REVIEW OF CPB Flashcards
(34 cards)
Pre-Bypass PROCESS
Review the patient chart.
Calculate/ determine the necessary blood flow
Determine proper cannulas required for procedure
Calculate drug doses
Calculate predicted hematocrit
Discuss with surgeon Aware of predicted hct Plan for blood product usage
WHAT IS Pre-Bypass Checklist
Checklist that is completed prior to handing up the lines (most of it)
Usually has a component to complete once lines are up at the field just prior to initiation of bypass.
Patient prebyass
Chart reviewed
Procedure verified
Sterility
Components checked for package integrity/ expiration date
Heat exchanger(s) leak tested
pump
Speed controls operational
Roller heads smooth and quiet
Occlusions set
Flow meter in correct direction/ calibrated
Flow rate indicator correct for patient and tubing size
Holders secure
elctrical
Power cords securely connected
Gas Supply
Gas line securely connected Blender functional Hoses leak-free Gas exhaust is unobstructed
Lines/Pump Tubing
Connections secure Tubing direction traced and correct No kinks noted One way valve(s) in correct direction Debubbled/leak-free Patency of arterial line/ cannula verified
Cardioplegia
olution(s) checked System debubbled/ leak-free
Safety Mechanisms
Alarms operational and engaged Arterial filter/ bubble trap debubbled Cardiotomy reservoir vented
Monitoring
Temperature probes in place and calibrated Pump pressure monitors calibrated In-line and/or online sensors calibrated Oxygen analyzer calibrated
Temperature control
Water source connected and functional
supplies
Tubing clamps available
Drugs available and properly labeled Solutions available Blood available Sampling syringes/laboratory tubes available
Anticoagulation
eparin time and dose verified Anticoagulation tested and reported
back up
Hand cranks available
Emergency lighting available Duplicate circuit components available
Preparing to Initiate – Handing up lines
Hand up lines Prime was recirculating warm. Arterial AND Venous Lines clamped Lines handed up
Surgeon/ Assistant/ Scrub Tech will ask to divide the lines. Make sure the arterial and venous lines are in fact clamped!! Will remove the pre-bypass filter
Preparing to Initiate - Heparin
Heparin is given
Loding dose usually 300units/kg given via central line
3-5 minutes later draw an ACT Goal of 480 seconds for initiation of bypass Suckers may be turned on once ACT reaches 2x baseline
Cannulation
Once heparin is in, surgeon will put in purse string sutures
Cannulate De-air arterial cannula and clamp the cannula Bring up arterial line to the cannula Will ask to “come forward”/ “roll up”/ “trickle flow”… Turn on arterial pump SLOWLY!!
Will make a wet-wet connection to the arterial cannula Check for air/bubbles Surgeon will remove clamp on arterial cannula
Check for pulsations Make sure there is adequate line pressure, and adequate
pulsations May be asked to do a test transfusion
Make sure the cannula is in fact in the aorta and not in a false lumen/ misplaced.
If pressure rises greatly during test transfusion Check cannula placement! Check cannula position
Cannulation Venous cannula will be placed
Connected to venous line
Retrograde cardioplegia cannula placed
Now all lines should be placed, we should be ready to go on bypass.
ACT should be complete by this time
Immediately pre-bypass
Double check you’re ready!! Everything’s clamped that should be clamped. Last chance to change anything Last chance to check/tighten any and all connections FiO2 is preset CDI is ready to be turned on Timers are ready to be turned on Heater-cooler is set appropriately
Initiation of Bypass
Surgeon will instruct to “go on bypass”/ “let’s go on” Repeat command – LOUD!!! “Going on bypass” Thengoon
Start arterial pump first Give a little preload Start slow, don’t just hit the patient with 5 liters right away!!
Remove the clamp from the venous line Watch your level Make sure it rises
Keepturninguparterialpumpuntilyoureachfullflow Meanwhile… Openshunts Turn on gas flow
Start your timers Announce “On bypass at _______”
Gettofullflow Most places announce when full flow is obtained (“At full flow!”) Anesthesia stops ventilating
Whew… we’re on! NOW WHAT?!
Do Checks/Scan What are we flowing? Arterial Line Pressure? Oxygen started? Arterial sat coming up? SaO2 / SvO2 normal? Patient blood pressure normal? Temperature – time too cool? Once you’re happy and stable…
Turn on Anesthetic Gas (Vaporizer)
Get ready for AoXC placement Make sure CPG line is filled / clear of bubbles to the table Cool to desired systemic temperature
When you’re settled, draw ACT Never want to be caught behind with heparinization
Cross Clamp Placement
Once you’re cool enough, and surgeon is ready Surgeon will instruct “Flow Down” Repeat command: “Flow Down” Do the action – turn your flow down
Confirm the action: “Flow is down” AoXC on
Listen for the clicks of the clamp Once the AoXC has been placed, the surgeon will tell you “Cross clamp on, come back up on flow”.
Repeat command : “Cross clamp on, coming up on flow” Come up on flow gradually Watch line pressures
Cardioplegia: Abbreviated Version
After the AoXC is on, Cardioplegia will be given. Surgeon will instruct, “Start Cardioplegia” Repeat command “Starting Cardioplegia” Start cardioplegia
Watch delivery pressures Notify surgeon of flow and pressures Give antegrade and retrograde doses
Run the Case
Manage Volume/ Fluid Balance Blood products
Hemoconcentration Manage Anticoagulation Manage Hypothermia Manage Blood Gases (Acid/Base Balance) Management of Myocardial Protection
