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PERFUSION  Also called as the heart-lung machine

 It involves the study of physiology, pathology and the  Device that takes over the body’s heart and lung during
associated equipment used to support the function of surgeries
heart’s and/or lungs during surgical procedures.  This machine circulates the essential oxygen rich blood
 Example: Cardiopulmonary bypass, Open-heart to the brain and to other vital organs during open-heart
surgery surgery
 Allows the surgeon or the operating team to conduct
Definition of Terms surgery, blood-free
PERFUSION  Continuous circulation of blood
 can be defined as the process in which blood is forced  After the surgery, heart is restarted and heart-lung
to flow through a network of microscopic vessels within machine is disconnected.
biologic tissue, allowing exchange of oxygen and other
molecules across semipermeable microvascular walls.

PERFUSATE
 any fluid flowing through a tissue or organ

PERFUSIONIST
 individual responsible for operating extracorporeal
circulation equipment during an open-heart surgery or
any other medical procedure in which it is necessary to
artificially support or temporarily replace a patient's
circulatory or respiratory function. CARDIOPULMONARY MACHINE
 Has proper training and seminar  is a machine that temporarily takes over the function of
 Has a licensed individual that operates the heart and the heart and lungs during a cardiac surgery by
lung function maintaining the circulation of blood and oxygen
throughout the body.
CARDIOPULMONARY BYPASS (CPB)
 technique that temporarily replaces the function of the MECHANISM OF CARDIOPULMONARY MACHINE
heart and lungs while the heart is arrested to provide a  Venous blood is drained by gravity in to the reservoir
still and bloodless surgical field via cannula/cannulae
 Place in the right atrium or large vein then pumped to
CARDIOPULMONARY BYPASS the oxygenator and returned to the patient’s arterial
 provides a pump to substitute for the function of the system via cannula in the aorta or other large artery
heart and a gas exchange device, the “oxygenator,” to vein
act as an artificial lung
 allows the patient’s heart and lungs to be temporarily JOHN GIBBON
devoid of circulation, and respiratory and cardiac
activity suspended, so that intricate cardiac, vascular
or thoracic surgery can be performed in a safe and
controlled environment.
 Use of heart-lung machine during a surgery ○ Provides
patient to have a cardiac and pulmonary support while
bypassing the heart and lungs ○ Stops the heart and
needs replacement ○ It provides 3 physiologic
processes/function:
 Adds oxygen to the blood (the operation of the lungs
will be stop)
 Pumps and circulates the blood through bothe the  Credited for developing the first mechanical
cardiopulmonary bypass circuit and the patient cardiopulmonary bypass machine
 Removes excess Carbon dioxide (CO2) from the  Used on repairing atrial septal defect - birth defect in
blood. which there is a hole in wall of the septum that divides
 Allows the patient’s heart and lungs to be temporarily the upper chamber of the heart
devoid of circulation, and respiratory and cardiac  That hole may close on its own or not
activity suspended, so that intricate cardiac, vascular  Type of a congenital heart defect
or thoracic surgery can be performed in a safe and
controlled environment.

SPDX311 | Ortega, J.
TYPICAL CPB CIRCUIT

COMPONENTS OF THE CPB MACHINE AND THE Kinds of Tubing:

EXTRACORPOREAL CIRCUIT 1. POLYVINYL CHLORIDE
 most commonly used
 Versatility, flexible but fairly rigid plastic
 Because of the component, Tend to induce escalation,
release of microplastic particles in the circulation
2. SILICONE
 reserved for arterial pump boot
 Arterial puncture
 Less hemolysis and more microplastics than PVC
3. LATEX RUBBER
 Least used because it generated more hemolysis

TUBING SIZES COMMONLY USED IN DIFFERENT PARTS

Example: like the refrigerator in the lab, there is an alarm to OF THE EXTRACORPOREAL CIRCUIT (ADULTS)
determine if the blood does not have oxygen (referring to the
low-level alarm)
 All alarm systems are linked in a computer system of
the cardiopulmonary bypass machine that directly
regulates or stops the pump flow when appropriate
 Monitoring levels of component of blood (pressure,
bubble detector, oxygen sensor, hemoglobin monitor,  Bigger tube – removing of the blood
in-line blood gas monitoring
TUBING
 Interconnects all of the main components of the circuit

SPDX311 | Ortega, J.
CANNULAE PUMP HEADS
 Connects the patient to the circuit and hence to the o responsible for creating the necessary pressure to
CPB machine. They are made of PVC and are wire circulate oxygenated blood from the CPB machine to
reinforced to prevent obstruction due to kinking. the patient's body and then return deoxygenated blood
back to the machine.
Two types: Roller pump and centrifugal pump
Roller pump
 Produce a flow
 Positively displace blood through the tubing through a
Peristaltic motion ○ 2 rollers - : roll the blood through
the tubing, through the tubing continuously
 Tend to resemble the pattern of a blood flow generated
by a cardiac cycle
 Commonly used because of it is less expensive and
reusable and only the tubing is replace
Centrifugal pump
 Produce a pressure
 Cones that spins as a result to a magnetic force that is
2 Types (Arterial Cannula and Venous Cannula) generated by a pump that is activated
1. Arterial cannula: is used to connect the “arterial limb”  Less hemolysis compared to roller pump
of the CPB circuit to the patient and so deliver  Not a factor but depends on the machine
oxygenated blood from the heart-lung machine directly  Expensive because the pump is disposable and single
into the patient’s arterial system. use only.
o Ascending aorta - most common site of  Use when the surgery is complex and tend to produce
arterial cannulation for routine cardiovascular less damage/trauma to the blood
surgery.
o Commonly used arterial cannulae

2. Venous cannula: allows deoxygenated blood to be

drained from the patient into the extracorporeal circuit
of venous
o Use: patients does not involve opening the
chambers of the heart
o Bicaval Cannulation - An alternative method
of venous cannulation for CPB
o Commonly used venous cannulae

RESERVOIR
 May be hardshell or collapsible.
 Acts as a chamber for the venous blood to drain into
before it is pumped into the oxygenator and permits
ready access for the addition of fluids and drugs.
 Hardshell reservoir is commonly use in adult surgery
 Collapsible reservoir, can be use in some adult cases
but mainly, pediatric cases

SPDX311 | Ortega, J.
 major concern is the protection of the heart during
operation
 maintain the condition of the heart
 CPB temporarily stops the heart - it can result in a
 may be hardshell or collapsible. decrease of energy reserve and production of the lactic
 acts as a chamber for the venous blood to drain into acid/acid blood. That process produces a decrease in
before it is pumped into the oxygenator myocardial activity, immediately followed by restoration
 permits ready access for the addition of fluids and of blood flow and heart function with the help of
drugs. equipment to maintain the reserve component of the
heart.
OXYGENATOR  Cardioplegia delivery system delivers the preserved
 the oxygenator component serves as the lung and is heart function during the ischemic period (pagtigil ng
designed to expose the blood to oxygen and remove function) until gumana yung cardiopulmonary bypass.
carbon dioxide.  Cardioplegia - we put the heart to a state of hibernation
 Provides an interface of high surface area between  Potassium
blood on one side and gas on the other.  Cause a diastolic cardiac rest
 The distance gas has to travel across the interface is  Produce a flaccid heart that facilitate the surgery
minimized by constructing the membrane from very  NSS can be use, complex antioxidants but potassium
thin material. is mainly used
 The present success relies heavily on extracorporeal MONITORS
perfusion techniques which employ an efficient gas  In-line blood gas analysis and venous
exchange mechanism because of the oxygenator. saturation/hematocrit monitors
Requirements Of The Oxygenator:  pH, hemoglobin level, temperature etc
 efficient oxygenation of the saturated hemoglobin
 continuous/simultaneous removal of CO2 on the blood
 acts as an artificial lungs
 most commonly used is membrane oxygenator
microporous polypropylene fiber structure

HEMOFILTERS
 Also known as ultrafilters or hemoconcentrators
 Contain semipermeable membranes that permit
passage of water and electrolytes out of blood
 Fluid removal is usually 30 to 50 ml/minute, and Pre-bypass checklist
depending on the membrane used, molecules of up to  minimum requirements for cardiopulmonary bypass
20 000 Daltons are removed. procedures
 covering all aspects from sterility to backup
components.

 Hemofilters mainly for management for hyperkalemia,

prevent acidosis
 Sustain a healthy level

CARDIOPLEGIA DELIVERY SYSTEM

 The common constituent of all cardioplegia solutions is
a high concentration of potassium as this produces
diastolic cardiac arrest.

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 Checklist is important because the life of the patient SAFETY ON SEPARATING FROM CPB MACHINE
relies here.
 Human error has the highest impact of incident
 Check the expiration date, sterile items, integrity of the
materials

SAFETY CONCERNS PRIOR TO, DURING, AND AFTER CPB

 planned procedure and likelihood of additional
procedures
 allergies
 significant comorbid conditions, such as diabetes or
renal dysfunction; and
 metabolic or hematological abnormalities CONDUCT OF CPB: When is CPB done?
(e.g. anemia, thrombocytopenia or hyperkalemia)  Coronary Artery Bypass
 The patient’s blood group should be confirmed and the  Heart Transplantation
availability of donor blood bags are checked. (In case  Heart Septal Defect Repairs
of blood loss, ready for transfusion)

Details of the patient’s height and weight are essential to

calculate:
 dose of heparin (usually 300 mg/kg) required for CPB;
 body surface area (BSA) in square meters, which is
required to determine the “ideal” flow rate at
normothermia (BSA × cardiac index) and so to select
appropriately sized venous and arterial cannulae;
 predicted HCT on initiation of CPB

SAFETY CONSIDERATIONS BEFORE CPB

SAFETY CONSIDERATIONS DURING CPB

THINGS TO CONSIDER BEFORE PERFORMING CPB

1. Priming
2. Anticoagulation
3. Temperature Management
4. Acid Base Management

PRIMING
 Dealing of the CPB circuit is done by priming solutions,
consisting of a mixture of crystalloids and colloids.
Priming causes hemodilution which improves flows
during hypothermia.
 CPB circuit/ machine must be primed with fluid solution
so that adequate flow rates can be achieved on the
initiation of CPB without the air embolism.

SPDX311 | Ortega, J.
 use a solution similar electrolyte content with the CPB Circuit (Simplified)
osmolarity of blood content to improve blood flow
 use dextrose, saline, bicarbonate

Weaning
 Process of transition from cardiopulmonary bypass
ANTICOAGULATION
(CPB) to normal, physiological circulation
Unfractionated heparin (UFH)
 remains the standard anticoagulant for CBP for several Complications
reasons. It is relatively safe, easy to use, has a fast 1. Selective cerebral perfusion
onset of action, measurable, titratable and reversible. 2. Plaque dislodgement and dissection
It is also cost-effective. 3. Massive air embolism
 anticoagulation is required for any form of 4. Qualitative and quantitative platelet dysfunction
extracorporeal circulation to prevent the activation of Inflammatory response
clotting 5. Hypotension
6. Acute kidney injury (AKI)
TEMPERATURE MANAGEMENT 7. Acute respiratory distress syndrome
 Hypothermia is frequently used during CPB for its
presumed organ protective effects.
 Blood viscosity increases with hypothermia and allows References
maintenance of a higher perfusion pressure despite  Prof. Rose Dyane Nunag, SPDX311 Lecture Notes
hemodilution.

ACID-BASE MANAGEMENT
 With cooling, co2 becomes more soluble in the blood
(partial pressure decreases)

SPDX311 | Ortega, J.