Role of Perfusionist in Cardiac Surgery PDF

P res e nt e d by: T hit ipho ng Ra k s ak i t  Operation of Cardiac surgery in adult 0 1 Operati on of Cardiac surger y i n adult Principle of Cardiopulmonary bypass 0 2 Pri nc ipl e of Cardiopulmonary bypass Cardiopulmonary bypass management 0 3 Cardiopulmonary bypass managem ent Extr...

P res e nt e d by: T hit ipho ng Ra k s ak i t  Operation of Cardiac surgery in adult 0 1 Operati on of Cardiac surger y i n adult Principle of Cardiopulmonary bypass 0 2 Pri nc ipl e of Cardiopulmonary bypass Cardiopulmonary bypass management 0 3 Cardiopulmonary bypass managem ent Extracorporeal circulation in Thoracic Aortic surgery 0 4 Extracorporeal circulati on in Thorac ic Aortic surgery 0 5 Cell Saver  AVR CABG MVR Valve MV repair Open TVA Heart Congenital Simple (ASD , VSD) Surgery Complex Ascending AO Aorta Arch of AO Other Descending AO Operation of Cardiac surgery in adult Bypass conduit Internal mammary artery (LIMA , RIMA) Radial artery Saphenous vein Gastroepiploic artery Operation of Cardiac surgery in adult Vein to Vein Y graft sequential graft Operation of Cardiac surgery in adult Operation of Cardiac surgery in adult Operation of Cardiac surgery in adult Operation of Cardiac surgery in adult Principle of Cardiopulmonary bypass 1. Inability to operate on a heart that was still beating. 2. Stop and Restart heart less than 3 min. Principle of Cardiopulmonary bypass First use of Hypothermia in adult and pediatric open heart surgery. Principle of Cardiopulmonary bypass Dr. Lillehei initiated Cross-Circulation : linked the two Circulatory systems between child and adult donor. Principle of Cardiopulmonary bypass John H. Gibbon, on May 20, 1953, ASD. The first successful application in humans. P ri ncip le of C ardi op ulm ona r y bypas s P ri ncip le of C ardi op ulm ona r y bypas s P ri ncip le of C ardi op ulm ona r y bypas s Heart Lung Machine Heater Cooler Gas Blender Tubing Set Cardioplegia Set Hemoconcentator Arterial Filter Oxygenator P ri ncip le of C ardi op ulm ona r y bypas s Principle of Cardiopulmonary bypass Role of Cannulas - Venous Cannula - Aortic Cannula - Suction Cannula - Vent Cannula - Cardioplegia Cannula - Other Accessory Principle of Cardiopulmonary bypass Venous Cannula Principle of Cardiopulmonary bypass Used in case : CABG AVR Aorta Two Stage Venous Cannula (Single Caval) Principle of Cardiopulmonary bypass Single Stage Used in case : Venous Cannula (Bi Caval) MV repair MVR TV repair ASD VSD Principle of Cardiopulmonary bypass Femoral Venous Cannula Principle of Cardiopulmonary bypass Aortic Cannula Principle of Cardiopulmonary bypass Femoral Aortic Cannula Principle of Cardiopulmonary bypass Vent Cannula Principle of Cardiopulmonary bypass Suction Cannula Principle of Cardiopulmonary bypass Antegrade Cardioplegia Cannula Principle of Cardiopulmonary bypass Retrograde Cardioplegia Cannula Principle of Cardiopulmonary bypass Direct Cardioplegia Cannula Principle of Cardiopulmonary bypass Cardioplegia Adaptor Multiple perfusion Y type adaptor Principle of Cardiopulmonary bypass Other Accessory in CABG Aortic Punch Principle of Cardiopulmonary bypass Other Accessory in CABG Coronary Suction Principle of Cardiopulmonary bypass Other Accessory in Valve replacement Valve sizer Principle of Cardiopulmonary bypass Other Accessory in Valve repair Ring sizer Principle of Cardiopulmonary bypass Other Accessory in Aortic Dissection / Aneurysm Distal perfusion Adaptor Principle of Cardiopulmonary bypass Other Accessory in Open Chamber Case A picture containing indoor Description automatically generated CO2 Circuit Cardiopu lmon ary byp ass managem en t Surgical Procedure Incision & Cannulate & Median ON CPB On AOX Connect to HLM sternotomy De-air & Maintain Start Start OFF AOX Cardioplegia Procedure Cardioplegia Wean De-cannulate OFF CPB & Stop bleed Cardiopu lmon ary byp ass managem en t CPB TIME ON CPB On AOX De-air & Maintain Start Start OFF AOX Cardioplegia Procedure Cardioplegia Wean OFF CPB Cardiopu lmon ary byp ass managem en t AOX TIME On AOX De-air & Maintain Start Start OFF AOX Cardioplegia Procedure Cardioplegia 01 Pharmacology & Fluid management 02 Temperature management 03 Acid - base management 04 Hemodynamic management 05 Myocardial protection Patient 3 mg/kg Dose 3 mg/kg CPB circuit 1 mg/kg - is a heparin antagonist Before Canulation ACT > 200 sec - produced from the sperm of salmon Before on Suction pump ACT > 300 sec Before on CPB ACT > 480 sec Pharmacology & Fluid management ACT baseline Cannulation On Pump Bolus Heparin (80-120 sec) 3 mg/kg by Anest (ACT > 200 sec) Suction (ACT > 300 sec) Maintain OFF CPB ACT > 480 mins Start Procedure ON CPB (check ACT or Heparin 1 mg/kg ACT > 460 or 480 sec every 1 hr.) Start De-cannulation Check ACT Protamine 3 mg/kg Pharmacology & Fluid management Vasopressor Pharmacology & Fluid management Vasopressor SVR Vasodilator SVR ▪ Levophed® / Norepinephrine ▪ Sevoflurane ▪ Phenylephrine ▪ Nicardipine ▪ Adrenaline / Epinephrine ▪ Ephedrine Pharmacology & Fluid management KCL 𝚫𝑲 ×𝑩𝑾 ×𝟎.𝟑 KCL = 𝟐 โดยที่ 𝚫𝑲 = 𝟒 − 𝑲ล่าสุด Cardiopu lmon ary byp ass managem en t Magnesium Sulfate Regular Insulin, RI Lidocaine Pharmacology & Fluid management Mannitol 20% 20% Albumin Dose 3-5 cc/kg Priming 4 cc/kg Before off CPB 1 cc/kg Pharmacology & Fluid management FLUID MANAGEMENT CRYSTALLOIDS Adequate hemodilution allowing cooling safely Reduces colloid osmotic pressure leading to extracellular water retention COLLOIDS Albumin coats circuit surfaces- reducing interaction of blood components, HCT during CPB reduces platelet activation and destruction Adult (Europe) 20 - 25 % Adult (Asian) 25 - 30 % Pediatric 30 - 35 %  Pharmacology & Fluid management Volume Overload with Low Hct Conventional Ultrafiltration (CUF) CKD or ESRD Hemodialysis Modified Ultrafiltration (MUF) Electrolyte imbalance Zero balance Ultrafiltration (Z-BUF) Hemoconcentator Pharmacology & Fluid management Conventional Ultrafiltration (CUF) Pharmacology & Fluid management Zero balance Ultrafiltration (Z-BUF) Pharmacology & Fluid management Hemodialysis Dialysate 0.45% NSS 1,000 ml 3% Sodium chloride 50 ml Sodium bicarbonate 50 ml Pharmacology & Fluid management Modified Ultrafiltration (MUF) Temperature management Classification of hypothermia ๐ Normothermia 36.5 – 37.5 C ๐ Mild hypothermia 32 – 35 C ๐ Moderate hypothermia 26 – 31 C ๐ Deep hypothermia 20 – 25 C ๐ Profound hypothermia < 20 C Rapid rewarm and Cooldown → cerebral injury and Micro air embolism ๐ 1. Core temp. (No different 4 C ) - Nasopharyngeal or Esophagus temp. - Rectal Temp. ๐ 2. Blood temp. & Water temp. (No different 10 C ) Nasopharyngeal temp. < 37.5 °C Rectal Temp. acceptable range of 35.5°C – 36.5°C Heater Cooler Acid-base management Respiratory Acidosis / Alkalosis 𝑃𝐶𝑂2 ×𝑮𝒂𝒔 𝒇𝒍𝒐𝒘 Adjusted gas flow = 𝟒𝟎 𝑃𝑎𝑂2 adjusted by 𝐹𝑖𝑂2 (Normal 200 – 300 mmHg) Gas flow 𝑭𝒊𝑶𝟐 Acid-base management Metabolic Acidosis / Alkalosis 𝑩𝑬 × 𝑩𝒘 Metabolic Acidosis = add 𝑁𝑎𝐻𝐶𝑂3 ( ) 𝟒 (Keep 𝐻𝐶𝑂3 = 22-26 mmol/L and BE ± 2) Metabolic Alkalosis = Stop Diuretic drug Acid-base management pH 7.35 – 7.45 𝑃𝐶𝑂2 35 – 45 mmHg 𝐻𝐶𝑂3 22-26 mmol/L BE ±2 Sa𝑂2 100 % Sv𝑂2 >75 % Glucose < 200 mg/dL Lactate < 2 mmol/d + 𝑵𝒂 135 – 145 mEq/L + 𝑲 3.5 – 5.0 mEq/L  Hemodynamic management A - line C - line CPB Hemodynamic management Arterial Blood Pressure Blood pressure = Pump flow rate (CO) × SVR Pump flow rate = BSA × Cardiac index Cardiac index (CI) = 2.4 – 3.5 L/min/m2 𝑯𝒕 × 𝑩𝒘 𝑩𝑺𝑨 = 𝟑𝟔𝟎𝟎 𝑴𝑨𝑷 − 𝑪𝑽𝑷 𝑺𝑽𝑹 = × 𝟖𝟎 𝑪𝒂𝒓𝒅𝒊𝒂𝒄 𝒐𝒖𝒕𝒑𝒖𝒕 Hemodynamic management Autoregulation of Cerebral blood Flow Hemodynamic management Autoregulation of Renal blood Flow MAP In mild to moderate hypothermia Normal adult 50-70 mmHg Higher pressure required in Hypertension, DM, risk of stroke, CKD and old age Hemodynamic management CVP approximate 0 mmHg Urine Output 0.5 - 1 cc. / Kg. / hour Arterial line Pressure < 250 mmHg Hemodynamic management Hemodynamic management Goal directed perfusion Goal directed perfusion is a type of blood flow management used during Cardiopulmonary Bypass. The goal is to maintain adequate blood flow to vital organs and tissue to provide enough Oxygen, with the use of various monitoring techniques such as blood pressure, mixed venous Oxygen saturation and Cardiac index. This approach is intended to improve patient outcomes by reducing the risk of organ damage and also to maintain Aerobic metabolism Hemodynamic management WHAT GOAL DIRECTED PERFUSION CAN PREVENT? Acute Kidney Injury (AKI) Hypoperfusion at Tissue Levels which cause HyperLactemia Tissue Hypoxia leading to Anaerobic Cellular Metabolism Oxygen Supply/ Demand Imbalance leading to Vital Organs injury Risk of morbidity and mortality Longer Length of ICU stay and overall hospital length of stay Hemodynamic management Keep 𝑫𝑶𝟐 > 𝟐𝟕𝟐 𝒎𝒍𝑶𝟐 /min/m2 Hemodynamic management Hemodynamic management Hemodynamic management Myocardial protection Strategies of myocardial protection in CPB 1. Without cardioplegia - Beating - Fibrillating heart 2. With cardioplegia (Stop the heart) Myocardial protection Good cardioplegia composition Immediate arrest Decrease temperature Provide substrate for energy production Buffer, to maintain appropriate pH Membrane stabilization Avoid myocardial edema Myocardial protection Types of cardioplegia Crystalloid cardioplegia - Neonate, short operation (ASD) Blood cardioplegia (1:1, 4:1) - Acetar 500 cc - Cardioplegia solution 60 cc - Sodium bicarbonate 28 cc - 50% Glucose 25 cc - Hydrocortisone 1.25 cc ( 1 vial = 100 + sterile water 2 cc) - Humulin R 0.05 cc Myocardial protection ECG Pattern of Hyperkalemia Myocardial protection Custodiol HTK solution The only single shot cardioplegia Perfusion Volume 30 ml/kg during 8 min Arrest heart 90 min Myocardial protection Del Nido Cardioplegia Blood : Cardioplegia 1:4 Single dose 20 cc/kg Maintenance dose 10 cc/kg Arrest heart 90 min Myocardial protection Route Flow (cc/min) Pressure (mmHg) Antegrade 250 - 350 250 - 300 Retrograde 100 - 150 100 – 150 or 30 – 50 in Coronary sinus pressure Direct (Right coronary) 100 - 150 100 - 150 Direct (Left coronary) 150 - 200 150 - 200 Graft > 50 < 100 E xtr ac or po re al ci rcul ati on i n Th oraci c A or ti c sur ge r y E xtr ac or po re al ci rcul ati on i n Th oraci c A or ti c sur ge r y  Thoracic Aortic surgery Ascending aorta Arch of aorta Descending aorta  Thoracic Aortic surgery Ascending aorta Arch of aorta Descending aorta Conventional CPB Deep hypothermia Deep hypothermia Partial bypass TEVAR circulatory arrest with circulatory arrest Cerebral perfusion Femoro-Femoral bypass Left heart bypass Cannulation Cannul ation Axillary artery cannulation Cannulation Cannul ation Femoral Aortic and venous Cannula Cannulation Cannul ati on Single Stage Venous Cannula (RCP) Two Stage Venous Cannula (ACP) Deep Hypothermia Circulatory Arrest (DHCA) Deep Hypotherm ia Circ ulatory Arrest (DH CA) HYPOTHERMIA DEFINITIONS OF BODY TEMPERATURE Term Temperature Hyperpyrexia > 40 - 41.5 °C Hyperthermia >37 Normothermia 35-37 Mild hypothermia 32-35 Moderate hypothermia 25-31 Deep hypothermia 18-24 Profound hypothermia 1 L or >20% of blood volume. Preoperative anemia or increased risk factors for bleeding. Indication: Patients with rare blood group type or antibodies. Patient refusal to receive allogeneic blood transfusion. The American Association of Blood Banks suggest cell salvage is indicated in surgery where blood would ordinarily be cross-matched or where more than 10% of patients undergoing the procedure require transfusion. Patients with the presence of sickle-cell disease, sickle-cell trait, and other RBC disorders. Patients undergoing surgery for Contraindication: malignancy. Patients undergoing bowel surgery, penetrating abdominal injury, or surgery where infection is present. Patients undergoing surgery with major obstetric hemorrhage.