Management of Incident in Cardiopulmonary Bypass

1. Management of Incident in Cardiopulmonary Bypass Pyo Won Park Dept. Thoracic & Cardiovascular Surgery Samsung Medical Center Sungkyunkwan University School of Medicine

2. CPB Incident Rate per Case Number

3. Perfusion Survey of 1030 USA Hospital Mejak BL, perfusion 2000;15:51

4. Mortality Serious Injury

5. Australasian Perfusion Incident Survey perfusion 1997;12:279-88

6. Iatrogenic Aortic dissection • Very low incidence ; 0.2-0.4% • High mortality; 20-40% • Location; ascending aortic cannulation, • aortic root cardioplegic cannulation • femoral & axillary cannulation • partial & cross clamp site • proximal amastomosis of CABG • aortotomy site • Risk factor; Aorta dilatation, atherosclerotic change, • previous CABG, old age, hypertension at • decannulation, femoral cannulation, • preoperative steroid, asian race

7. Aortic dissection at the time of cannulation • Diagnosis byperfusionist • unexpected high arterial line pressure • systemic hypotension • reduced venous return • Diagnosis by operator • difficult aortic cannulation • low back flow through aortic cannulae • aortic wall hematoma • descending aorta dissection in TEE

8. Aortic dissection at the time of cannulation Management • Stop CPB • Clamp venous line • Maintain self cardiac function • Change arterial cannulae to proximal aorta • Restart CPB • Tear site repair graft replacement under circulatory arrest primary repair

9. Aortic dissection at the time of decannulation • Prevention • Secure purse string suture • Keep low BP (80-90mmHg) in high risk pts • at the time of decannulation • Management • Proximal ascending aorta & venous cannulation • Restart CPB • Tear site replacement with graft under arrest • Transapical aortic cannulation, if needed

10. Transapical Aortic Cannulation Wada JTCS 2006;132:369-72 Figure 1. A 1-cm incision is made in the apex of the left ventricle without a purse-string suture. Figure 2. A 7-mm cannula (Sarns Soft-flow Extended Aortic cannula) is passed through the apex. Figure 3. The cannula is passed across the aortic valve until positioned in the ascending aorta under transesophageal echocardiographic guidance.

11. Personal Experiences of Aortic Dissection • Early aortic dissection in intramural aortic cannulation in adult ASD Ascending Ao replacement • Root cannulae dissection in AVR during rewarming Ao reclamp, ascending Ao replacement • Iliac artery dissection in HTX in redo cardiac surgery Iliac artery repair after HTX

12. Massive air embolism • Critical complication due to residual neurologic damage and high mortality • Cause sudden reduction in venous reservoir level (ex. large AP collateral) Inverson of left sided vent Reversal of pump head Air from cardiac chambers Runaway pump head

13. Management of Massive Air Embolism • Stop CPB immediately • Clamping venous line • Steep Trendelenberg position • Remove aortic cannulae • Remove arterial filter • Deair arterial cannulae & pump line • Retrograde hypothermic SVC perfusion • Resume antegrade CPB • Finish cardiac procedure • Rewarming; up to 34°C, no overheating • Induce hypertension

14. Management of Massive Air Embolism Retrograde Cerebral perfusion • Direct connect arterial line to SVC • Use arterio-venous shunt line • Flow; 1-2 L/min (adult) • Temp; 20-24°C • Duration; 1-4 min • Pressure; up to 40mmHg • Carotid compression • Confirm no air on aortic cannulation site

15. Management of Massive Air Embolism Medication • OR Methyprednisolone 30mg/kg Thiopental 20mg/kg Mannitol 1gm/kg • ICU Mannitol 0.5gm/kg Q 8hrs Methyprednisolone 30mg/kg Phenytoin 25mg Q 12hrs • Temperature control

16. Protamine reaction • Type transient hypotension severe pulmonary vasoconstriction anaphylaxis • High risk group fish allergy prior protamine exposure Insulin dependent diabetics vasectomy

17. Prevention of Protamine reaction • Slow injection • Give 5-10mg test dose • Careful history taking • Extreme caution in high risk group Vasectomy, previous exposure, fish allergy, poor LV & RV dysfunction, Pul Ht • Keep CPB circuit intact during protamine infusion

18. Management of Protamine Reaction • Administer fluid for hypotension via arterial line • Give oxygen, steroid, epinephrine, antihistamine for anaphylactic type reaction • Vasopressor • Restart CPB • LVAD or ECMO, if needed

19. Electric Failure • Extremely rare in mordern hospital • Usually failure of backup system (OR & CPB console) Prevention • Be familiar with operating facilities and devices in case of emergency backup • Check flashlight and hand crank • Need battery operated emergency light source, portable monitor, infusion pump, suction

20. Management of Electric Failure • Source of light ; flashlight, laryngoscope • Venous line clamping to avoid exanguination • Manual systemic perfusion with hand crank high speed(60-100rpm/min), extra manpower • Manual ventilation • Battery operated monitor, infusion pump, suction device • CPB console battery; limted duration of support 30min for arterial pump, sucker, vent, light 50 min for only arterial pump

21. Oxygenator failure • Diagnosis Dark colored blood exiting oxygenator ABGA or in line blood gas sensor • Causes Loss of gas supply ( failure of blender, leak or obstruction of gas delivery system ) Inadequate anticoagulation ( after protamine infusion, high incidence in aprotinin use ) Oxygenator leakage & malfunction High transmembrane pressure gradient

22. Management of Oxygenator Failure • Notify surgeon & anesthesiologist • Seek qualified assistance • Turn off gas & water flow to oxygenator • Detach and attach oxygenator • Reconnect oxygenator lines • Recirculate oxygenator for deairing via shunt line • Restart CPB

23. Parallel Replacement of Oxygenator Routine shunt with 3/8 in tubing & 3/8 connector

24. Right coronary air embolism • Diagnosis ST segment elevation Decreased RV function Flaccid & dilated RV Ventricular arrythmia • Management Restart CPB High BP Coronary artery massage Coronary artery injection

25. Inadequate Blood flow • Acute aortic dissection • Low circulating volume reduced priming volume limited prebypass fluid infusion • Inadequate cannulae size • Malpositioned venous & arterial cannulae • During bypass vasodilator infusion, blood loss (pleural space, cell savor)

26. Management of Hypoperfusion • Add crystalloid/blood as needed • Watch line pressure at initiation to insure proper cannulation • Scan venous line for air • Monitor venous O2 saturation • Reposition of IVC cannulae • Use vasodilator as needed

27. Other Problems • Air lock • False display of CPB pump output due to incorrect setting of tubing size (hyperperfusion or underperfusion) • Arterial line rupture • Aortic cannulae dislodgement • Drug error • ABO incompatible blood transfusion

28. Problem Solving & Prevention/Treatment protocol Problem Identification Development & treatment protocol Evaluation of Protocol Case evaluation M & M report Occurrence screen Literature review Equipment bulletins Education Drill

29. Prevention & Management of CPB Incident • Use of safety equipment • Human error account for 70-85%(2 perf) • Checklist for CPB • Written protocol for crisis management • Simulation; reusable training circuit • Mental rehearsal • Practice of skill • Communication between surgical teams • National survey & exchange experiences

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