Flashcards in Cardioplegia and MUF Deck (67):
CHOOSING A CARDIOPLEGIA SYSTEM
What we want in pediatrics:
Good heat exchange
Air handling capabilities
A versatile system
air detector used
for shutting down system when air is detected
csc actually has _____ cc of prime
28cc instead of 14 cc
csc 14 put a 4 way stop cock to
allow for recirculation prime
retro cardioplegia cannula sizes DLP neonatal
retro cardioplegia cannula sizes DLP ped.
retro cardioplegia cannula sizes DLP small adult
retro cardioplegia cannula sizes adult
hard tip coronary ostium come in what sizes
soft tip coronary ostium tip size
aortic root cardioplegia cannula 0-7 kg
dlp 18 gauge
aortic root cardioplegia cannula 7-20kg
dlp 16 gauge
aortic root cardioplegia cannula 20-35 kg
dlp 14 gauge
aortic root cardioplegia cannula >35 kg
dlp 12 gauge
dlp vents malleable tip
10 fr on surgeons request
dlp vent curved lv <14 kg
dlp curved lv vent 14-30 kg
dlp adult lv vent 30-50 kg
dlp adult lv vent >50 kg
ANTEGRADE DELIVERY equals
30 mL/kg in pediatric patients.
antegrade line pressure depends
pressure drop across the cardioplegia system (the goal is to maintain root pressure approximately 70 mmHg).
Look at your pre-op pressures
Flow is variable depending on patient size
Retrograde cardioplegia is given into the coronary sinus A balloon is inflated or self inflated and provides two functions:
Prevents backflow Holds cannula in place
RETROGRADE DELIVERY Flow should be titrated to maintain
a coronary sinus pressure of 30-40 mmHg. DO NOT EXCEED 40 mmHg on kidlets
percentage of blood based cp
percentage of crystalloid based cp
del nido solution what type and percentage
blood based 1:4 38%
Customized solutions blood
St. Thomas, Plegisol, or Baxter what type and percentage
blood based 11%
Microplegia what type and percentage
blood based 5%
custodial what type and percentage
St. Thomas, Plegisol, or Baxter crystalloid
customized crystalloid solutions
percentage that uses cold cardioplegia under 10 degrees
percentage that uses hot shots
most common type of hypothermia in neonates an infants
moderate 28 to 31 degrees
most common route of administration in neonates and infants is_______ and the percentage is _____
Longer intervals between cardioplegia doses were associated with surgeons using
del Nido and Custodiol solutions
(these solutions were commonly administered with a single dose regardless of aortic cross-clamp time
del nido solution lies betwee
hyper polarizing and depolarizing solutions
del nido osolarity
dosing to get arrest with del nido
del nido doing for maintenance
del nido delivery rate
90-180 mL min
intracellular low na solution
custodial single administration lasts
up to 2 hours
each component of histidine tryptophan ketoglutarate are used for what
histidine:buffer against acidosis during XC. tryptophan: cell membrane stabilizer. ketoglutarate: improves atp production during reperfusion
The addition of magnesium may provide
a protective effect on the hypoxic-ischemic immature heart.
protective effect of mag. due to
antiarrhythmic effect of magnesium, inhibited entry of calcium into the myocytes, and decreased uptake of sodium by myocytes during ischemia.
during reperfusion mag is exchanged for
MUF is huge advance because
allow recovery of the pump blood for the patient, while allowing the patient to be in a hemodynamic state to accept the volume is the a significant advance for pediatric perfusionists
MUF developed by
Mr. Martin Elliott (Great Ormand Street/Hospital for Sick Children London UK) in 1985
What’s really happening at the hemoconcentrator level 7 things
A. Raising Hct
B. Extravascular fluid crosses ( rapid, large increase in COP and OSMO)
C. Removes inflammatory mediators
D. C-Reactive Proteins cross
E.Protein reactive cytokines cross
F.Complement activation factors cross (C3a, sC56-9, C3 bound)
G. Pulmonary effects > Systemic effects with IL-6, IL-8, and TNF
The principal finding of multiple studies is that :
MUF after CPB in infants did result
in immediate improvements in both static and dynamic pulmonary compliance, but the effect was not sustained after admission to the PICU or 24 hours after the operation.
WHY ARE THESE IMPROVEMENTS NOT SUSTAINED?
A possible reason is that pulmonary compliance is affected both by excess fluid from the hemodilutional effect of bypass,
(As well as by the systemic inflammatory response)
WHY ARE THESE IMPROVEMENTS NOT SUSTAINED? 2
Ultrafiltration after bypass decreases total body water and removes inflammatory cytokines. However, the initiation of the systemic inflammatory response most likely occurs during rewarming.
(MUF starts after the inflammatory cascade has been activated)
WHY ARE THESE IMPROVEMENTS NOT SUSTAINED? 3
It may be that the salutary effects of hemoconcentration and removal of water after bypass by MUF are unable to overcome the ongoing effects of capillary leak possibly caused by an activated ongoing inflammatory response.
The technique of MUF is performed after
CPB is complete and allows filtration of both the patient and remaining contents of the CPB circuit, including the venous reservoir.
Using the MUF technique, an ultrafilter is interposed in the CPB circuit between
the aortic arterial line and the venous After weaning from CPB, the blood is removed from the patient via the aortic canula and fed through the ultrafilter. The outlet of the ultrafilter is fed to the right atrium of the patient.
Blood flow through the ultrafilter approximates
during MUF suction is applied to the_____ which can result in a filtration rate of ______
filter port of the ultrafilter, 100 to 150 mL per minute.
Ultrafiltration is carried out with the end point being either
ime (10–20 minutes) or the achievement of a hematocrit value of approximately 40-50.
Beneficial effects of MUF (5):
total body water is reduced as a direct result of removing the ultrafiltrate.
Reduced hospital stay
Reduced ventilation times
Reduced incidence of pleural and pericardial effusions.
Arguments against MUF(6):
Possible air embolism Remember that air would be entering
Circuit complexity and cost
Prolonged exposure to foreign surface
“Patient can be concentrated before coming of CPB”
What are your endpoints?
Endpoints of hemofiltration vary
mong institutions and can be defined by time, volume, or hematocrit.
In the postoperative period, patients receiving MUF have smaller increases in
In addition to decreasing edema, hemofiltration increases
the hematocrit, which translates into increased oxygen-carrying capacity.
Removed fluids also contain
inflammatory mediators and vasoactive substances.