Exam 7 - Vent / Suction / Prime Flashcards
Normal return to Ventricles
- Right: systemic venous return coronary sinus drainage \+/- small cardiac vein - Left: Bronchial circulation - Both: Thebesian veins Cardioplegia
Abnormal return to Ventricles
- Right: LSVC
Atrial/Ventricular septal defects
-Left: PDA (bypass lungs)
Systemic to PA shunt
Anomalous systemic venous drainage to heart
AI
Atrial/ventricular septal defects
Bronchial circulation
- nutrients to lungs
- Normal: 1-3% CO
- can be up to 10% if COPD / lung infection / lung inflammation - Bronchial veins empty to pulmonary veins then back to LA
Small cardiac vein
- usually empties to coronary sinus but may also to:
- RA / middle cardiac vein / or may not be there
Thebesian Veins
- Spongy veins in endocardium of heart
- blood bleeds through these into all 4 chambers of heart
- only minor blood return to heart
Antegrade Cardioplegia
- Left coronary
- drains into coronary sinus and RA - Right coronary
- drains into RA via small cardiac vein - Some flow return to all chambers via thebesian veins
Retrograde Cardioplegia
- Most empty into aortic root / L ventricle via left coronary ostia
- not that good at protecting heart (not protecting R heart)
- can’t do at same time as antegrade…heart will blow
LSVC
- normally drains into coronary sinus (92%)
- 0.3-0.5% of pop but 2-10% of patients w/ heart disease
- Problem if opening right heart or bi-caval cannulation
- Problem w/ retrograde cardioplegia
- delivery up the LSVC and/or dilution of solution from return
- Failure of L. Brachiocephalic vein to develop
- Failure of L common cardinal vein to disappear
Blalock-Taussig Shunt
- Right subclavian to Right PA
Waterston Shunt
- Posterior ascending aorta to anterior R PA
AI
- not a problem if heart is beating
- X-clamp stops regurgitation from arterial cannula - can occur during cardioplegia delivery (low aortic root pressure)
- can cause LV distension in fib or arrested heart
- makes putting in balloon pump not worth it
Vent purpose
- prevent ventricular distension
- improve exposure
- aid in myocardial protection
- remove air
- prevent pulmonary venous hypertension
Where to vent
- Both R and L ventricles
- PA vent used if blood is coming back to RV
Myocardial protection
- Keep heart empty
- Decompression: reduces resting O2 use by reducing stretch
40% of protection - Increased subendocardial perfusion: keeping LV empty is optimal for LV coronary perfusion
- Prevent myocardial rewarming: 10% / remove systemic return keeps cool
Air removal
- Venting removes air that got in after closure but before x-clamp removal
Venous cannulation and Return Concerns
- must collect from: SVC / IVC / Coronary sinus
- Bi-caval cannot collect from coronary sinus
- Improper cannula placement
- wrong cannula size
- improper height gradient
Vent locations
- Aortic root: can add cardioplegia line if want
- Right Superior Pulmonary vein: can go into LA or LV
- Main PA: can interfere with Swan catheter (rarely used)
- Apex of LV (least common)
Mechanical drainage
- roller pump
- one way valve to prevent air backflow
- OK to use high RPM w/ vacuum relief valve (prevent hickies)
- Must use low RPM in no vacuum relief valve
- best to monitor LA pressure (to prevent hickies) - just occlusive
Gravity drainage
- Wye vent line into venous return line
- vent line must be primed to prevent air lock
- creates venturi effect
- surgeon controls vent on and off
- Can also use solo siphon drainage tubing
- may not vent enough depending on venous return
Cardiotomy / Pump Suction
- Separate cardiotomy filter reduces microemboli
- More coag factors / endotoxins / complements / Interleukins
- Profound drop in arterial bp often seen when suction blood is infused into patient
- just non-occlusive: don’t want to squish blood
- might be better to use cell savers instead of suckers
- reduction in post op bleeding
- reduction in cerebral fat emboli and stroke rate (SCADs)
Cell-Saver guidelines
- 40-150 micron filter
- vacuum should not exceed -120 mmHg
- Anticoagulant drip must be used: heparin saline / CPD / Bivalirudin
- Washed product returned through filter
- Should be washed with at least 1000 mls of saline - clear effluent
- washed product into separate reinfusion bag - less air
~bag labeled w/ patient name ID / exp time / volume / autologous note - never use pressure bag to speed reinfusion time
Transfusion practices
- product hematocrit > 40%
- product K < 3.0 mEq/L
- product free hemo [ ] < 100 mg/dL
- product heparin [ ] < 0.5 units/ml
Colloid
- Mixture
- Larger insoluble molecules
- Blood
Crystalloid
- aqueous solution of mineral salts or other water soluble
- Normal saline
Colloid osmotic pressure (oncotic pressure)
- Protein [ ] that pulls fluid into capillary system
Osmotic pressure
- pressure needed to prevent inward flow of water across semi-permeable membrane
History of prime
- Used to be primed with fresh haparinized blood
- now crystalloid is used
- no simple consensus on what is best
Crystalloid base prime
- Dextrose, pH balanced crystalloids, Mannitol
- mimic normal plasma electrolyte concentrations
- Most lack oncotic activity (except Mannitol)
- easy to handle / cheaper / no allergic reactions
- improve post-op pulmonary and renal function
Crystalloid solution examples
- Plasmalyte
- Normosol
- 0.9% NS (overtime will become acidodic)
- LR (added lactate-convert to bicarb IF liver works-good for acidosis)
- D5 (with diff % NS)
Colloid Primes
- contain protein or starch
- can maintain high colloid oncotic pressure and reduce edema
- can increase incidence of allergy rxns and coag
Colloid prime examples
- albumin (most common)
- dextrans
- gelatins
- hespan
Hypertonic
- Osmolarity > 350 mOsm/L
- raise serum osmolarity…pulls fluid from cells
- D10 is temporarily hypertonic
Hypotonic
- Osmolarity < 250 mOsm/L
- 0.45% NS and 0.25% NS
Isotonic
- 285-295 mOsm/L
- 0.9% NS
Hydrostatic pressure
- Pressure of intravascular fluid against wall of vessel
- higher at proximal end (oncotic higher at distal)
1 L of H20 at 4C
- 1 Kg
- this means for dilute aq solutions…osmolarity=osmolality
Colloid Osmotic Pressure (COP)
- Normally higher in capillaries due to proteins
- CPB hemodilution disrupts this balance
Hemodilution considerations
- decreases bypass related complications
- or maybe it is fact that you are not giving blood? - affects the properties of drugs used in CPB
- changes protein binding through dilution of plasma proteins - can cause edema (not good)
Advantages of hemodilution
- decrease blood viscosity
- improve regional blood flow / oxygen delivery
- decrease exposure to blood products
- improved flow at lower perfusion pressures (lower shear stress)
- especially at low temps
Allowable hemodilution
- most try to keep Hct below 30%
- can get this with 1000-1500 mls of prime
- big patients or high Hct may need more dilution while on pump
Optimal fluid for priming
- not known
- most blood free
- albumin can increase colloid oncotic pressure while attenuating the platelet lowering effects of CPB
Basic Prime ingredients for Adults
- Normosol/Plasmalyte
- Hetastarch (JeWtns) / Albumin
- Antibiotic
- NaHCO3 (makes more alkaline)
- Mannitol
- Heparin 10 K units
Basic Prime ingredients for Peds
- Normosol
- 25% albumin (pacification of tubing) (large molecule)
- Antibiotic
- Solumedrol - corticosteroid
- NaHCO3
- Heparin 100 units
- Mannitol
- CaCl
- PRBC
NaHCO3 calculation for PRBC
= 0.3 x kg x BE
BE should be 0…if acidic…BE is negative
Mannitol
- Osmotic diuretic
- elevates osmolarity rapidly
- dilutes a lot more than just crystalloid
- oxygen radical scavenger?
- 0.25 g/kg in prime
- can drop BP more than just CPB
- lose reservoir volume
- will always end up giving more blood….bad
CaCl normal
- 0.7-0.8 mM/L
Glucose
- 75 to 115