,
Senior Clinical Perfusion Scientist, Cam-
Papworth Hospital, Cambridge, UK
bridge Perfusion Services, Cambridge, UK

vii
List of contributors



Linda Shore-Lesserson MD
G. Burkhard Mackensen MD PhD FASE
Associate Professor, Department of Anes- Professor, Department of Anesthesiol-
thesiology, Duke University Medical Center, ogy, Montefiore Medical Center, Albert
Durham, North Carolina, USA Einstein College of Medicine, New York,
USA
Sukumaran Nair MBBS FRCS
Consultant Cardiothoracic Surgeon, Pap- Andrew Snell MBChB, FANZCA
worth Hospital, Cambridge, UK Clinical Fellow in Cardiothoracic Anaes-
thesia, Papworth Hospital, Cambridge,
Barbora Parizkova MD
UK
Clinical Fellow in Cardiothoracic Anaes-
thesia, Papworth Hospital, Cambridge, UK Steven Tsui MBBCh FRCS
Consultant in Cardiothoracic Surgery/Di-
Giles J Peek MD FRCS
rector of Transplant Services, Papworth
Consultant in Cardiothoracic Surgery &
Hospital, Cambridge, UK
ECMO, Glenfield Hospital, Leicester, UK
John Wallwork MA MBBCh FRCS FRCP
Susanna Price MBBS BSc MRCP EDICM
Professor, Department of Cardiothoracic
PhD
Surgery, Papworth Hospital, Cambridge,
Consultant Cardiologist and Intensivist,
UK
Royal Brompton & Harefield NHS Trust, UK




viii
Preface
This book has been written to provide an easily readable source of material for the everyday
practice of clinical perfusion. For the past few years there has been a dearth of books, other
than large reference tomes, relating to cardiopulmonary bypass. We hope that newcomers
to the subject will find this book useful, both in the clinical setting and in preparation for
examinations, and that more experienced perfusionists and medical staff will find it useful for
preparing teaching material or for guidance.
We would like to thank everyone who helped in the preparation of the manuscript, par-
ticularly those who contributed their expertise by writing chapters for this book.

S. Ghosh, F. Falter and D. J. Cook




ix
Equipment and monitoring
Chapter
Victoria Chilton and Andrew Klein


1
The optimum conditions for cardiothoracic surgery have traditionally been regarded as a
“still and bloodless” surgical field. Cardiopulmonary bypass (CPB) provides this by incor-
porating a pump to substitute for the function of the heart and a gas exchange device, the
“oxygenator,” to act as an artificial lung. Cardiopulmonary bypass thus allows the patient™s
heart and lungs to be temporarily devoid of circulation, and respiratory and cardiac activity
suspended, so that intricate cardiac, vascular or thoracic surgery can be performed in a safe
and controlled environment.

History
In its most basic form, the CPB machine and circuit comprises of plastic tubing, a reservoir,
an oxygenator and a pump. Venous blood is drained by gravity into the reservoir via a cannula
placed in the right atrium or a large vein, pumped through the oxygenator and returned into
the patient™s arterial system via a cannula in the aorta or other large artery. Transit through
the oxygenator reduces the partial pressure of carbon dioxide in the blood and raises oxygen
content. A typical CPB circuit is shown in Figure 1.1.
Cardiac surgery has widely been regarded as one of the most important medical advances
of the twentieth century. The concept of a CPB machine arose from the technique of “cross-
circulation” in which the arterial and venous circulations of mother and child were connected
by tubing in series. The mother™s heart and lungs maintained the circulatory and respiratory
functions of both, whilst surgeons operated on the child™s heart (Dr Walton Lillehei, Minne-
sota, 1953, see Figure 1.2a). Modern CPB machines (see Figure 1.2b) have evolved to incor-
porate monitoring and safety features in their design.
John Gibbon (Philadelphia, 1953) is credited with developing the first mechanical CPB
system, which he used when repairing an atrial secundum defect (ASD). Initially, the technol-
ogy was complex and unreliable and was therefore slow to develop. The equipment used in a
typical extracorporeal circuit has advanced rapidly since this time and although circuits vary
considerably among surgeons and hospitals, the basic concepts are essentially common to all
CPB circuits.
This chapter describes the standard equipment and monitoring components of the CPB
machine and extracorporeal circuit as well as additional equipment such as the suckers used
to scavenge blood from the operative field, cardioplegia delivery systems and hemofilters (see
Tables 1.1 and 1.2).

Tubing
The tubing in the CPB circuit interconnects all of the main components of the circuit. A variety
of materials may be used for the manufacture of the tubing; these include polyvinyl chloride
1
Cardiopulmonary Bypass, ed. S. Ghosh, F. Falter and D. J. Cook. Published by Cambridge University Press.
© Cambridge University Press 2009.
Chapter 1: Equipment and monitoring




Figure 1.1. Typical configuration of a basic cardiopulmonary bypass circuit. BGM = blood gas monitor; SAT =
oxygen saturation.


Figure 1.2a. Depiction of the method of direct vision
intracardiac surgery utilizing extracorporeal circulation
by means of controlled cross circulation. The patient
(A), showing sites of arterial and venous cannulations.
The donor (B), showing sites of arterial and venous
(superficial femoral and great saphenous) cannulations.
The Sigma motor pump (C) controlling precisely the
reciprocal exchange of blood between the patient and
donor. Close-up of the patient™s heart (D), showing the
vena caval catheter positioned to draw venous blood
from both the superior and inferior venae cavae during
the cardiac bypass interval. The arterial blood from the
donor circulated to the patient™s body through the
catheter that was inserted into the left subclavian artery.
(Reproduced with kind permission from Lillehei CW,
Cohen M, Warden HE, et al. The results of direct vision
closure of ventricular septal defects in eight patients
by means of controlled cross circulation. Surg Gynecol
Obstet 1955; 101: 446. Copyright American College of
Surgeons.)


(PVC, by far the most commonly used), silicone (reserved for the arterial pump boot) and
latex rubber. The size of tubing used at different points in the circuit is determined by the pres-
sure and rate of blood flow that will be required through that region of the circuit, or through
a particular component of the circuit (see Table 1.3).
PVC is made up of polymer chains with polar carbon-chloride (C-Cl) bonds. These bonds
result in considerable intermolecular attraction between the polymer chains, making PVC a
fairly strong material. The feature of PVC that accounts for its widespread use is its versatility.
On its own, PVC is a fairly rigid plastic, but plasticizers can be added to make it highly flex-
ible. Plasticizers are molecules that incorporate between the polymer chains allowing them
2
Chapter 1: Equipment and monitoring



Figure 1.2b. Cardiopulmonary
bypass machine (reproduced
with kind permission of Sorin
Group).




to slide over one another more easily, thus increasing the flexibility of the PVC. However, one
disadvantage is that PVC tubing stiffens during hypothermic CPB and tends to induce spal-
lation; that is, the release of plastic microparticles from the inner wall of tubing as a result of
pump compressions.
Other materials used to manufacture perfusion tubing include latex rubber and silicone
rubber. Latex rubber generates more hemolysis than PVC, whereas silicone rubber is known
to produce less hemolysis when the pump is completely occluded, but can release more par-
ticles than PVC. As a result of this, and because of PVC™s durability and accepted hemolysis
rates, PVC is the most widely used tubing material. The arterial roller pump boot is the main
exception to this, as the tubing at this site is constantly compressed by the rollers themselves,
leading to the use of silicone tubing for this purpose.

Arterial cannulae
The arterial cannula is used to connect the “arterial limb” of the CPB circuit to the patient
and so deliver oxygenated blood from the heart-lung machine directly into the patient™s arte-
rial system. The required size is determined by the size of the vessel that is being cannulated,
3
Chapter 1: Equipment and monitoring



Table 1.1. Components of the CPB machine and the extracorporeal circuit

Equipment Function
Oxygenator system, venous reservoir, Oxygenate, remove carbon dioxide and cool/re-
oxygenator, heat exchanger warm blood
Gas line and FiO2 blender Delivers fresh gas to the oxygenator in a controlled
mixture
Arterial pump Pumps blood at a set flow rate to the patient
Cardiotomy suckers and vents Scavenges blood from the operative field and vents
the heart
Arterial line filter Removes microaggregates and particulate
matter >40 μm
Cardioplegia systems Deliver high-dose potassium solutions to arrest the
heart and preserve the myocardium
Cannulae Connect the patient to the extracorporeal circuit


Table 1.2. Monitoring components of the CPB machine and the extracorporeal circuit

Monitoring device Function
Low-level alarm Alarms when level in the reservoir reaches minimum
running volume
Pressure monitoring (line pressure, blood cardioplegia Alarms when line pressure exceeds set limits
pressure and vent pressure)
Bubble detector (arterial line and blood cardioplegia) Alarms when bubbles are sensed
Oxygen sensor Alarms when oxygen supply to the oxygenator fails
SaO2, SvO2, and hemoglobin monitor Continuously measures these levels from the
extracorporeal circuit
In-line blood gas monitoring Continuously measures arterial and venous gases from
the extracorporeal circuit
Perfusionist Constantly monitors the cardiopulmonary bypass
machine and the extracorporeal circuit


Table 1.3. Tubing sizes commonly used in different parts of the extracorporeal circuit (adults only)

Tubing size Function
3/16˝ (4.5 mm) Cardioplegia section of the blood cardioplegia delivery system
1/4˝ (6.0 mm) Suction tubing, blood section of the blood cardioplegia delivery system
3/8˝ (9.0 mm) Arterial pump line for flow rates <6.7 l/minute, majority of the arterial tubing in the
extracorporeal circuit
1/2˝ (12.0 mm) Venous line, larger tubing is required to gravity drain blood from the patient


as well as the blood flow required. The ascending aorta is the most common site of arterial
cannulation for routine cardiovascular surgery. This is because the ascending aorta is readily
accessible for cannulation when a median sternotomy approach is used and has the lowest
associated incidence of aortic dissection (0.01“0.09%). After sternotomy and exposure, the
surgeon is able to assess the size of the aorta before choosing the most appropriately sized
cannula (see Table 1.4).
4
Chapter 1: Equipment and monitoring



Table 1.4. Arterial cannulae flow rates in relation to type/size

Size
Cannulae French gauge mm Flow rate (l/minute)
DLP angled tip 20 6.7 6.5
22 7.3 8.0
24 8.0 9.0
DLD straight tip 21 7.0 5.0
24 8.0 6.0
Sarns high flow angled tip 15.6 5.2 3.5
19.5 6.5 5.25
24 8.0 8.0
Sarns straight tip 20 6.7 5.9
22 7.3 6.0
24 8.0 6.0


Figure 1.3. Commonly used arterial cannulae.
(Reproduced with kind permission from Edwards
Lifesciences.)




Thin-walled cannulae are preferred, as they present lower resistance to flow because of
their larger effective internal diameter. This leads to a reduction in arterial line pressure with-
in the extracorporeal circuit and increased blood flow to the patient.
Arterial cannulae with an angled tip are available. These direct blood flow towards the
aortic arch rather than towards the wall of the aorta; this may minimize damage to the vessel
wall. In addition, cannulae with a flange near the tip to aid secure fixation to the vessel wall
and cannulae that incorporate a spirally wound wire within their wall to prevent “kinking”
and obstruction are commonly used (see Figure 1.3).
5
Chapter 1: Equipment and monitoring




Figure 1.4. Commonly used venous cannulae: (a) Y-connector to connect single-stage cannulae; (b) single-stage
cannula; (c) two-stage cannula. RA, right atrial; SVC, superior vena cava; IVC, inferior vena cava.



Venous cannulae
Venous cannulation for CPB allows deoxygenated blood to be drained from the patient into
the extracorporeal circuit. The type of venous cannulation used is dependent upon the opera-
tion being undertaken. For cardiac surgery that does not involve opening the chambers of
the heart, for example, coronary artery bypass grafts (CABG), a two-stage venous cannula is
often used. The distal portion, i.e., the tip of the cannula, sits in the inferior vena cava (IVC)
and drains blood from the IVC through holes around the tip. A second series of holes in the
cannula, a few centimeters above the tip, is sited in the right atrium, to drain venous blood
entering the atrium via the superior vena cava (SVC).
An alternative method of venous cannulation for CPB is bicaval cannulation “ this uses
two single-stage cannulae that sit in the inferior and superior vena cavae, respectively. The two
single-stage cannulae are connected using a Y-connector to the venous line of the CPB circuit.
Bicaval cannulation is generally used for procedures that require the cardiac chambers to be
opened, as the two separate pipes in the IVC and SVC permit unobstructed venous drainage
during surgical manipulation of the dissected heart and keep the heart completely empty of
blood (see Figure 1.4).
The femoral veins may also be used as a cannulation site for more complex surgery. In this
instance, a long cannula, which is in essence an elongated single-stage cannula, may be passed
up the femoral vein into the vena cava in order to achieve venous drainage.
As with arterial cannulation, the size of the cannulae will depend on the vessels being can-
nulated as well as the desired blood flow. It is important to use appropriately sized cannulae in
order to obtain maximum venous drainage from the patient so that full flow can be achieved
when CPB is commenced.


Pump heads
There are two types of pumps used in extracorporeal circuits:
1. Those that produce a flow “ roller pumps.
2. Those that produce a pressure “ centrifugal pumps.
6
Chapter 1: Equipment and monitoring




Figure 1.5. (a) Line drawing of a roller pump; (b) a roller pump. (Reproduced with kind permission from
Sorin Group.)


Roller pumps
Initial technology developed in the mid twentieth century used non-pulsatile roller pumps in
CPB machines. This technology has not changed greatly over the past 50 years.
Roller pumps positively displace blood through the tubing using a peristaltic motion.
Two rollers, opposite each other, “roll” the blood through the tubing. When the tubing is
7
Chapter 1: Equipment and monitoring



intermittently occluded, positive and negative pressures are generated on either side of the
point of occlusion. Forward or retrograde flow of blood can be achieved by altering the direc-
tion of pump head rotation; thus roller pumps are commonly used as the primary arterial
flow pump as well as for suction of blood from the heart and mediastinal cavity during CPB
to salvage blood. Roller pumps are relatively independent of circuit resistance and hydrostatic
pressure; output depends on the number of rotations of the pump head and the internal diam-
eter of the tubing used (see Figure 1.5a,b).
This type of positive displacement pump can be set to provide pulsatile or non-pul-
satile (laminar) flow. Debate over the advantages and disadvantages of non-pulsatile or
pulsatile perfusion during cardiopulmonary bypass still continues. Non-pulsatile per-
fusion is known to have a detrimental effect on cell metabolism and organ function. The
main argument in favor of pulsatile perfusion is that it more closely resembles the pattern
of blood flow generated by the cardiac cycle and should therefore more closely emulate
the flow characteristics of the physiological circulation, particularly enhancing flow
through smaller capillary networks in comparison to non-pulsatile perfusion. The increased
shear stress from the changing positive and negative pressures generated to aid pulsatile per-
fusion may, however, lead to increased hemolysis. Roller pumps have one further disadvantage:
sudden occlusion of the inflow to the pump, as a result of low circulating volume or venous can-
nula obstruction, can result in “cavitation,” the formation and collapse of gas bubbles due to the
creation of pockets of low pressure by precipitous change in mechanical forces.


Centrifugal pumps
In 1973, the Biomedicus model 600 became the first disposable centrifugal pump head for
clinical use. The Biomedicus head contains a cone with a metal bearing encased in an outer
housing, forming a sealed unit through which blood can flow. When in use the head is seated
on a pump drive unit. The cone spins as a result of the magnetic force that is generated when
the pump is activated. The spinning cone creates a negative pressure that sucks blood into the
inlet, creating a vortex. Centrifugal force imparts kinetic energy on the blood as the pump
spins at 2000“4000 rpm (this speed is set by the user). The energy created in the cone creates
pressure and blood is then forced out of the outlet. The resulting blood flow will depend on
the pressure gradient and the resistance at the outlet of the pump (a combination of the CPB
circuit and the systemic vascular resistance of the patient). Flow meters are included in all
centrifugal pumps and rely on ultrasonic or electromagnetic principles to determine blood
flow velocity accurately (see Figure 1.6a“c).
Despite extensive research, there is little evidence to show any benefit of one type of pump
over another in clinical practice. Centrifugal pumps may produce less hemolysis and platelet
activation than roller pumps, but this does not correlate with any difference in clinical out-
come, including neurological function. They are certainly more expensive (as the pump head
is single use) and may be prone to heat generation and clot formation on the rotating surfaces
in contact with blood. In general, they are reserved for more complex surgery of prolonged
duration, during which the damage to blood components associated with roller pumps may
be theoretically disadvantageous.


Reservoirs
Cardiotomy reservoirs may be hardshell or collapsible. Hardshell reservoirs are most com-
monly used in adult cardiac surgery; collapsible reservoirs are still used by some institutions
8
Chapter 1: Equipment and monitoring



Figure 1.6. (a) Centrifugal pump. (b) Schematic
diagram of centrifugal pump. (c) Schematic cut
through centrifugal pump. (a, b Reproduced with
kind permission from Sorin Group.)




for pediatric and adult cases. Hardshell reservoirs usually comprise of a polycarbonate hous-
ing, a polyester depth filter and a polyurethane de-foamer. The reservoir component of the
CPB circuit therefore provides high-efficiency filtration, de-foaming and the removal of for-
eign particles (see Figure 1.7).
The reservoir acts as a chamber for the venous blood to drain into before it is pumped into
the oxygenator and permits ready access for the addition of fluids and drugs. A level of fluid is
maintained in the reservoir for the duration of CPB. This reduces the risks of perfusion acci-
dents, such as pumping large volumes of air into the arterial circulation if the venous return
to the CPB machine from the patient is occluded for any reason.
Blood that is scavenged from the operative field via the suckers is returned to the reservoir.
The salvaged blood is mixed with air and may contain tissue debris. It is therefore vital for this
blood to be filtered through the reservoir before being pumped to the patient. The reservoir
is constantly vented to prevent the pressure build-up that could occur if the suckers were left
running at a high level for the duration of the procedure. The salvaged blood from the vents
that the surgeon uses to prevent the heart from distending during CPB also returns to the
reservoir.
9
Chapter 1: Equipment and monitoring




Figure 1.7. Reservoir in CPB circuit.



Oxygenators
The present success of cardiac surgery relies heavily on extracorporeal perfusion techniques
employing an efficient gas exchange mechanism: the oxygenator. The requirements of the oxy-
genator include efficient oxygenation of desaturated hemoglobin and simultaneous removal
of carbon dioxide from the blood. The oxygenator therefore acts as an artificial alveolar-
pulmonary capillary system.
Gas exchange is based on Fick™s Law of Diffusion:
Diffusion coefficient Partial pressure difference
Volume of Gas diffused
Distance to travel
The oxygenator provides an interface of high surface area between blood on one side and
gas on the other. The distance gas has to travel across the interface is minimized by construct-
ing the membrane from very thin material.
In the early 1950s, attempts were made to oxygenate the blood using techniques such
as cross circulation between related humans, or using animal lungs for patients undergoing
open heart surgery. In 1955, DeWall and Lillehei devised the first helical reservoir to be used;
this was an early form of the bubble oxygenator. One year later, in 1956, the rotating disc
oxygenator was developed. In 1966, DeWall introduced the hardshell bubble oxygenator with
integral heat exchanger. Subsequently, Lillehei and Lande developed a commercially manu-
factured, disposable, compact membrane oxygenator.
Currently, most commonly used oxygenators are membrane oxygenators with a micro-
porous polypropylene hollow fiber structure. The membrane is initially porous, but proteins
in blood rapidly coat it, preventing direct blood/gas contact. The surface tension of the blood
also prevents plasma water from entering the gas phase of the micropores during CPB and
prevents gas leakage into the blood phase, thus reducing microemboli. However, after several
hours of use, evaporation and condensation of serum leaking through micropores leads to
10
Chapter 1: Equipment and monitoring




Figure 1.8. Schematic cut through an oxygenator.



reduced efficiency and therefore the majority of these types of oxygenators must be changed
after about 6 hours.
The majority of oxygenators consist of a module for gas exchange with an integrated
heat exchanger. An external heater“cooler pumps temperature-controlled water into the
heat exchanger, which is separated from the blood by a highly thermally conductive mat-
erial. This is biologically inert, to reduce the risk of blood component activation. The exter-
nal heater“cooler has digital regulating modules to allow precise control of temperature
through thermostat-controlled heating and cooling elements within the console. Con-
trolled cooling and re-warming of the patient are crucial to ensure an even distribution of
11
Chapter 1: Equipment and monitoring




Figure 1.9. Oxygenator combined with a reservoir and a heat exchanger in a single unit.




Figure 1.10 Rotameters on a CPB machine to regulate sweep gas flow.




12
Chapter 1: Equipment and monitoring



temperature throughout the body and to prevent damage to blood components, proteins
and tissues.
The Cobe Duo (Cobe Cardiovascular CML-Duo) adult cardiovascular membrane oxy-
genator comprises of a microporous polypropylene pleated sheet that has a prime volume of
approximately 250 ml and works on the principle of diffusion. Blood first passes over an inte-
gral heat exchanger, changes temperature and then moves into the oxygenator compartment.
Gas supplies of oxygen, air and carbon dioxide are delivered to the membrane in controlled
quantities. This “sweep” gas flows inside the fibers and has a higher concentration of oxygen
than venous blood on the outside of the fibers, enabling oxygen to move along a concentration
gradient across the membrane into the blood to create equilibrium. Carbon dioxide, which is
present in a high concentration in the venous blood, moves in the opposite direction, across
the membrane into the gas phase (see Figures 1.8 and 1.9). The exhaust gases are scavenged
from outlet ports on the back of the oxygenator.

Gas supply system
The gas supply system provides a source of oxygen, air and carbon dioxide to the oxygenator.
A blender mixes piped oxygen and air to the concentration set by the user, and the gas is deliv-
ered at a rate set on a flow meter (see Figure 1.10). Flow meters may be digital or mechanical
rotameters. An oxygen analyzer is included in the gas circuit to continuously display the con-
centration of oxygen delivered in order to prevent the inadvertent administration of a hypoxic
mixture. An anesthetic vaporizer may be incorporated, along with a means of scavenging
waste gases.

Filters and bubble traps
There are numerous filters that can be used within the extracorporeal circuit. These range
from 0.2 μm gas line filters to 40 μm arterial line filters (see Table 1.5).

Table 1.5. Filtration devices used within the cardiopulmonary bypass circuit

Filter type Application and specification
Gas line Removes 99.999% of bacteria found in the gas stream minimizing
cross-contamination between the patient and the equipment
Pre-CPB 0.2 μm filter is used during the priming and re-circulation phase. It is
designed for the removal of inadvertent particulate debris and microbial
contaminants and their associated endotoxins
Arterial line Designed to remove microemboli >40 μm in size from the perfusate during
extracorporeal circulation. This includes gas emboli, fat emboli and
aggregates composed of platelets, red blood cells and other debris
Leukodepletion Reduces the levels of leukocytes, either from the arterial line or cardioplegia
system, and excludes microemboli >40 μm
Cardioplegia Blood cardioplegia: >40 μm filter. Crystalloid cardioplegia: >0.2 μm filter. Low
priming volume filter for cell-free solutions. Removes inadvertent particulate
debris and microbial contaminants and their associated endotoxins
Blood transfusion Designed to reduce the levels of leukocytes and microaggregates from 1
unit of packed red blood cells or whole blood
Cell salvage Designed for the filtration of salvaged blood to remove potentially harmful
microaggregates, leukocytes and lipid particles
Adapted from Pall product specifications 2007.

13
Chapter 1: Equipment and monitoring



Table 1.6. Different commercially available arterial line filters

Manufacturer Filter type Fiber material Filter size (μm)
Bentley Screen Heparin-coated polyester 25
Delta Screen Nylon 40
Lifeline-Delhi Screen Unspecified 40
Pall Screen Heparin-coated polyester 40
Swank Depth Dacron wool 13



Arterial line filters are the most commonly used additional filtration devices. They are
indicated for use in all CPB procedures and there are a number of filters available with slightly
different characteristics (see Table 1.6).
Screen filters remove particles by mechanical retention and impaction. They have a specific
pore size and remove air by velocity separation and venting. Swank is the only manufacturer
of depth filters at present. This type of filter creates a tortuous path between fibers and retains
particles mechanically. There is not normally a specific pore size. Air is removed by entrap-
ment during transit of blood through the pathway between fibers.
The US Food and Drug Administration (FDA) have outlined key areas of importance
pertaining to arterial line filters (FDA, 2000). These are summarized as follows:
• amount of damage to formed blood elements, for example, clotting and hemolysis;
• degree of pressure drop resulting in inadequate blood flow, damage to the device,
structural integrity and damage to the arterial line;
• structural integrity of the product;
• excessive pressure gradients, for example, blood damage and inadequate blood flow;
• filtration efficiency and gas emboli-handling capacities;
• user error;
• blood incompatibility and the requirements of ISO 10993: Biological Evaluation of
Medical Devices;
• compatibility of the product when exposed to circulating blood and infections; and
• shelf life.
These stringent criteria aim to ensure the production of high-quality arterial line filters
that will not have any deleterious effects on the CPB circuit or patient.


Suckers and vents
The suckers attached to the CPB circuit allow blood to be salvaged from the operative field to
be returned to the circuit via the reservoir.
“Vent” suckers are specifically used to drain blood that has not been directly removed
from the heart by the venous pipes. The most common sites for placing dedicated vents are:
• the aortic root;
• the left ventricle;
• the right superior pulmonary vein;
• the left ventricular apex; and
• the left atrium or pulmonary artery.
14
Chapter 1: Equipment and monitoring



There are a number of reasons for venting the heart during CPB:
• to prevent distension of the heart;
• to reduce myocardial re-warming;
• to evacuate air from the cardiac chambers during the de-airing phase of the procedure;
• to improve surgical exposure; and
• to create a dry surgical field, especially during the distal coronary anastamosis phase of
CABG surgery.
There are complications associated with all sites used for venting, most commonly relating
to injury to tissues at the site. Venting via the left ventricular (LV) apex, however, is associated
with particularly serious consequences including:
• damage to the LV wall due to excessive suction;
• LV wall rupture if inadequately closed at the end of the bypass period; and
• embolization through air entrained into the LV.
Active venting with high levels of suction can lead to air being introduced into the arte-
rial side of the CPB circuit due to a small percentage of air sucked into the venous side of the
reservoir and oxygenator passing through the circuit into the arterial side. Therefore, suction
pressure and duration should be kept to a minimum.


Cardioplegia delivery systems
One of the major concerns during cardiac surgery is protection of the heart during the
operation. Myocardial protection is discussed more fully in Chapter 7. During the period
in which the heart is devoid of blood supply, the myocardial cells continue to utilize high-
energy phosphates (adenosine triphosphate, ATP) to fuel metabolic reactions anaerobi-
cally. This results in depletion of energy reserves and the build up of products of anaero-
bic metabolism, such as lactic acid. These processes decrease myocardial contractility
in the period immediately following restoration of blood flow and myocardial function
remains compromised until ATP reserves are restored and the products of anaerobic
metabolism decline in concentration. Preservation of myocardial function during the
ischemic period, that is, during the period in which the aorta is cross-clamped, is best
achieved by putting the heart into a state of hibernation using a solution “ generically
termed “cardioplegia.” The purpose of cardioplegia is to cause rapid diastolic cardiac
arrest. This produces a still, flaccid heart, which facilitates surgery and also is the state
in which myocardial metabolism is almost at its lowest levels. Further reduction in the
metabolic state of the heart is achieved by cooling using cold cardioplegia and also by core
cooling of the body.
The common constituent of all cardioplegia solutions is a high concentration of potassium,
as this produces diastolic cardiac arrest. The other constituents of cardioplegia vary widely
from normal saline solution to blood mixed with complex antioxidants. The delivery of cardi-
oplegia may be as a single bolus, intermittent boluses or continuous infusion or combinations
of all three. The administration techniques have progressed from un-monitored pressurized
delivery into the root of the aorta; current practice is discussed more fully in Chapter 7. The
delivery sites for the cardioplegia vary according to surgical preference and the operation
being performed and include: directly into the aortic root, the coronary ostia, the saphe-
nous vein graft or retrograde via the coronary sinus. The flow rates and pressures that
the cardioplegia solution is delivered at will vary depending on the mode of delivery.
15
Chapter 1: Equipment and monitoring




Figure 1.11 (a) Double-lumen aortic root cannula, which can be used to deliver cardioplegia and as an aortic root
vent. (b) Retrograde cardioplegia delivery cannula. (c) Schematic drawing of antegrade and retrograde cardioplegia
delivery. (Reproduced with kind permission from Edwards Lifesciences.)




16
Chapter 1: Equipment and monitoring



Figure 1.12 Cardioplegia
delivery system: allows mixing of
blood and cardioplegia solution
and warming or cooling of solu-
tion before application.




Table 1.7. Cardioplegia delivery systems

Integrated heat
Manufacturer exchanger Air trap removal Delivery system
Sorin Yes Yes Blood cardioplegia 4:1 ratio
via roller pump
Medtronic Yes Yes Blood cardioplegia 4:1
ratio via roller pump (can
also be used with a syringe
driver for the potassium
solutions)
Lifeline-Delhi Yes Yes Blood cardioplegia 4:1 ratio
via a roller pump
Aeon Medical Yes Yes Blood cardioplegia 4:1 ratio
via a roller pump



Different types of cannulae are available for delivery of cardioplegia via the various sites
(see Figure 1.11).
Many different designs of cardioplegia delivery systems are available (see Figure 1.12).
Almost all of the systems allow delivery of warm and cold solutions and allow the mixing of
crystalloid solutions with blood (see Table 1.7). The systems also allow the monitoring of the
cardioplegia infusion line pressure. This is essential when delivering cardioplegia into small
vessels and the coronary sinus to prevent damage.

Hemofilters
Also known as ultrafilters or hemoconcentrators, these contain semipermeable membranes
(hollow fibers) that permit passage of water and electrolytes out of blood. They are normally
17
Chapter 1: Equipment and monitoring



Figure 1.13 Hemofilters.
(Reproduced with kind permis-
sion from Sorin Group.)




connected to the CPB circuit at a high pressure port or line, such as the systemic flow line, to
provide a driving force for blood through the device. This allows blood to be filtered before
being returned to the patient. Fluid removal is usually 30 to 50 ml/minute, and depending on
the membrane used, molecules of up to 20 000 Daltons are removed. Hemofiltration may be
used during or after CPB, mainly to manage hyperkalemia or acidosis, but also to concentrate
the blood if the hematocrit (HCT) is low and circulating volume is adequate (see Figure 1.13).

Monitoring
Extracorporeal perfusion techniques require a large amount of vigilance from the entire team
involved in the patient™s care. Setup and safety features during CPB are discussed in more
detail in Chapter 2.

In-line blood gas analysis and venous saturation/hematocrit monitors
The theoretical advantages of using continuous in-line blood gas and electrolyte monitoring
during CPB are well established; however, the clinical impact remains controversial. These
devices may be divided into those using electrochemical electrodes and cuvettes, which are
placed in the circuit, and those that use light absorbance or reflectance, which require sensors
placed external to the circuit tubing.
18
Chapter 1: Equipment and monitoring




Figure 1.14 Terumo CDI 500 in-line monitoring system, providing real-time blood gas, acid/base, Hb/HCT and
electrolyte analysis.




The Terumo CDI 500 in-line blood gas analyzer is an optical fluorescence and reflectance
based in-line system that continuously monitors 11 critical blood gas parameters with labo-
ratory quality accuracy (see Figure 1.14). This level of sophistication and accuracy is, not sur-
prisingly, expensive, and is reserved in many centers for particularly complex or prolonged
cases “ such as when gas analysis is changed from alpha-stat to pH-stat during the cooling or
re-warming periods of procedures involving deep hypothermic circulatory arrest (DHCA).
There are more basic and commonly used forms of in-line monitoring available for use
during CPB. Venous and arterial blood oxygen saturations can be continuously monitored
during CPB using devices that rely on the absorbance or reflectance of infrared light signals.
Although not always completely accurate, these devices are a valuable tool for observing and
recording trends.
Non-invasive simultaneous arterial and venous saturation monitors are also available
for use during CPB (see Figure 1.15). These have sensors that clip onto the outside of the
venous and arterial tubing and continuously display venous and arterial saturations simul-
taneously on a computerized screen that is mounted on the frame of the CPB circuit. These
tools all aid safe perfusion practice and are used in conjunction with laboratory blood gas
analysis.
19
Chapter 1: Equipment and monitoring




Figure 1.15 Spectrum Medical in-line real-time saturation and Hb monitoring system.




Alarms
Ideally all alarm systems are linked into the computer system of the CPB circuit and directly
regulate or stop the pump flow when appropriate. The alarm systems used within the circuit
aid the perfusionist in running a safe pump and are all vital components of the circuit.
The alarms are engaged prior to initiating CPB and are not turned off, or over-ridden, until
the patient has been weaned from CPB. The perfusionist, in an analogous fashion to a pilot,
is the main safety device for the CPB circuit and constantly monitors all of the parameters
associated with running the pump.


Mini bypass system
There has been some recent interest in the development of miniature extracorporeal
circuits (see Figure 1.16a). These are designed to reduce foreign surface area, priming
volume (as little as 500 ml) and blood-air contact. This leads to decreased hemodilution, and
thus reduced blood transfusion requirements, and may reduce the inflammatory response
to CPB.
20
Chapter 1: Equipment and monitoring




Figure 1.16 (a) Mini bypass system. (b) Schematic drawing of mini bypass circuit. (Reproduced with kind permission
from Sorin Group.)


21
Chapter 1: Equipment and monitoring



Such circuits usually do not include a reservoir, heat exchanger and cardiotomy suction
but increasingly incorporate arterial filters (see Figure 1.16b). Research and further develop-
ment is ongoing, but early trials have been promising, some demonstrating a reduced release
of vasoactive substances and a reduced activation of the coagulation cascade.

• Gibbon JH Jr. Development of the artificial
Suggested Further Reading heart and lung extracorporeal blood circuit.
• Anderson KS, Nygreen EL, Grong K, et al. JAMA 1968; 206: 1983“6.
Comparison of the centrifugal and roller
• Kmiecik SA, Liu JL, Vaadia TS, et al.
pump in elective coronary bypass surgery: a
Quantative evaluation of hypothermia,
prospective randomized study with a special
hyperthermia and hemodilution on
emphasis upon platelet activation. Scand
coagulation. J Extra Corpor Technol 2001;
Cardiovasc J 2003; 37: 356“62.
33: 100“5.
• Black S, Bolman RM III. C. Walton Lillehei
• Mejak BL, Stammers A, Rauch E, et al.
and the birth of open heart surgery. J Card
A retrospective study on perfusion
Surg 2006; 21: 205“8.
incidents and safety devices. Perfusion 2000;
• Driessen JJ, Dhaese H, Fransen G, et al. 15: 51“61.
Pulsatile compared with non-pulsatile
• Mulholland JW, Shelton JC, Luo XY. Blood
perfusion using a centrifugal pump for
flow and damage by the roller pumps
cardiopulmonary bypass during coronary
during cardiopulmonary bypass. J Fluid
artery bypass grafting: effects on systemic
Struct 2005; 20: 129“40.
haemodynamics, oxygenation and
• Peek GJ, Thompson A, Killer HM, et al.
inflammatory response parameters.
Spallation performance of extracorporeal
Perfusion 1995; 10: 3“12.
membrane oxygenation tubing. Perfusion
• Fried DW. Performance evaluation of
2000; 15: 457“66.
blood-gas exchange devices. Int Anesthesiol
Clin 1996; 34: 47“60.




22
Circuit setup and safety checks
Chapter
Simon Colah and Steve Gray


2
Assembling the CPB circuit and checking the CPB machine for faults prior to clinical use
is an essential part of the provision of extracorporeal perfusion. This chapter describes the
procedure for “setting up” the CPB system and the safety checks that should be undertaken
before embarking on a case.
Philip Kay and Christopher Munsch (2004) in “Techniques in Extracorporeal Circulation”
state: “Cardiopulmonary bypass is a dynamic artificial environment conferring a shock state
on the body with its own potential for severe morbidity and mortality.” Vigilance is thus para-
mount to the conduct of cardiopulmonary bypass. Modern perfusion systems are designed to
optimize safety. Technological advances have seen the incorporation of automatic alarms and
fail-safe devices; however, the perfusionist™s attention to detail and observance of prebypass
checklists and protocols still underpins safe practice. Human error is a far greater cause of
accidents than mechanical mishap.
Preparing the CPB circuit and machine, attention to the patient™s clinical details and the
surgical requirements for the procedure all form part of the process of safe provision of car-
diopulmonary bypass. By necessity the preparation of the CPB machine and assembly of the
disposable circuit components should be “ritualistic” following a routine dictated by institu-
tional protocols.

CPB machine preparation and circuit setup
CPB circuits are made up of a number of disposable items. Principally these are:
• the integrated membrane oxygenator/hardshell (or softshell) venous reservoir:
• cardioplegia set;
• arterial line filter; and
• custom tubing pack.
All components are rigorously checked. In particular, the disposable items are closely
examined with regard to expiry date and integrity of the packaging.
There are many ways to set up a CPB circuit. Departmental preferences and specific patient
requirements dictate the approach. A commonly used sequence for setting up and priming a
standard CPB system is outlined in Appendix 2A, together with a synopsis of electronic safety
devices in Appendix 2B, at the end of this chapter.
Securing the gas hoses to the gas source, checking that gas supplies of air and oxygen are
functional and attaching the scavenging line initiates the process. The CPB machine console
is then powered and temporarily disconnected to ascertain that the power failure alarm and
backup battery unit are fully functional. Most operating rooms have an uninterruptible power
supply (UPS), essentially a series of batteries linked to the hospital generator that powers the
CPB machine, anesthetic machine, intravenous infusion pumps and other vital equipment
23
Cardiopulmonary Bypass, ed. S. Ghosh, F. Falter and D. J. Cook. Published by Cambridge University Press.
© Cambridge University Press 2009.
Chapter 2: Circuit setup and safety checks



should there be a mains power failure. It must be ensured that the CPB machine is connected
to a UPS.
The integrated oxygenator/venous reservoir is placed on its secure holder and orien-
tated to allow full view of the reservoir. The oxygen/air delivery line and scavenging hose are
attached to the appropriate ports on the base of the oxygenator. The sampling port manifold
is positioned with taps secured. Tubing to the dedicated systemic, arterial flow pump is put
into place and connected to the venous reservoir outlet and oxygenator inlet. The cardiople-
gia tubing is positioned, but not aligned at this stage, in the designated pump backplate. This
expedites the priming of the cardioplegia circuit. The cardioplegia delivery system differs
from the systemic flow pump or sucker pumps in that a pump which accommodates two seg-
ments of tubing with varying diameters within it may be used, so that blood and cardioplegia
mixed in the desired ratio (usually 4 parts blood to 1 part cardioplegia) can be dispensed.
Alternatively, two separate pumps may be used to independently deliver the blood and car-
dioplegia in a 4:1 ratio.
Roller pump heads are checked to ensure that they only rotate in one direction.
The arterio-venous loop (A-V loop), which when divided will be connected to the venous
and arterial cannulae by the surgeon, is connected to the venous reservoir inlet and oxygena-
tor outlet. The arterial line filter (with bypass link), pressure transducer and bubble detector
are attached to the systemic flow tubing (see Fig. 1.1). The bubble detector is coupled to the
CPB machine console so that if air is sensed in the arterial line an alarmed automatic pump
cut out facility is activated. Likewise, the transduced pressure in the arterial line links to the
CPB machine console, so that if the line pressure exceeds a set limit (usually 350 mmHg),
through unintentional clamping or kinking, the pump will stop. This is preceded by slowing
of the pump at a slightly lower pressure threshold (usually 300 mmHg). Suction and vent-
ing tubing (color coded for safety and ease of use) are then fixed into the various roller head
assemblies. Two sets of water lines from the heater“cooler unit are attached to the oxygenator
and blood cardioplegia heat exchange device. Water is circulated to ensure that there is no
dangerous water leak.
The cardioplegia pressure transducer and purge lines are connected to the cardioplegia
delivery device.
Just prior to priming, the arterial line filter is flushed with CO2. Once flushed, the CO2 is
turned off and disconnected, the arterial line filter inlet and outlet and the cardioplegia deliv-
ery line are clamped off. The arterial line should also be clamped if there is a re-circulation shunt
line distal to the arterial line filter. Some centers flush the whole circuit with CO2 to displace
air. This reduces the risk of gaseous emboli as carbon dioxide is nearly 30 times more soluble
in blood than nitrogen.
One to two liters of prime fluid is added to the venous reservoir. The arterial pump is
turned on at approximately 4“5 l/minute whilst the perfusionist observes prime filling the
pump tubing, the oxygenator and any ancilliary lines. These must be closed or clamped after
priming whilst fluid re-circulates via the arterial re-circulation line back into the venous res-
ervoir. The arterial pressure dome is primed and secured to the transducer, the arterial line
filter is retrogradely primed and its bypass line clamped. Flow through the A-V loop is estab-
lished, left-recirculating and inspected for air bubbles, before clamping the re-circulation
line. It is necessary to ensure that the cardioplegia circuit is primed and air free and that the
pump occlusions have been adjusted, so that they are just “under-occlusive.” The arterial and
venous lines are then clamped and the prime allowed to re-circulate through the filter and
purge lines.

24
Chapter 2: Circuit setup and safety checks



There are two ways to check the roller heads for occlusion: either check each roller at the “6
o™clock” position or together at the “9.15” position, with the circuit pressurized at 250 mmHg
and the arterial line clamped. Any rapid drop in pressure may indicate that connections are
not secure or that an “occlusion” has been incorrectly set. Centrifugal pumps are non-occlu-
sive and should be gravity filled to ensure good de-airing. Centrifugal consoles have inte-
grated flow probes that are unidirectional. As they are afterload sensitive, pump speed must
be set to produce forward flow before initiating bypass.
The inflow to the sucker pumps is clamped and the rollers are adjusted to avoid collapse of
the tubing. The vent line should have a one-way pressure relief valve in-line to prevent inad-
vertent air entry into the heart and to prevent cavitation inside cardiac chambers.
Temperature probes are placed into the arterial, venous and cardiolegia ports and visual-
ized on the LED display. The level sensor is placed at, or above, 400 ml and the bubble detector
placed on the arterial line distal to the filter. All alarms, pressure ranges, timers and cardiople-
gia parameters can now be set in preparation for bypass.


Design and use of a prebypass checklist
Experience from other high-risk industries, such as aviation or maritime, demonstrate that
disasters are often associated with poor checking procedures. The format of the CPB checklist
is either written or automated and best signed off by two perfusionists. Ideally, the primary
perfusionist does the checking whilst the second perfusionist works through the list. The
American Society of Extracorporeal Technology and the European Board of Cardiovascular
Perfusion publish an excellent array of perfusion guidelines and checklists (see Figure 2.1). As
expected the list is comprehensive yet targeted, covering all aspects from sterility to backup
components.


Safety concerns prior to, during and after CPB
Before embarking on a case the perfusionist should review the patient™s notes. The most
important details are:
• planned procedure and likelihood of additional procedures;
• allergies;
• significant comorbid conditions, such as diabetes or renal dysfunction; and
• metabolic or hematological abnormalities, such as anemia, thrombocytopenia or
hyperkalemia.
The patient™s blood group should be confirmed and the availability of bank blood
checked.
Details of the patient™s height and weight are essential to calculate:
• dose of heparin (usually 300 mg/kg) required for CPB;
• body surface area (BSA) in square meters, which is required to determine the “ideal”
flow rate at normothermia (BSA — cardiac index) and so to select appropriately sized
venous and arterial cannulae; and
• predicted HCT on initiation of CPB
Safety issues relating to the pre-, intra- and post-CPB periods are summarized in Tables
2.1, 2.2 and 2.3, respectively.

25
Chapter 2: Circuit setup and safety checks



Figure 2.1. Prebypass
checklist. The European Board of
Pre-bypass checklist
Cardiovascular Perfusion (EBCP)
promotes the use of prebypass
ID:_____________________
Patient: _____________________
checklists in the practice of clini-
ID correct
cal perfusion. The suggestions
Monitoring
Chart reviewed in this checklist are designed
Temperature probes positioned
as the minimum requirements
Pressure transducers calibrated
Sterility
for cardiopulmonary bypass
In/on-line sensors calibrated
Components: integrity and expiry
procedures and each institution
date should adapt this to suit its own
Safety & alarms
requirements. The EBCP can
Low-level alarm engaged
Heart-lung machine
accept no liability whatsoever for
Air detector engaged
Power connected
the adoption and practice of this
Pressure alarm limits set
Start-up normal suggested checklist. (Repro-
Temperature alarm limits set
Back-up power duced by kind permission of The
Cardiotomy reservoir vented European Board of Cardiovascu-
Heater-cooler
lar Perfusion: http://www.ebcp.
Oxygenator
Start-up normal org)
Gas line attached
Water connections: flow verified
Heat exchanger integrity inspected
Water temperature: _______° C/F
Scavenger attached
Gas supply
Debubbling
Gas lines connected
Tubing
Flow meter/blender in order
Oxygenator
Vaporizer shut off
Cardioplegia
CO2 flush
Arterial filter/bubble trap
Pump
Accessories
Roller heads not obstructed
Tubing clamps
Flow meter: calibration & direction
Hand cranks
Tubing holders secure
Backup circuit components
Occlusion set : ______ mmHg
______cmH20/min
Anticoagulation
Heparin in: _______time
Tubing
Patient properly anticoagulated
Pump tubing condition inspected
Ready to start bypass
Suckers functional and sucking
One-way valves: direction correct
Circuit shunts closed Signature: ..........................................




Table 2.1. Pre-CPB safety concerns

Heparin given, activated clotting time (ACT) >400 seconds
Arterial cannula correctly placed, pulsatile swing on an anaeroid pressure gauge connected to a side arm of the
arterial line
Venous reservoir has a safe level of prime, additional fluid available to add, low level alarm activated
Oxygen analyzer monitoring gas supply to oxygenator on, alarm activated
Sweep rate appropriate for patient (usually 2“3 l, FiO2 = 0.6)
Venous cannula relatively free of air
Shunt lines are clamped, apart from arterial filter purge line and drug administration manifold line
No clamps on the arterial or venous lines placed by surgical team
Alarm overrides deactivated
Vasopressors prescribed and available

26
Chapter 2: Circuit setup and safety checks



Table 2.2. Safety concerns during CPB

Concern Common causes
Low level alarm on venous reservoir Impaired venous return
Tubing kinked
Air lock
Hemorrhage
Misplaced venous canula
Clotting within circuit
High-pressure alarm on arterial line Clamping or kinking of line
Manipulation of the aorta
Clotting within circuit
Aortic dissection
Bubble alarm Air in line
Sensor malfunction
Low mixed venous oxygen saturation Erratic flow
Considerable time spent with suboptimal flows
Hemorrhage
Depth of anesthesia lightening
Shunt clamp inadvertently removed
Excessive transfusion with non-blood products
Clotting Inadequate heparinization
Poor blood gasses despite adequate Oxygenator failure
sweep gas delivery and pump flow
Electrical activity of the heart Intervals between cardioplegia too long
Too little cardioplegia delivered
Aortic regurgitation
Hyperthermia Overaggressive re-warming strategy
Failure to maintain temperature gradient between heat
exchanger and venous blood <10°C


Table 2.3. Safety concerns on separating from CPB

Ventilation not established
Intracardiac vent still in place
Shunt lines open on CPB with the potential to exsanguinate the patient into circuit
Suction still in use during protamine administration
Inattention to level in venous reservoir whilst transfusing
Draining the venous line while cannula still positioned in the right atrium
Dismantling the CPB circuit before hemodynamic stability has been achieved




27
Chapter 2: Circuit setup and safety checks



Table 2.4. Key factors contributing to a safer perfusion service

Accreditation of training programs
Certification and re-certification of perfusionists
Conferences, yearly appraisals, departmental quality assurance meetings
Reporting of adverse occurrences
Quality in-house training
Electronic data acquisition with associated audit facilities
Departmental protocols, especially outlining procedures in abnormal and emergency situations
Manufacturer product alerts acted on
Equipment maintenance records and quality assurance logs kept


Conclusion
Surveys by Jenkins et al. (1997) and Mejak et al. (2000) report the number of pump-related
incidents to be 1:140 and the likelihood of permanent injury or death of the patient after such
an incident to be 1:1350. A multitude of healthcare organizations, not least the Institute of
Medicine (IOM), have called for a 90% reduction in preventable patient injuries.
Since the introduction of CPB in the early 1950s the focus on safety has evolved
and improved. Today, the quality of components is excellent. CPB machines incorporate in-
built alarms with auto-regulatory feedback systems, together with real-time data acquisition.
Yet surveys confirm the mishap rate is slow to fall. Accredited training, scrupulous attention
to detail and use of checklists and protocols will hopefully continue to improve safety. The key
factors contributing to a safer perfusion service are summarized in Table 2.4.

Appendix 2A: Procedure for setting up and priming a
standard heart“lung bypass system
(Adapted, with permission, from London Perfusion Science Protocols.)

2A.1: The heart“lung machine and accessories
2A1.1: Connection checks
(a) All cables, plugs and sockets are checked
(b) All cables should be laid neatly, so that they are not likely to be damaged and where
they are least likely to cause accidents
(c) All parts of the apparatus, including heater/chiller and pump light (if it is to be used)
are checked for power
(d) Gas lines are fitted to the wall outlets and connections, hoses, mixers and flow meters
are checked for leaks
(e) Gas flow to the oxygenator is checked

2A1.2: Pump head checks
Each pump head is checked:
(a) For power
28
Chapter 2: Circuit setup and safety checks



(b) The rollers and guides are moving
(c) The pump heads are free from foreign bodies
(d) The pump heads are set to rotate in the correct direction
(e) The flow/rpm settings on the console are accurately calibrated
(f) For winding handles
(g) That the tubing inserts are of the correct size for the tubing to be used


2A1.3: Checks that other electrical safety devices are in working order
(a) Battery backup (UPS) is charged
(b) Pressure transducers
(c) Level detectors
(d) Bubble detectors


2A.2: The setup of disposable heart“lung equipment
2A2.1: The oxygenator
(a) Remove packaging and check its integrity and sterility
(b) The oxygenator is examined for obvious faults and debris
(c) The oxygenator is placed securely into its holder
(d) Any gas outflow cap is removed
(e) The gas connection is made
(f) Remove any venting cap on the reservoir
(g) The CO2 flush is initiated until priming
(h) The water connections to the heater/chiller are now made, the heat exchanger and all
connections are checked for leaks with the water running at 37°C


2A2.2: The circuitry
(a) Remove packaging and check its integrity and sterility
(b) The circuitry is checked for faults (cracked connectors, kinked tubing, etc.)
(c) Check the silicone pump boot and place so it is lying correctly in order to prevent
wear or damage from the tube guides or rollers
(d) Check that the pump boot tube is securely held at both the outlet and the inlet.
Rotate the pump to check the tubing is correctly seated
(e) Do the same with sucker tubing, checking direction of flow
(f) With attention to sterile technique, connect the pump lines to the oxygenator, ensure
they have been connected in the correct direction and not crossed over
(g) The lines should be sufficiently long so that they may be moved to the neighboring
pump head if necessary
(h) Any cuts to tubing should be made cleanly and perpendicular to the length of the
tubing, using a sterile blade
(i) The outflow line should now be connected to the outflow port of the oxygenator
(j) The re-circulating lines should now be similarly connected as required by manufac-
turer™s specifications
(k) All pressure connections can be made secure using nylon ties
29
Chapter 2: Circuit setup and safety checks

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