Management of Incident in

Cardiopulmonary Bypass

Pyo Won ParkDept. Thoracic & Cardiovascular SurgerySamsung Medical CenterSungkyunkwan University School of Medicine

CPB Incident Rate per Case Number

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

Mortality

Serious Injury

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

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

Aortic dissection at the time of cannulation

• Diagnosis by perfusionist 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

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

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

Figure 3. The cannula is passed across the aortic valve until positioned in the ascending aorta under transesophageal echocardiographic guidance.

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.

Transapical Aortic Cannulation Wada JTCS 2006;132:369-72

Personal Experiences of Aortic Dissection

1. Early aortic dissection in intramural aortic cannulation in adult ASD Ascending Ao replacement

2. Root cannulae dissection in AVR during rewarming Ao reclamp, ascending Ao replacement

3. Iliac artery dissection in HTX in redo cardiac surgery Iliac artery repair after HTX

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

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

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

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

Protamine reaction

• Type transient hypotension severe pulmonary vasoconstriction anaphylaxis

• High risk group fish allergy prior protamine exposure Insulin dependent diabetics vasectomy

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

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

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

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

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

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

Parallel Replacement of Oxygenator

Routine shunt with 3/8 in tubing & 3/8 connector

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

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)

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

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

Problem Solving & Prevention/Treatment protocol

Development & treatment protocol

Case evaluation M & M report Occurrence screen Literature review Equipment bulletins Education Drill

Evaluation of Protocol

Problem Identification

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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