PROTOCOLS and GUIDELINES<\/p>\n
OF PERFUSION<\/p>\n
Table of Contents<\/p>\n
Section 1: Principles<\/p>\n
Purpose\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.<\/p>\n
Goal Statement\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.<\/p>\n
Essentials & Guidelines For Perfusion Practice In (xxxxxxxx)<\/p>\n
Section 2: Qualification, Competency and Support Staff<\/p>\n
Section 3: Clinical Perfusion Activities <\/p>\n
Primary\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.<\/p>\n
Secondary\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.<\/p>\n
Section 4: Communication <\/p>\n
Section 5: Staffing & Duty Hours <\/p>\n
Section 6: Perfusion Record <\/p>\n
Section 7: Checklist <\/p>\n
Section 8: CPB Machine, Circuit Preparation<\/p>\n
Section 9: Quality Assurance, Improvement, And Maintenance<\/p>\n
Section 10: Safety Devices <\/p>\n
Section 11: Patient Management & Perfusion Technique<\/p>\n
Section 12: Monitoring<\/p>\n
Section 13: Permitted Cardiovascular Perfusion Medical Drugs <\/p>\n
Section 14: Special Devices Management<\/p>\n
SECTION I<\/p>\n
Principles<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
PURPOSE: This manual has been developed, overseen, and created the following document based on clinical evidence and currently accepted perfusion practices. The purpose of Protocols and Guidelines for Adult perfusion is to improve the continuity and quality of care provided by perfusion services at the (XXXX). To that end, this manual presents the basic information necessary for the safe and effective conduct of Adult perfusion as suggested by the Essentials and Guidelines for Perfusion Practice of the American Society of Extracorporeal Technology. Accordingly, the Essentials and Guidelines for Perfusion Practice are included as a reference and serve only as basis for the protocols and guidelines which follow. The procedural information contained herein is not intended to replace common sense and good judgment. The appropriate course of action in any situation is dictated by a combination of policy, common sense, and experience. Meaningful communication, however, between the perfusionist, the attending surgeon, and anesthesiologist is essential whenever a serious departure from established protocols and guidelines is undertaken.<\/p>\n
POLICY: A certified cardiovascular perfusionist (or an eligible perfusionist or a student perfusionist, both of whom are under the direct supervision of a certified cardiovascular perfusionist) should perform this procedure.<\/p>\n
GOAL: The goal of this project was to provide Perfusionist with a framework to guide safe and effective extracorporeal care and other therapeutic interventions to their patients. Ministry of health recommends that clinical teams use this document as a guide for developing institution-specific protocols for patients receiving extracorporeal support. <\/p>\n
Essentials & Guidelines For Perfusion Practice In The (XXXXX)<\/p>\n
SECTION 2<\/p>\n
Qualification, Competency and Support Staff<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
2.1: A Perfusionist, who is Certified by (XXXX) of Cardiovascular Perfusion, shall conduct cardiopulmonary bypass (CPB). <\/p>\n
2.2: An individual graduating from an accredited perfusion education program should get Saudi council license within one year. In the first year can conduct cardiopulmonary bypass under supervision of certified perfusionist. <\/p>\n
2.3: Perfusionist competency shall be assessed once for new staff to evaluate compliance with departmental protocols. <\/p>\n
2.4: perfusionist should do at least 15 cases of cardiac surgery on pump to renew the S.C license. <\/p>\n
2.5: Each cardiac surgery center must have two certified perfusionist staff members at least.<\/p>\n
2.6: Support staff shall be available on site to assist the primary Perfusionist during CPB procedures.<\/p>\n
2.7: A standardized process should be developed and followed to identify, orient and educate support staff to ensure they have general knowledge of the duties performed by the Perfusionist, flow of the operation and location of primary and ancillary items required during CPB. Support staff may include a Perfusionist, nursing or technical staff.<\/p>\n
SECTION 3<\/p>\n
Clinical Perfusion Activities<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
Primary Clinical Perfusion Activities (PCPA)<\/p>\n
Clinical Definition<\/p>\n
Core Elements<\/p>\n
1P<\/p>\n
Cardiopulmonary Bypass (CPB), Primary<\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary operator of the heart-lung machine, used during cardiac surgery and other surgeries that require extracorporeal circulation, used to manage the patient\u2019s physiological status.<\/p>\n
Blood pump, reservoir, heat exchanger, oxygenator, extracorporeal circuit used accordingly with hemodynamic\/lab value monitoring.<\/p>\n
2P<\/p>\n
Instructor CPB Bypass, Primary <\/p>\n
A Certified Clinical Perfusionist (CCP) Specialist who serves as a clinical instructor to a student enrolled in an accredited perfusion program during primary clinical perfusion activities that require extracorporeal circulation, used to manage the patient\u2019s physiological status.<\/p>\n
Blood pump, reservoir, heat exchanger, oxygenator, extracorporeal circuit used accordingly with hemodynamic\/ lab value monitoring. Primary clinical perfusion activities (PCPA) performed as clinical instructor in an accredited program are considered a primary perfusion activity and will receive full case credit. During clinical instruction in which the student is operating extracorporeal circulation equipment, there must be direct one-to-one supervision by the clinical instructor. Students may also receive credit toward certification eligibility for the same case.<\/p>\n
3P<\/p>\n
Extra-Corporeal Membrane Oxygenation (ECMO), Primary<\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary operator of ExtraCorporeal Membrane Oxygenation (ECMO) circuit that provides life support for respiratory and\/or cardiac failure. The CCP must be documented at the institution as a member of the patient care team for that period and a physician name must accompany the case in the Clinical Activity Report.<\/p>\n
Extracorporeal circuit, oxygenator, heat exchanger used accordingly with hemodynamic\/lab value monitoring. For each ECMO case, one case credit per 24 hours will be awarded for initiating and bedside managing ECMO (4-hour minimum) or bedside managing (6-hour minimum). No simultaneous credit will be awarded for managing multiple ECMO patients in this time period.<\/p>\n
4P<\/p>\n
Isolated Limb, Ex Vivo Organ Perfusion, Primary<\/p>\n
A Certified Clinical Perfusionist (CCP) Specialist, who is (1) the primary operator of an extracorporeal device used to deliver anticancer drugs directly to an arm, leg, or organ that manages the patient\u2019s physiological status or (2) the primary operator of an extracorporeal device, including an oxygenator\/de-oxygenator and pump, used to manage the physiologic state of isolated and separated human organs from the body, for potential transplant opportunities<\/p>\n
Reservoir, blood pump, heat exchanger, oxygenator, extracorporeal circuit used accordingly with hemodynamic, temperature, and lab value monitoring. No simultaneous credit will be awarded for managing multiple organs<\/p>\n
5P<\/p>\n
Veno-Venous or Left Heart Bypass, Primary<\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary operator of an extracorporeal device, used to perfuse specific vascular regions within the circulatory system or recirculate venous blood for purposes such as clot\/tissue removal.<\/p>\n
Blood pump, extracorporeal circuit used accordingly with hemodynamic\/lab value monitoring<\/p>\n
6P<\/p>\n
Ventricular Assist Device (VAD), Primary<\/p>\n
A Certified Clinical Perfusionist (CCP) Specialist who is the primary operator of the Ventricular Assist Device (VAD) that provides cardiac support for the failing heart.<\/p>\n
For each VAD case, one case credit per 24 hours will be awarded for initiating and managing VAD or bedside managing (6- hour minimum). No simultaneous credit will be awarded for managing multiple VAD patients in this time period.<\/p>\n
7P<\/p>\n
Intraperitoneal Hyperthermic Chemoperfusion or Intrapleural Hyperthermic Chemoperfusion (HIPEC)<\/p>\n
A Certified Clinical Perfusionist (CCP) Specialist who is the primary operator of an intraperitoneal or intrapleural device<\/p>\n
A device with pump flow, circulation, temperature, monitoring, and regulation of chemotherapeutic fluids within abdominal or thoracic cavity for periods exceeding 30 minutes. Syringe infusion devices will not be counted as an SCPA.<\/p>\n
_____________________________________________________________________________<\/p>\n
SECONDARY CLINICAL PERFUSION ACTIVITIES (SCPA)<\/p>\n
Secondary Clinical Perfusion Activities (SCPA)<\/p>\n
Clinical Definition<\/p>\n
Core Elements<\/p>\n
1S<\/p>\n
CPB, First Assistant<\/p>\n
The \u201cCPB First Assistant\u201d is the Certified Clinical Perfusionist (CCP) whom the hospital\/ institution recognizes as the assistant to the primary perfusionist during the conduction of perfusion.<\/p>\n
The \u201cCPB First Assistant\u201d must be documented within the operating suite and actively assisting during the operative case. Multiple First Assistant credits will not be allowed during concurrent operative procedures.<\/p>\n
2S<\/p>\n
Ex Vivo, First Assistant<\/p>\n
A Certified Clinical Perfusionist (CCP) who is the secondary operator of an extracorporeal device, used to perfuse isolated and separated human organs from the body, for potential transplant opportunities.<\/p>\n
Reservoir, blood pump, heat exchanger, oxygenator, extracorporeal circuit used accordingly with hemodynamic, temperature, and lab value monitoring. No simultaneous credit will be awarded for managing multiple organs.<\/p>\n
3S<\/p>\n
Cardiopulmonary Bypass (CPB) Standby Procedures, and Extracorporeal Membrane Oxygenation (ECMO) Standby Procedures<\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary standby operator of the heartlung machine which is used during cardiac surgery that may require extracorporeal circulation to manage the patient\u2019s physiological status or is the primary standby operator of the Extracorporeal Membrane Oxygenator (ECMO) that provides life support for respiratory and \/or cardiac failure.<\/p>\n
Any procedure that may require immediate and onsite extracorporeal circulatory support. Standby procedures must be documented, requested by the attending physician, and verifiable in an audit.<\/p>\n
4S<\/p>\n
Intra-Aortic Balloon Pump (IABP) Service <\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary operator of the IABP inside OR during cardiac surgery, till indorse the patient to the next unit for the management at their site.<\/p>\n
(The service of IABP can be initiated by Perfusionist at OR, Cath-lab tech at Cath-lab, CCU nurse at CCU.)<\/p>\n
IABP console different models balloon (with or without central lumen), including percutaneous insertion kit, Catheter extension, Pressure cable, Five-lead patient cable with electrosurgical interference suppresser filter blocks, Slave cable for both electrocardiography (ECG) and pressure monitoring, Silver-Silver chloride ECG skin electrodes, Fibreoptic sensation balloon<\/p>\n
5S<\/p>\n
Cell-saver <\/p>\n
A Certified Clinical Perfusionist (CCP) who is the primary operator of the Cell-saver used to reduce patient exposure to allogeneic blood during and after surgery inside operating room. (also called cell salvage) <\/p>\n
For each cell-saver usage credit will not awarded.<\/p>\n
SECTION 4<\/p>\n
Communication<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
.41: A patient-specific management plan for the cardiopulmonary bypass (CPB) procedure shall be prepared and communicated to the surgical team either during the pre- operative briefing or prior to beginning the procedure. <\/p>\n
.42: The primary Perfusionist shall use the approved CPB chart when transitioning the management of the case to a second Perfusionist. <\/p>\n
.43: Protocol driven communication, should be utilized to acknowledge verbal commands, verify the content, and reduce ambiguity. <\/p>\n
.44: The primary Perfusionist should participate in the operating room with the surgical team until the patient shifted outside the room. <\/p>\n
4.5: Each Perfusion must have log book which contain <\/p>\n
Case number<\/p>\n
Date <\/p>\n
Patient information <\/p>\n
Name of : Surgeon, Anesthiologist, Perfusionist primary & secondary, <\/p>\n
Time: CPB, Cross-clamp <\/p>\n
Remark ( for example IABP, ECMO, VAD, Circulatory arrest, etc\u2026) <\/p>\n
SECTION 5<\/p>\n
Staffing & Duty Hours<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
5.1: Perfusion site location at the facility<\/p>\n
The perfusion department must match the following criteria:<\/p>\n
Close to operation department, intensive care unit, and cardiac care unit.<\/p>\n
Office for perfusionist members<\/p>\n
On-call room should be available for Perfusionist covering 24 hours duty.<\/p>\n
Supply room size must have enough space and secured for the perfusion supplies <\/p>\n
Equipment room size must have enough space and secured for perfusion machines<\/p>\n
5.2: Perfusion department\/services should maintain a policy and procedures manual<\/p>\n
Practice Guidelines<\/p>\n
Routine and emergency procedures<\/p>\n
Departmental policies<\/p>\n
Continuing education policies<\/p>\n
4. Staff files must be completed<\/p>\n
5.3: The \u201cn+2\u201d staffing model should be utilized at all times, where \u201cn\u201d equals the number of operating\/procedure rooms in use at any given time at a single site.<\/p>\n
5.4: If there are two or more procedures running at same time, floating perfusionist must be available <\/p>\n
5.5: An on-call Perfusionist should be present and clinically ready for unscheduled and emergency procedures within 60 minutes of being called.<\/p>\n
5.6: The maximum number of duty hours that employees can work in an average working week is 48 hours which: <\/p>\n
a: In order for the Perfusionist to ensure proper provision of care, he\/she must<\/p>\n
shall receive an adequate rest period between scheduled work hours.<\/p>\n
b. The Perfusionist should receive a minimum of 8 hours of rest period for every<\/p>\n
16-hour consecutive work period.<\/p>\n
5.7: Chief Perfusionist responsibilities <\/p>\n
Duties, staff annul leave plan, monthly meeting, continuing education, interviewing new contractor perfusionist, and annul evaluation for perfusionist members. Chief Perfusionist can assign anyone from perfusionist members for any mission if needed.<\/p>\n
SECTION 6<\/p>\n
Perfusion Record <\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
5.1: The perfusion record (written and\/or electronic) for each cardiopulmonary bypass (CPB) procedure shall be included as part of the patient\u2019s permanent medical record. The perfusion records shall be maintained and stored according to institution policy for retaining patient medical records.<\/p>\n
5.2: The perfusion record should include open text (factual) commentary including supervising physician verbal orders pertinent to the CPB procedure.<\/p>\n
5.3: The perfusion record should include the signatures of the physician(s) providing oversight for the CPB procedure. <\/p>\n
Case#<\/p>\n
OR#<\/p>\n
Date:<\/p>\n
CrossClamp<\/p>\n
ByPass<\/p>\n
PROCEDURE:<\/p>\n
Allergy:<\/p>\n
Pre-Op Diagnosis:<\/p>\n
OFF<\/p>\n
ON<\/p>\n
OFF<\/p>\n
ON<\/p>\n
Clamp Time:<\/p>\n
Min<\/p>\n
CPB Time:<\/p>\n
Min <\/p>\n
Hgb gm\/dl<\/p>\n
CREAT mg\/dl<\/p>\n
Bun mg\/dl<\/p>\n
Pre-Op Labs<\/p>\n
HISTORY:<\/p>\n
PLT <\/p>\n
PTT Sec<\/p>\n
PT Sec<\/p>\n
Blood Type<\/p>\n
AGE<\/p>\n
GANDER <\/p>\n
F M <\/p>\n
BSA m2<\/p>\n
WT KG<\/p>\n
HT CM<\/p>\n
PAITENT DATA<\/p>\n
PERSONNAL<\/p>\n
patient name : <\/p>\n
File :<\/p>\n
Age :<\/p>\n
Gender :<\/p>\n
patient name : <\/p>\n
File :<\/p>\n
Age :<\/p>\n
Gender : <\/p>\n
Anesthesiologist:<\/p>\n
Surgeon:<\/p>\n
Secondary Perfusion:<\/p>\n
Primary Perfusionist: <\/p>\n
2.6<\/p>\n
2.4<\/p>\n
2.2<\/p>\n
2<\/p>\n
1.8<\/p>\n
CL<\/p>\n
FLOW<\/p>\n
Comments<\/p>\n
ACT<\/p>\n
Lact<\/p>\n
Ca+<\/p>\n
B.S<\/p>\n
SaO2 %<\/p>\n
Na<\/p>\n
K<\/p>\n
Hgb<\/p>\n
HCO3<\/p>\n
BE<\/p>\n
PO2<\/p>\n
PCO2<\/p>\n
PH<\/p>\n
Sevo%<\/p>\n
SWEEP<\/p>\n
FIO2<\/p>\n
A-L<\/p>\n
MAP<\/p>\n
FLOW<\/p>\n
TIME<\/p>\n
SECTION 7<\/p>\n
Checklist<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
6.1: The Perfusionist shall use a checklist for each cardiopulmonary bypass (CPB) procedure.<\/p>\n
6.2: Checklists shall be included as part of the patient’s permanent medical record.<\/p>\n
6.3: The Perfusionist should use checklists in a read-verify manner where critical steps<\/p>\n
that should have been performed are confirmed. Completion of the checklist should be<\/p>\n
performed by two people, one person being the primary Perfusionist responsible for<\/p>\n
operation of the heart lung machine during the intra-operative period.<\/p>\n
SECTION 8<\/p>\n
CPB Machine, Circuit Preparation<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
9.1: Heart Lung Machine<\/p>\n
Machine is intended to perform, control, monitor and support extracorporeal blood circulation replacing the mechanical pumping function of the heart, monitoring, and regulating physiologic parameters during procedures requiring extracorporeal circulation. The heart-lung machine consisting of a sterile extracorporeal set-up and ancillary equipment shall be readily available for the procedure.<\/p>\n
ancillary equipments:<\/p>\n
Oxygenator<\/p>\n
Cardiotomy reservoir<\/p>\n
Tubing pack\/Arterial line filter<\/p>\n
Centrifugal pump head<\/p>\n
Cardioplegia Delivery System<\/p>\n
Cell Salvage (autotransfusion)<\/p>\n
Ultrafiltration Device<\/p>\n
Arterial Cannula<\/p>\n
Venous Cannula<\/p>\n
Cardioplegia Cannula <\/p>\n
Sump\/vent(s)<\/p>\n
9.2: Circuit Preparation<\/p>\n
The Perfusionist shall assure that properly maintained and functioning equipment is used in the conduct of cardiopulmonary bypass (CPB), including (but not limited to):<\/p>\n
A. Heart lung machine:<\/p>\n
Pumps <\/p>\n
Timers <\/p>\n
Pressure monitors <\/p>\n
Temperature monitors <\/p>\n
Low Level alarm <\/p>\n
Air bubble detector(s)<\/p>\n
Safety arterial line clamp <\/p>\n
Backup arterial head panel<\/p>\n
Blood flow sensors<\/p>\n
Hand cranks<\/p>\n
Flush light<\/p>\n
Backup CPB Machine<\/p>\n
Extra CPB circuit<\/p>\n
Heater\/Cooler <\/p>\n
Anesthetic vaporizer <\/p>\n
Oxygen Blender\/Flow Meter <\/p>\n
Oxygen analyzer <\/p>\n
Ancillary Equipment:<\/p>\n
IABP <\/p>\n
VAD device <\/p>\n
ECMO <\/p>\n
Cell salvage device<\/p>\n
ACT Machine<\/p>\n
ABG Machine<\/p>\n
Oxygen gas cylinder<\/p>\n
ER flush light <\/p>\n
9.3: Arterial Roller-pump Calibration<\/p>\n
The arterial roller-pump should be calibrated prior to the initiation of CPB.<\/p>\n
Make sure that the digital readout on the arterial pump console.<\/p>\n
The stroke volume\/Revolution for 3\/8\u201d boot is 27ml. The stroke volume\/Revolution for \u00bd\u201d boot is 45ml.<\/p>\n
Tubing Diameters and Their Associated Prime Volume Per Inch of Tubing<\/p>\n
Tubing Diameter in Inches<\/p>\n
Cc\/Inch<\/p>\n
\u00bd<\/p>\n
3.5<\/p>\n
3\/8<\/p>\n
1.8<\/p>\n
5\/16<\/p>\n
1.3<\/p>\n
\u00bc<\/p>\n
.82<\/p>\n
3\/16<\/p>\n
.45<\/p>\n
1\/8<\/p>\n
.20<\/p>\n
9.4: CPB Circuit Set-Up Standardization Protocol<\/p>\n
A. Purpose<\/p>\n
To establish a consistent circuit set-up facilitating the transfer of case from one perfusionist to another.<\/p>\n
B. Principles<\/p>\n
Always use the manufacturer\u2019s specific holders for each component for all systems.<\/p>\n
Avoid wrapping lines around the mast.<\/p>\n
C. Circuit Set-Up<\/p>\n
Remove the oxygenator from its package and examine it for defects.<\/p>\n
(If the product is dropped during set-up, don\u2019t use it. Replace with another oxygenator)<\/p>\n
Place the oxygenator on its designated holder. Setup the holder at the appropriate height to prevent the arterial line and other lines from kinking.<\/p>\n
Connect the tubes in the tubing pack sterilely (the boot, suckers, vent and purge lines) to the designated ports on the oxygenator, and make sure the one way valve of vents is in the right directions. <\/p>\n
Connect water lines to the water ports of the oxygenator.<\/p>\n
Start water circulation through heat exchanger and circulate for at least 5 min at max cool setting, and check for leaks. (Do not use any oxygenator that leaks).<\/p>\n
D. Circuit Priming Procedure<\/p>\n
Perform priming using crystalloid solution which contains no blood, plasma and\/or blood derived products. Therefore, if blood derived products are used during priming, start bypass after performing air purge thoroughly.<\/p>\n
SECTION 9<\/p>\n
Quality Assurance, Improvement, And Maintenance<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
9.1: The Perfusionist shall actively participate in both institutional and departmental quality assurance and improvement programs. <\/p>\n
9.2: The Perfusionist should collect data concerning the conduct of perfusion via a clinical registry or database. <\/p>\n
9.3: The Perfusionist should use such data for quality assurance, and improvement projects.<\/p>\n
9.4: The Perfusionist shall assure that properly maintained and functioning equipment is used in the conduct of cardiopulmonary bypass (CPB), including (but not limited to): <\/p>\n
\u2022 Heart lung machine
o Pumps<\/p>\n
o Timers <\/p>\n
o Pressure monitors
o Temperature monitors <\/p>\n
o Low Level alarm
o Air bubble detector(s) <\/p>\n
o Blood flow sensors <\/p>\n
Heater\/Cooler <\/p>\n
Anesthetic vaporizer <\/p>\n
Oxygen Blender\/Flow Meter <\/p>\n
Oxygen analyzer <\/p>\n
Ancillary Equipment <\/p>\n
o IABP
o VADdevice
o Cellsalvage device <\/p>\n
9.5: Preventive maintenance on perfusion equipment shall be performed by appropriately trained and qualified manufacturer technicians, representatives or Bio-Medical technicians. Regularly scheduled maintenance shall be documented by the perfusion department and\/or Bio-Medical engineering staff. The interval of such maintenance shall be consistent with manufacturer recommendations, applicable external accrediting agency guidelines and institutional requirements.<\/p>\n
9.6: The facility shall follow a protocol for perfusion equipment failures.<\/p>\n
9.7: Appropriate backup perfusion supplies shall be readily available. <\/p>\n
9.8: The institutional shall follow a protocol for acknowledging and addressing perfusion equipment notices (e.g., recalls, warnings, and advisories). <\/p>\n
SECTION 10<\/p>\n
Safety Devices<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
7. 1: Pressure monitoring of the arterial line, cardioplegia delivery systems and venous reservoir (when augmented venous drainage is utilized), shall be employed during cardiopulmonary bypass (CPB) procedures. <\/p>\n
\u2022 The pressure monitor shall be either servo regulated to control the arterial\/cardioplegia pump or to allow interruption to the arterial\/cardioplegia flow. <\/p>\n
\u2022 The pressure monitor shall include an audible and visual alarm. <\/p>\n
2: Air bubble detector shall be employed during CPB procedures <\/p>\n
\u2022 The gross\/macro bubble detector shall be used to control the arterial pump or to allow interruption of the arterial blood flow. <\/p>\n
\u2022 The detector system shall include an audible and visual alarm, and be positioned according to manufacturer instructions for use to enable timely identification and action. <\/p>\n
3: A level sensor shall be employed during CPB procedures utilizing a (hard- shell) reservoir. <\/p>\n
\u2022 The level sensor shall be either servo regulated to control the arterial pump or to allow interruption of the arterial blood flow. <\/p>\n
\u2022 The level sensor shall include an audible and visual alarm, and be positioned according to manufacturer\u2019s instructions to allow an appropriate reaction time and a safe operational volume. <\/p>\n
4: Temperature monitoring of the arterial outflow from the oxygenator shall be employed during CPB procedures. <\/p>\n
\u2022 The temperature sensor shall include an audible and visual alarm to prevent high arterial outlet temperatures. <\/p>\n
5: An arterial-line filter shall be employed during CPB procedures if arterial filter not integrated.<\/p>\n
6: A one-way valve in the vent line shall be employed during CPB procedures. <\/p>\n
7: A method for back flow avoidance when using a centrifugal pump shall be employed during CPB procedures. <\/p>\n
Hard stop detent controls to prevent accidental reduction in pump speed <\/p>\n
Electronically activated arterial line clamps <\/p>\n
Low speed visual and audible alarm. <\/p>\n
8: An anesthetic gas scavenge line shall be employed whenever inhalation agents are introduced into the circuit during CPB procedures. <\/p>\n
9: Hand cranks shall be readily available during CPB procedures. <\/p>\n
10: A back-up oxygen cylinder shall be available during CPB procedures. <\/p>\n
11: A back-up CPB machine shall be available during CPB procedures.<\/p>\n
12: A ventilating gas oxygen analyzer should be employed during CPB procedures. <\/p>\n
SECTION 11<\/p>\n
Patient Management & Perfusion Technique<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
10.1 : Extracorporeal circulation shall be conducted by a knowledgeable and competent perfusionist.<\/p>\n
Practice Guidelines<\/p>\n
Extracorporeal circulation should be conducted by perfusionist who certified through the Saudi Commission for Health Specialties.<\/p>\n
A perfusionist should conduct cardiopulmonary bypass with perfusion assistance available.<\/p>\n
The perfusionist must be notified if there\u2019s any expected needs for perfusionist presences in the hospital while making decision. <\/p>\n
10.2: An accurate perfusion record must be maintained according to an established protocol.<\/p>\n
Practice Guidelines:<\/p>\n
A. The perfusion record should include the following patient information:<\/p>\n
Hospital ID<\/p>\n
Age<\/p>\n
Gender<\/p>\n
Height<\/p>\n
Weight<\/p>\n
Body Surface Area (BSA)<\/p>\n
Allergies<\/p>\n
Blood Type<\/p>\n
Pre-op Laboratory Data<\/p>\n
Diagnosis\/History<\/p>\n
Others <\/p>\n
B. Additional procedure information should include:<\/p>\n
Date<\/p>\n
Procedure<\/p>\n
Perfusionist(s)<\/p>\n
Surgeon(s)<\/p>\n
Anesthesiologist<\/p>\n
Comments\/Events<\/p>\n
C. The following disposable lot numbers should be recorded:<\/p>\n
Oxygenator<\/p>\n
Cardiotomy Reservoir<\/p>\n
Tubing Pack\/Arterial Filter<\/p>\n
Cardioplegia set<\/p>\n
Ultrafiltration set<\/p>\n
Cell washing set<\/p>\n
7. Centrifugal pumphead<\/p>\n
10.3: The perfusionist shall monitor the anticoagulation status of the patient according to an established protocol.<\/p>\n
Practice Guidelines<\/p>\n
A. Monitoring of the anticoagulation status of the patient intra-operatively should include the testing of activated clotting time (ACT), and it should be run during bypass every 30 mins. Other monitoring tests may include:<\/p>\n
Platelet count<\/p>\n
Heparin\/Protamine assay<\/p>\n
Prothrombin Time (PT)<\/p>\n
Partial Thromboplastin Time (PTT)<\/p>\n
Thromboelastogram<\/p>\n
B. Patient specific initial heparin dose should be determined by one of the following methods:<\/p>\n
Weight<\/p>\n
Dose Response Curve, automated or manual<\/p>\n
C. ACT Criteria for CPB Initiation:<\/p>\n
1. ACT > 480 seconds is considered adequate for the initiation and maintenance of safe CPB.<\/p>\n
D. Heparin Maintenance:<\/p>\n
Maintain ACT > 480 seconds.<\/p>\n
Any additional heparin needed to maintain ACT> 480 will be given by the perfusionist.<\/p>\n
Pump heparinizing Dose: when priming the extracorporeal circuit on adult 10,000 Units of heparin must be added. <\/p>\n
E. Heparin Resistance<\/p>\n
If the heparin loading dose results in an ACT < 480 seconds, then the anesthesiologist and the surgeon should be consulted, and an additional bolus of heparin should be administered.<\/p>\n
If the resulting ACT is still < 480 seconds, then the surgeon and anesthesiologist should again be consulted on the possible diagnosis of Antithrombin-III deficiency.<\/p>\n
If a diagnosis of Antithrombin-III deficiency is reached, then the appropriate amount of fresh frozen plasma, ATIII should be ordered and administered before CPB by the anesthesiologist, then repeat ACT.<\/p>\n
4. Additional heparin in the prime should be considered.<\/p>\n
D. The perfusionist may determine the protamine dose. <\/p>\n
10.4: Appropriate gas exchange shall be maintained during extracorporeal circulation according to an established protocol.<\/p>\n
Practice Guidelines<\/p>\n
A. Appropriate oxygenator gas flow rate and concentration should be determined by using blood gas analysis which may include monitoring devices. Further determinations may be guided by perfusion parameters such as blood flow rate and temperature.<\/p>\n
B. Blood gas analysis should be performed and recorded a minimum of every 30 minutes. Blood gas analysis may be performed at reasonable intervals as clinical conditions dictate.<\/p>\n
10.5: The perfusionist shall maintain an appropriate blood flow rate during extracorporeal circulation according to an established protocol.<\/p>\n
Practice Guidelines<\/p>\n
Calculated blood flow rate should be determined prior to cardiopulmonary bypass using the patient\u2019s body surface area (BSA) or weight.<\/p>\n
BFR is calculated by patient kilogram weight according to the following chart:<\/p>\n
Patient Kilogram Weight<\/p>\n
Blood Flow Rate<\/p>\n
0-3 kg<\/p>\n
200 ml\/kg\/min<\/p>\n
3- 10 kg<\/p>\n
150ml\/kg\/min<\/p>\n
10- 15 kg<\/p>\n
125ml\/kg\/min<\/p>\n
15- 30 kg<\/p>\n
100ml\/kg\/min<\/p>\n
>30 kg<\/p>\n
75ml\/kg\/min<\/p>\n
>55 kg<\/p>\n
65ml\/kg\/min<\/p>\n
B. Appropriate blood flow rate should be determined by combination of:<\/p>\n
Venous oxygen saturation<\/p>\n
Body surface area<\/p>\n
Arterial blood pressure<\/p>\n
Temperature <\/p>\n
C. Additional parameters that may guide blood flow rate include:<\/p>\n
Base excess<\/p>\n
Oxygen consumption<\/p>\n
Venous pO2<\/p>\n
Arterial pO2<\/p>\n
Circuit volume<\/p>\n
Physician request<\/p>\n
Body weight<\/p>\n
Anesthesia level<\/p>\n
Arterial oxygen saturation<\/p>\n
10.6: The perfusionist shall maintain an appropriate blood pressure during extracorporeal circulation according to an established protocol.<\/p>\n
Practice Guidelines<\/p>\n
Arterial blood pressure should be monitored and recorded.<\/p>\n
B. maintained mean arterial blood pressure 60mmHg- 90mmHg, or follow surgeon preference. <\/p>\n
(Note: some patients may have vascular diseases that may affect the blood pressure)<\/p>\n
C. Low MAP Intervention Checklist<\/p>\n
1. Verify closure of membrane recirculation line.<\/p>\n
2.Compensate for blood steal whenever the arterial purge line is open and during cardioplegia delivery, hemofiltration, and aortic needle vent usage.<\/p>\n
D. High MAP Intervention Checklist<\/p>\n
1. make sure arterial line reading is accurate (The patency of the arterial pressure monitoring line, and the zero and calibration of A-line transducer) <\/p>\n
2. Administer Sevfluorane at 0.1 – 2.0%. Administration of Svefluorane at > 2.0% has been linked to the uncoupling of cerebral auto-regulation and should, therefore, probably be avoided.<\/p>\n
3. Consult the anesthesiologist as to whether Opioid or muscle relaxer agents should be administered.<\/p>\n
4. Lower BFR if SvO2 > 65%.<\/p>\n
E. Alpha Stat pH Management Strategy<\/p>\n
pH Range measured at 37C0: 7.35 – 7.45<\/p>\n
PaCO2 Range measured at 37C0: 35 – 45 mmHg<\/p>\n
F. Blood Gas Management <\/p>\n
PaO2 Range measured at 37C0: 200 < mmHg<\/p>\n
PaCO2 Range measured at 37C0: 35 – 45 mmHg<\/p>\n
Avoid extended excessively low PaCO2 values in order to ensure uniform cerebral perfusion.<\/p>\n
G. SvO2 Management <\/p>\n
SvO2 Range: \u2265 65%<\/p>\n
Avoid excessive transfusion of PRBC’s during re-warming and following aortic cross-clamp release when drops in SvO2 are transitory.<\/p>\n
Low SvO2 Intervention Checklist:<\/p>\n
Communicate with the surgeon<\/p>\n
Increase Blood Flow Rate.<\/p>\n
Increase isofluorane delivery.<\/p>\n
Consult anesthesiologist as to whether the patient opioid or muscle relaxer agents should be administered.<\/p>\n
Add PRBC’s.<\/p>\n
H. Electrolyte Management<\/p>\n
Ca++<\/p>\n
1. Maintain an ionized Ca++ level of \u2264 0.8 mmol\/L during first 15 – 20 minutes of myocardial reperfusion.<\/p>\n
2. Correct the ionized Ca++ level to approximately 1.2 mmol\/L, beginning at \u2265 15 \u2013 20 minutes after myocardial reperfusion ( Calcium should be administered slowly ) .<\/p>\n
B. Potassium K+ <\/p>\n
Maintain K+ normal range 3.5 – 5.5 mEq\/L before reach the time of Cross-Clamp release <\/p>\n
High Potassium <\/p>\n
Ultrafiltration technique <\/p>\n
If low volume utilizes Z-buf technique by using normal saline<\/p>\n
Regular insulin (blood glucose should be considered and consult anesthesia) <\/p>\n
Diuretic (Furosemide drug, renal function should be considered )<\/p>\n
C. Blood glucose Management<\/p>\n
Normal Glucose Range: 72 – 110 mg\/dL<\/p>\n
a. Causes of Progressive Hyperglycemia during CPB<\/p>\n
surgical stress<\/p>\n
CPB<\/p>\n
hypothermia<\/p>\n
cardioplegia solution<\/p>\n
IV solutions containing glucose<\/p>\n
Clinical treatment of hyperglycemia during CPB<\/p>\n
Glucose levels during CPB should be kept < 200 mg\/dL by conducting hemofiltration replacement therapy with buffered Isolyte.<\/p>\n
Upon consultation with the surgeon and the anesthesiologist, insulin administration could be considered on cases where hyperglycemia persists.<\/p>\n
I. Mild cooling 32-37 \u2070C technique <\/p>\n
b. Perfusate Temperature and Temperature Gradients<\/p>\n
1) During rewarming, maintain 10\u2070C gradient between the water bath of the heater\/cooler unit and the nasopharyngeal or rectal whichever is lowest.<\/p>\n
2) Do not allow the perfusate temperature to exceed 37\u2070C.<\/p>\n
3) Do not allow the water bath temperature of the heater\/cooler unit to exceed 40\u2070C.<\/p>\n
4) When the nasopharyngeal temperature reaches 36\u2070C, lower the perfusate temperature to avoid overheating the brain.<\/p>\n
c. Topical Re-warming<\/p>\n
The water blanket is set to 40\u2070C.<\/p>\n
d. Re-warming Rate<\/p>\n
The re-warming rate should probably be limited to a 1\u2070C increase every 3 – 5 mins.<\/p>\n
e. Increase hematocrit gradually during re-warming to 35\u2070C.<\/p>\n
During re-warming, the Hct is increased by adding PRBC\u2019s and ultrafiltration to remove any excess volume to bring the patient Hct to the desired level designated by the surgeon before the patient is weaned from CPB.<\/p>\n
The addition of PRBC’s is avoided, if possible<\/p>\n
J. Moderate Cooling 28- 31\u2070C.Technique<\/p>\n
Perfusate Temperature and Temperature Gradient<\/p>\n
During cooling, do not exceed a 10\u2070C temperature gradient between the perfusate and rectal or nasopharyngeal temperature whichever is highest.<\/p>\n
The perfusate temperature should never fall < 15\u2070C.<\/p>\n
When the temperature gradient in excess of 5\u2070C arise between the rectal and nasopharyngeal temperatures titrate the patient with 0.25 \u2013 1.0% Sevofluorane. If the cooling gradient persists, consult the anesthesiologist for methods of therapeutic vasodilation.<\/p>\n
Topical Cooling<\/p>\n
Once the arterial line is set by anesthesia and it is functional, set the water blanket temperature 28\u2070C.<\/p>\n
3. Temperature Maintenance<\/p>\n
The target cooling temperature is obtained and maintained by keeping the perfusate at the target temperature.<\/p>\n
K. DHCA Cooling 18- 28\u2070C.Technique<\/p>\n
Perfusate Temperature and Temperature Gradient<\/p>\n
During cooling, do not exceed a 10\u2070C temperature gradient between the perfusate and rectal or nasopharyngeal temperature whichever is highest.<\/p>\n
The minimum perfusate temperature is 18\u2070C.<\/p>\n
Once a perfusate temperature of 18\u2070C is safely reached, do not allow the perfusate temperature to rise above 18\u2070C prior to circulatory arrest.<\/p>\n
Should a temperature gradient in excess of 5\u2070C arise between the rectal and nasopharyngeal temperatures titrate the patient with 0.5 – 2.0% sevofluorane. If the cooling gradient persists, consult the anesthesiologist for methods of therapeutic vasodilation.<\/p>\n
Topical Cooling<\/p>\n
Set the water blanket temperature to ~18\u2070C.<\/p>\n
Consider pack patient\u2019s head with ice bags by anesthesia.<\/p>\n
L. Hemodilution <\/p>\n
1. Patient requiring cooling is hemodiluted to Hct % that matching patient\u2019s temperature or closed to it. (the border line for Hct is 21% ) <\/p>\n
2. Prior to re-warming, PRBC’s are slowly titrated according to oxygen demand. <\/p>\n
M. Re-warming<\/p>\n
1.Re-warming is initiated at the request of the surgeon.<\/p>\n
2. The ice bags are removed from the patient\u2019s head by anesthesia.<\/p>\n
3. During Re-warming , do not exceed a 10\u2070C temperature gradient between the perfusate and rectal or nasopharyngeal temperature.<\/p>\n
a. Pharmacology during re-warming<\/p>\n
1) NaHCO3<\/p>\n
a) Do not treat metabolic acidosis unless the Base Excess is higher than<\/p>\n
-3.0 mmol\/L.<\/p>\n
b) When the patient reaches 32 C, NaHCO3 is administered to resolve metabolic acidosis according to the following formula:<\/p>\n
(0.3 x BE x kg wt)\/2. <\/p>\n
c) When transfusing PRBC’s, 5 – 10 mEq NaHCO3\/RBC unit is added to correct the acid\/citrate in the donor unit.<\/p>\n
N. Blood Transfusion Guidelines<\/p>\n
Autologous<\/p>\n
Homologous<\/p>\n
Q. Deep Hypothermic Circulatory Arrest Technique<\/p>\n
Cooling<\/p>\n
Procedures requiring circulatory arrest typically utilize single venous cannulation.<\/p>\n
The perfusionist initiates topical cooling by setting the water bath of the warming blanket to 18\u2070C once the patient A-line is inserted and functional properly.<\/p>\n
Upon initiation of CPB, the perfusionist cools the patient by maintaining an 10\u2070C temperature gradient between the perfusate and rectal and\/or nasopharyngeal temperature whichever is highest. This technique avoids the generation of gaseous emboli when the solubility in the blood of atmospheric gases is lowered by excessive re-warming of the perfusate in the tissue. When a perfusate temperature of 18\u2070C is safely reached, do not allow the perfusate temperature to rise above 18\u2070C prior to circulatory arrest. At no point should the perfusate temperature be allowed to fall below 15\u2070C.<\/p>\n
When CPB is established, the anesthesiologist should pack the patient’s head in ice in order to facilitate cerebral preservation.<\/p>\n
If a significant temperature differential (> 5\u2070C) arises between the nasopharyngeal and rectal temperatures during cooling, the perfusionist should administer 0.1-2.0% Sevofluorane to facilitate uniform cooling.<\/p>\n
40-50 minutes is the usuall amount time required to cool the patient to 18 – 20\u2070C at which point the surgeon requests the perfusionist to take the patient off CPB.<\/p>\n
The perfusionist sequentially turns off the gas flow and purge line of the arterial line filter (ALF), slows down the arterial pump-head, simultaneously clamps the arterial line and unclamps the membrane recirculation line, stops the CPB clock, and declares “off bypass.<\/p>\n
Inform the surgeon with the arrest time every 5mins.<\/p>\n
Selective Cerebral Perfusion<\/p>\n
At surgeon request selective cerebral perfusion will start at the time of circulatory arrest or within few minutes.<\/p>\n
The flow rate will be dictated by the patient weight and the surgeon request at the time of selective cerebral perfusion. Flow is usually \u2265 10cc\/kg\/min.<\/p>\n
Inform the surgeon with the cerebral perfusion time every 10mins<\/p>\n
Re-initiation and Re-warming<\/p>\n
Just prior to re-initiation of CPB, the surgeon will request that the ice be removed from the patient\u2019s head.<\/p>\n
CPB is re-instituted at the surgeon’s request. The flow rate should begin slowly and to be increased gradually with increase in temperature.<\/p>\n
When CPB is fully re-established, the untoward effects of global tissue acidosis should be monitored carefully. Sodium bicarbonate should be administered in a timely manner according to the following formula: (0.3 x base deficit x kg weight)\/2.<\/p>\n
When re-warming is initiated, the perfusionist should also begin to hemoconcentrate to the target Hct.<\/p>\n
During re-warming, a 10oC temperature gradient between the water bath of the Heater\/Cooler Unit and the venous perfusate should not be exceeded.<\/p>\n
From this point onward, the conduct of perfusion during procedures utilizing circulatory arrest does not differ remarkably from other CPB procedures.<\/p>\n
R. CPB Termination<\/p>\n
Before termination, clear announcement of the termination to the heart team after making sure that anestisiologist is ventilating the patient well.<\/p>\n
CPB is terminated in the usual manner with clamps placed on both the venous and arterial lines.<\/p>\n
Before reducing blood flow rate, confirm that purge line is closed and that sampling line is also closed with arterial side stopcock.<\/p>\n
When stopping the pump, stop gas flow at once.<\/p>\n
During recirculation, check blood gas pressure. An excessive gas flow may cause low PaCO2, alkalosis, or blood damage.<\/p>\n
The perfusionist must consult with the surgeon and anesthesiologist to determine the target filling pressure necessary to achieve hemodynamic stability.<\/p>\n
Continuously monitor the hemodynamic status of the patient.<\/p>\n
In the event that the filling pressure drops below the target value, the surgeon or Anesthesia attending will ask the perfusionist to increase pump to refill the heart with ~ 50-100cc of pump blood to reach the targeted value.<\/p>\n
In the event that the filling pressure increases above the target value, the heart can be relieved by unclamping the venous line to steal some volume.<\/p>\n
SECTION 12<\/p>\n
Monitoring<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
_____________________________________________________________________________<\/p>\n
8.1: The perfusionist shall monitor and document all the following during open heart surgeries according to an established protocol.<\/p>\n
Practice Guidelines<\/p>\n
Arterial blood pressure<\/p>\n
Pump Arterial line pressure<\/p>\n
Blood flow (Calculated blood flow rate should be determined prior to cardiopulmonary bypass using the patient\u2019s body surface area (BSA) and Cardiac Index (CI).<\/p>\n
Body surface area m2<\/p>\n
Body temperature (cooling\/rewarming)<\/p>\n
CPG line pressure<\/p>\n
Coronary Sinus Pressure (during retrograde CPG)<\/p>\n
CVP\/PAP<\/p>\n
ABG<\/p>\n
ACT<\/p>\n
Cerebral O2 saturation <\/p>\n
Venous pO2<\/p>\n
Arterial pO2<\/p>\n
Urine output <\/p>\n
Anesthesia level<\/p>\n
Vacuum assisted device setting<\/p>\n
Gas blinder setting <\/p>\n
8.2: Appropriate monitoring devices shall be employed.<\/p>\n
Practice Guidelines<\/p>\n
A. Should include the following patient\/circuit devices:<\/p>\n
Blood flow indicator<\/p>\n
Gas flow meter<\/p>\n
Physiologic monitor(s)<\/p>\n
Hematologic monitor(s)<\/p>\n
Temperature probs <\/p>\n
Timers <\/p>\n
Pressure transducer\/ aneroid <\/p>\n
B. Also, it may include:<\/p>\n
Blood gas analyzer<\/p>\n
Continues blood parameters monitoring <\/p>\n
Oxygen saturation monitor(s)<\/p>\n
Chemistry monitor(s)<\/p>\n
8.3: Appropriate monitoring for the Cardiopleagia delivery system.<\/p>\n
Practice Guidelines<\/p>\n
Dose<\/p>\n
delivery method<\/p>\n
line pressure (antegrade)<\/p>\n
coronary sinus pressure (retrograde)<\/p>\n
ischemic intervals shall be monitored continually during CPB. <\/p>\n
8.4: Appropriate monitoring for patient\u2019s body temperature shall be employed.<\/p>\n
Practice Guidelines<\/p>\n
Patient Temperatures, including:<\/p>\n
a) Patient core (at least one)<\/p>\n
Nasopharyngeal <\/p>\n
Bladder<\/p>\n
Esophageal<\/p>\n
Rectal <\/p>\n
Tympanic<\/p>\n
b) Optional<\/p>\n
Myocardium<\/p>\n
CPB temperatures:<\/p>\n
Venous return blood <\/p>\n
Arterial blood inflow<\/p>\n
a) Optional <\/p>\n
Water bath(s)<\/p>\n
8.5: The temperature sensor shall include an audible and visual alarm to prevent high arterial outlet temperatures.<\/p>\n
SECTION 13<\/p>\n
Permitted Cardiovascular Perfusion Medical Drugs<\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
Priming Solutions<\/p>\n
Crystalloids (A crystalloid solution with electrolyte composition and osmolarity similar to plasma protein)<\/p>\n
Plasmalyte <\/p>\n
Normal Saline<\/p>\n
Ringer lactate<\/p>\n
Mannitol<\/p>\n
Colloids (A colloid solution exerts an osmotic pressure to keep water in vascular system) <\/p>\n
albumin or plasma protein fraction<\/p>\n
hydroxyethyl starch (HES)<\/p>\n
Anticoagulants<\/p>\n
Heparin (Heparin is used on CPB to prevent thrombus formation in the oxygenator and the circuit)<\/p>\n
Thrombate III (Antithrombin III deficiency in connection with surgery)<\/p>\n
Bivalirudin (As an alternative to heparin in case of Heparin-induced thrombocytopenia) <\/p>\n
Anticoagulant antagonists<\/p>\n
Protamine Sulfate (To reverse heparin after CPB surgery. In the presence of heparin forms inert salt to neutralize both drugs)<\/p>\n
Fibrinolytic Inhibitor<\/p>\n
Tranexamic acid (To reduce bleeding after cardiac surgery)<\/p>\n
Aminocarpoic Acid <\/p>\n
Antiarrhythmic (Ventricular arrhythmias, Anti-dysrhythmic, Ca Channel Blocker slow rate of SA node impulse formation in myocardium and prolong conduction time, and promotes movement of calcium, potassium, and sodium in and out of cells and stabilizes excitable membrane) <\/p>\n
Lidocaine HCL <\/p>\n
Magnesium Sulfate<\/p>\n
Hyperglycemia<\/p>\n
Glucagon (Treatment of hypoglycemia. Convert glycogen to glucose)<\/p>\n
Hyperglycemia<\/p>\n
Regular Insulin (Treatment of DM, on CPB sometimes used to lower serum potassium if glucose is also high)<\/p>\n
Cardiac Inotropic<\/p>\n
Epinephrine (Cardiac arrest to establish rhythm and increase heart rate)<\/p>\n
Norepineprine (Acute hypotensive crisis which alpha stimulation cause peripheral constriction and rise blood pressure. Beta stimulation increase myocardial contractility and vasodilates coronary arteries)<\/p>\n
Phenylephrine (Maintenance of blood pressure in the treatment of shock. Used on CPB to maintain blood pressure)<\/p>\n
Calcium chloride (Indicate for arrythmias associated with hypocalcemia, hyperkalemia, or hypermagnesemia) <\/p>\n
Antihypertensive (Used on CPB due to direct powerful vasodilator effect on arterial vessels)<\/p>\n
Sodium Nitroprusside <\/p>\n
Trimethaphan <\/p>\n
Agents for Acidosis (To correct metabolic acidosis during CPB)<\/p>\n
Sodium Bicarbonate<\/p>\n
THAM<\/p>\n
Diuretics<\/p>\n
Furosemide (No urine on CPB due to decreases of renal blood flow and glomerular filtration rate)<\/p>\n
Steroids<\/p>\n
Dexamethasone (Depresses response of affected tissue due to CPB circuit)<\/p>\n
Triostat (T3) (Unable to wean from CPB, increase synthesis and utilization of myocardial high energy phosphates)<\/p>\n
Cardioplegia Solutions<\/p>\n
Potassium Chloride (Used for Myocardial protection. Potassium in large doses causes electromechanical arrest. This requires the concentration of potassium in cardioplegia solution to be much higher if mixture of blood and cardioplegia is used)<\/p>\n
histidine-tryptophan-ketoglutarate (Custodial) (Custodial provide a long myocardial protection used in complex cardiac surgery and valve surgery, but not recommended for patient with impaired cardiac function which influence the susceptibility of the myocardium to ischaemia \u2013 reperfusion injury)<\/p>\n
SECTION 14<\/p>\n
Special Devices Management <\/p>\n
CATEGORY: Patient Care Code: <\/p>\n
Effective: mm\/yy<\/p>\n
Revised: mm\/yy<\/p>\n
SUBJECT: Cardiovascular Perfusion Page: 1 of 31<\/p>\n
Extracorporeal Membrane Oxygenation<\/p>\n
Preparing <\/p>\n
Make sure the console and warmer are connected to power.<\/p>\n
Battery test for both of them, if any concerns switch to another.<\/p>\n
Check out the all-screen bottoms are functioning well.<\/p>\n
Trace the oxygen blinder and air lines if any kink or tear.<\/p>\n
Oxygen cylinder should be attached on trolly and ready to use.<\/p>\n
Check expiry of oxygenator pack before using.<\/p>\n
All sterile single packs are ready such as (metallic scissor, syringes, tube ties, 4X4 gauzes, metal tube clamps).<\/p>\n
Heparin and normal saline 3 bottles. <\/p>\n
Cannulas chosen should equivalent to cardiac index 2.2 \u2013 2.4L\/m2\/min<\/p>\n
Arterial typically 15 to 25 Fr length 15&23 cm (be sure to prepare Art. Catheter kit 100-150 cm with J-tip guidewire) <\/p>\n
Venous 19 to 29 Fr length 38-55-70 cm (be sure to prepare Ven. Catheter kit 100-150 cm with J-tip guidewire)<\/p>\n
(Note that follow with manufacture details in regard of Pressure\/ Flow rate ratio) <\/p>\n
Priming <\/p>\n
Open the oxygenator pack and close all the clamps circuit.<\/p>\n
Hang-up the filling bag of circuit on stand.<\/p>\n
Connect the bag to circuit and be sure all clamps are shut.<\/p>\n
Connect the oxygenator to console then attach the sampling line to oxygenator and close it. Thereafter, check all ports are closed. <\/p>\n
Attach pressure sensor and water lines to the oxygenator. (don\u2019t connect flow meter and venous prop yet)<\/p>\n
Move to screen for zeroing all pressure bottoms then be sure the mode either VV or VA. <\/p>\n
Fill the priming bag with 3 bottles of normal saline and add 5,000 u of heparin.<\/p>\n
Be sure the rpm is a zero flow, then open the circuit clamps by sequence starting from access clamp to return clamp back to prime bag.<\/p>\n
Next, move to the oxygenator for deairing starting from sampling port of pre-oxygenator to post-oxygenator. <\/p>\n
Increase rpm upto 4000 for 2 mins with using timer of the machine.<\/p>\n
Calibrate venous saturation probe while its running.<\/p>\n
Stop the rpm then bleed all oxygenator ports.<\/p>\n
Start run the machine on high flow for 2 mins<\/p>\n
Stop rpm and place flow meter in the right direction, then apply two tubing clamps pre\/post flow meter probe, from machine screen zero the flow.<\/p>\n
Move the tubing clamp to the access line and clamp it. <\/p>\n
Initiation <\/p>\n
Before start the service make sure all consumables are available at patient bedsit, and the gas lines connected and functioning.<\/p>\n
1. Bolus of heparin must be administrated to the patient <\/p>\n
2. Both cannulas must be flushed with heparin.<\/p>\n
1. ACT machine with 2 cartridges must be available, and ACT reading must be 250 sec prior to initiation.<\/p>\n
2. ABG must be done before initiation. <\/p>\n
3. After connect the lines, trace both lines and inspect it for if there\u2019s any air bubbles.<\/p>\n
4. Increase the RPM up to 1500 and then unclamp the access line.<\/p>\n
5. Slowly unclamp the return line and increase the flow up to the calculated flow.<\/p>\n
6. Keep the FiO2 High and maintain SpO2 above 92%.<\/p>\n
7. keep the sweep gas setting on half of the flow.<\/p>\n
8. Gas setting changes must be done after running another ABG.<\/p>\n
Hyperthermic Intraperitoneal Chemotherapy<\/p>\n
Purpose:<\/p>\n
Delivery of hyperthermic (42.5 degrees Celsius) chemo-therapeutic peritoneal lavage for an extended period of time (60-90 minutes) in order to neutralize and\/or destroy residual tissue or cells containing malignant carcinoma, post surgical debulking of a malignant tumor in the abdomen or pelvis.<\/p>\n
Hyperthermia catalyzes the efficacy of the chemo-therapeutic agent, and potentiates targeting of cancer infected cells.<\/p>\n
Equipment:<\/p>\n
Roller head pump<\/p>\n
Venous Reservoir<\/p>\n
AV loop- \u00bc\u201d delivery and 3\/8\u201d return<\/p>\n
Fenestrated return tubing section (12 inch long segment of fenestrated 1\/2\u2033 tubing)<\/p>\n
\u201cY\u201d tubing to facilitate both forward and return lavage flows throughout the target area, and return to allow continuous circulation of this chemo-therapeutic lavage for an extended period of time.<\/p>\n
\u201cQuick Connect\u201d male and female adaptors to reduce the potential for blood\/chemo spills, or the need to cut in adaptors and connectors.<\/p>\n
Prime should constitute a 3 liter bag of peritoneal dialysis lavage solution that is typically employed for routine peritoneal dialysis.<\/p>\n
6 Liters of pre-warmed H2O for use after the peritoneal lavage, to chase and eliminate remaining chemo-therapeutic agents in the abdominal cavity.<\/p>\n
A predefined process for where to shunt potential 10-12 liters for disposal or away from your circuit (if returning volume overload becomes an issue)<\/p>\n
Cautionary Notes:<\/p>\n
The chemo-therapeutic drugs used in this procedure are potentially lethal or can cause significant harm if the clinician is inadequately protected or inadvertently exposed to direct contact with the drug, it\u2019s residue, or slight skin contact.<\/p>\n
Respiratory re-breather circuits are a necessary precaution and MUST be worn.<\/p>\n
Eye protection is mandatory.<\/p>\n
Latex gloves should be worn as they are thicker and less susceptible to accidental tearing. Double gloving is a significant consideration.<\/p>\n
OR Suites are typically access restricted-with \u201cNo Entry\u201d signs posted.<\/p>\n
Pregnancy is a contraindication for clinical involvement.<\/p>\n
It is essential that you confirm with pharmacy the total volume of the chemo-perfusate.\u00a0 To maintain proper concentrations (most often 3 liters of prime) if the drug is delivered in a 1000 cc bag, that volume will need to be taken off your priming volume in order to maintain desired concentration of the chemo agent.<\/p>\n
Perfusion Requirements:<\/p>\n
Thermoregulator\/Delivery Device<\/p>\n
Cardioplegia set with pressure monitoring capacity<\/p>\n
Bubble trap\/De-airing capability<\/p>\n
Please note: Air is NOT an issue here- as it is basically a pump-in and\u00a0pump-out chemical lavage of the abdominal cavity, with no intravascular communication or conduits in play.<\/p>\n
Reservoir<\/p>\n
Rapid prime line with 2 spikes<\/p>\n
Volume shunting capability shifting Q from return reservoir- to a waste bag: Will need at least two 4 liter containers (Brat drainage bags are EXCELLENT for this purpose). \u00a0Note: The waste bags are \u201cY\u2019d\u201d together with a 3\/8\u201d Y connector so as to reduce exposure risk by not having to disconnect and reconnect waste bags as they fill up.<\/p>\n
Pt Delivery temp monitoring<\/p>\n
Pt Outlet temp monitoring<\/p>\n
Procedure<\/p>\n
The HIPEC ECC should be primed and ready at least 1 hour prior to being deployed.<\/p>\n
Expect a reasonable 2-3 hours prior to HIPEC to allow for surgical debulking of tumor.<\/p>\n
Prime should constitute a 3 liter bag of peritoneal dialysis lavage solution that is typically employed for routine peritoneal dialysis.<\/p>\n
Prime should be warmed to roughly 44-45 degrees Celsius (assuming heat loss in transit to the patient body cavity).<\/p>\n
An AV loop to be opened and delivered sterilely to the operating field.<\/p>\n
An adjunct tubing kit- with \u201cY\u201d capability, should be considered as an integral part of optimizing lavage inflow as well as outflow in order to ensure optimal intra-abdominal surface area contact with the chemo-therapeutic agent.<\/p>\n
When initiating the initial peritoneal lavage (no chemo agent added yet) you will probably need to deliver 5 liters before having enough volume in the abdominal cavity to establish full flow. Once you see abdominal distension, open your return line to begin recirculating the warm peritoneal diasylate.<\/p>\n
Typical Q rate is 1.5 to 2.0 LPM, at 42.5 degrees Celsius.<\/p>\n
The surgeon will instruct you as to when to add the chemo agent, and start your timer for the established period of time (60-90 minutes) that the surgeon wants you to lavage the abdomen.<\/p>\n
Have at least 6 liters of pre\u2013warmed H2O ready to infuse into the system once the chemo run is completed.<\/p>\n
At the end of the chemo run, drain the patient\u2019s abdomen have the Surgeon depress the belly to help empty as much of the chemo agent as possible.<\/p>\n
You will need to shunt this volume to waste bags, so that it is removed from the perfusate.<\/p>\n
Once your reservoir is empty, drop 6 liters of warm H20 into your reservoir, and fill the abdomen as you did earlier.<\/p>\n
Essentially, you are now just rinsing the abdomen to remove as much residual chemo agent as possible.<\/p>\n
Establish Q and after a few cycles, start to drain the patient\u2019s abdomen when the perfusate looks clear.<\/p>\n
The Surgeon will assist by compressing the belly and once you are finished, he will suction out the remaining fluid into an outside suction source.<\/p>\n
When finished, your lines will be handed back, and all of your tubing and waste fluids must be handled with extreme caution and disposed of following the Hospital\u2019s protocol.<\/p>\n
INTRAAORTIC BALLOON PUMP (IABP)<\/p>\n
The IABP is an intravascular volume counterpulsation\u00a0 device that augments the circulation by the displacement of aortic blood volume in diastole and reduces the work load of ventricular ejection in systole.<\/p>\n
Expanded use of the IABP\u00a0 now includes the following:<\/p>\n
Unstable angina refractory to medical therapy.<\/p>\n
Preoperative and intraoperative assist in the patient presented with cardiogenic shock.<\/p>\n
Circulatory stabilization in patients with sudden development of ventricular septal defect and mitral regurgitation.<\/p>\n
Postoperative interim organ support.<\/p>\n
EQUIPMENT<\/p>\n
IABP console different models <\/p>\n
balloon (with or without central lumen), including percutaneous insertion kit<\/p>\n
Catheter extension<\/p>\n
Pressure cable<\/p>\n
Five-lead patient cable with electrosurgical interference suppresser filter blocks<\/p>\n
Slave cable for both electrocardiography (ECG) and pressure monitoring<\/p>\n
Silver-Silver chloride ECG skin electrodes<\/p>\n
Fibreoptic sensation balloon<\/p>\n
PROCEDURE<\/p>\n
CAUTION: Before operating the equipment the user must be familiar with controls and functions of the IABP console.<\/p>\n
Establish power. Console will automatically go through self test.<\/p>\n
Perform safety chamber leak test (refer to operators manual for instructions on performing this test), if applicable.<\/p>\n
Open helium cylinder (close when system is not in use).<\/p>\n
Acquire ECG either with skin leads or via slave of existing monitor.<\/p>\n
Acquire pressure trace either through central lumen of IABP catheter, arterial line, or via slave of existing monitor.<\/p>\n
Initiate assist. Best to start at an assist rate of 1:2 so that proper timing adjustments can be made.<\/p>\n
Adjust timing. The system automatically establishes correct timing of the IABP in the autotiming mode.\u00a0 The inflation and deflation controls may be adjusted to optimize IABP timing, following the manufacturer\u2019s guidelines.<\/p>\n
Myocardial Protection System (Quest MPS)<\/p>\n
Blood: Crystalloid setting<\/p>\n
All blood or \u201cb\u201d setting throughout case<\/p>\n
All Crystalloid or \u201cc\u201d setting throughout case<\/p>\n
Arrest Pouch Setting: 21mEq\/L<\/p>\n
Potassium chloride 2mEq\/ml<\/p>\n
Load arrest pouch with 40mEq of KCL (20ml)<\/p>\n
Additive Pouch Setting: 21ml\/L<\/p>\n
Mannitol 20% 32ml<\/p>\n
Lidocaine 2% 13ml<\/p>\n
Magnesium Sulfate 50% 8ml<\/p>\n
Total Volume: 53ml <\/p>\n
Load additive pouch with 40ml<\/p>\n
Temperature<\/p>\n
Cold 8-15 \u0366C<\/p>\n
Warm 33-36 \u0366C<\/p>\n
Induction Dose<\/p>\n
15ml\/kg Cold Antegrade<\/p>\n
Minimum Dose: 1000ml<\/p>\n
Maximum Dose: 1500ml<\/p>\n
Subsequent Doses<\/p>\n
200-300ml Cold <\/p>\n
SEE DOSING ASSESSMENT<\/p>\n
Half dose settings: arrest: 10mEq\/L, additive 10ml\/L<\/p>\n
If K+ is greater than 5.5mmol\/L, arrest setting should be 0 for next dose.<\/p>\n
Warm Re-animation Dose Additive setting: 21ml\/L Arrest setting: 0<\/p>\n
General Guidelines: <\/p>\n
Target Aortic Root Pressure: 200-250mmHg. It is important to achieve these pressures quickly. This will assure proper closure of the aortic valve and maximize distribution. <\/p>\n
Target MPS System Pressure: 250-300mmHg. This pressure is reflective of the pressure at the MPS. When targeting a higher root pressure, the pressure differential between the level of the patient and level of the machine must be taken into consideration.<\/p>\n
Retrograde\/coronary sinus Pressure: 35-45mmHg <\/p>\n
Dosing Assessment<\/p>\n
Reanimation dose<\/p>\n
400ml, No K+<\/p>\n
Reanimation dose<\/p>\n
400ml, No K+<\/p>\n
Inadequate arrest or premature activity?<\/p>\n
Inadequate arrest or premature activity?<\/p>\n
Redose at <\/p>\n
surgeon\u2019s discretion<\/p>\n
(desired concentration)<\/p>\n
Redose at <\/p>\n
surgeon\u2019s discretion<\/p>\n
(desired concentration)<\/p>\n
Evaluate patient K+ level\/ estimated remaining arrest time<\/p>\n
Evaluate patient K+ level\/ estimated remaining arrest time<\/p>\n
Sustained activity?<\/p>\n
Sustained activity?<\/p>\n
Evaluate <\/p>\n
delivery method<\/p>\n
Evaluate <\/p>\n
delivery method<\/p>\n
Induction Dose<\/p>\n
(15ml\/kg)<\/p>\n
1000ml minimum<\/p>\n
1500ml maximum<\/p>\n
Induction Dose<\/p>\n
(15ml\/kg)<\/p>\n
1000ml minimum<\/p>\n
1500ml maximum<\/p>\n
60 minute assessment <\/p>\n
(repeat as needed)<\/p>\n
60 minute assessment <\/p>\n
(repeat as needed)<\/p>\n","protected":false},"excerpt":{"rendered":"
PROTOCOLS and GUIDELINES OF PERFUSION Table of Contents Section 1: Principles Purpose\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026. Goal Statement\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026. Essentials & Guidelines For Perfusion Practice In (xxxxxxxx) Section 2: Qualification, Competency and Support Staff Section 3: Clinical Perfusion Activities Primary\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026. Secondary\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026. Section 4: Communication Section 5: Staffing & Duty Hours Section 6: Perfusion Record Section 7: Checklist Section 8: CPB […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10],"class_list":["post-97813","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97813","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=97813"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97813\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=97813"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=97813"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=97813"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}