Mod2: CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT Flashcards
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
When CPB is initiated, why is ventilation is stopped?
Pulmonary blood flow ceases
This is a critical time to talk with the perfusionist
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
prior to discontinuing ventilation, It’s imperative to ensure that
full pump flow has been established
Until left ventricular volume reaches a critically low level, ventricular ejection continues
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Prematurely stopping ventilation can cause
Right to left Shunting of
the remaining pulmonary blood flow,
causing hypoxemia
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass, there may be some initial hypotension that occur, why?
Reduced blood viscosity,
secondary to the hemodilution, and also
Dilution of circulating catecholamines
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
BP should be controlled by vasopressors that can be given by either
the anesthesia provider, or
by the perfusionist
It’s best a this point to have an open dialogue with the perfusionist regarding BP support
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
You should also know your institution policy regarding administration of drugs while on pump; why?
Some institutions will have the drugs only given by the perfusionist
While others will have drugs given by both anesthesia and perfusion
On bypass, MAP will be determined by
pump flow rate and
systemic vascular resistance
So at a constant SVR, the MAP is proportional to pump flow
MAP = Pump flow x SVR
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
The ideal flow is
2-2.5 L/min/m2
(50-60 ml/kg/min)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
The ideal Map is
50-80mmHg
With higher perfusions being for pts with renal disease or carotid artery disease
Higher (70-90 mmHg) if patient had carotid artery stenosis or renal insufficiency
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Hypertension is considered to be pressures above
100 mmHg
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Pressures above 150 are associated with
Aortic dissection, and
Cerebral hemorrhage
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
If pt is hypertensive while on pump, the perfusionist can
Increase the volatile anesthetic
Decrease pump flow (short-term fix), or
Give a vasodilator (e.g., NTG)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Arterial Hypotension or Decreases peripheral perfusion (systemic pressures) can be caused by?
Inadequate venous return, d/t
- cannula too small, kinked, bleeding*
- Low pump flow*
- Poor occlusion*
- Kinked arterial cannula*
- Reduced vascular tone*
- Having the table too low*
(remember the venous reservoir if filled by gravity, so if the bed is too low, this could cause in decrease in venous return)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Treatment for Arterial Hypotension or Decreases peripheral perfusion (systemic pressures) includes?
Increase volume
Increase pump flows
Vasopressors
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Arterial Hypertension can be caused by
Light anesthesia
Response to hypothermia
But also
- High pump flows*
- Arterial cannula misdirection*
- Vasoconstrictors*
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Treatment for Arterial Hypertension is to:
Decrease pump flow
Increase anesthetic depth
Make sure there are no background vasopressor running
Vasodilators
Narcotics
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: With the initiation of bypass, you must also assess the field, patient, and communicate with perfusion to ensure adequate pump pressures
True
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Assess patient/field for how long?
30-60 seconds after CPB initiated
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Assess pupils for correct cannula placement by looking for
unilateral dilation/conjunctival chemosis
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Asses face for correct cannula placement by looking for or at:
Symmetry
Temperature
Edema
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass, palpation of carotid pulses will reveal thrills only; why?
Non-pulsatile flow
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass, when will you check ACT, ABG, and other lab values?
Immediately, then
every 20-30 minutes
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass, Excessive decreases in MAP or persistent pump alarms can be indicative of:
Malpositionned cannula
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass and because of pt’s positioning, it may be difficult to do a physical assessment. What could indicate a malpositionned cannula?
Unilateral dilation,
Face color or symmetry
Increases in CVP
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass is initiated, what happens to coronary and systemic circulation after the Aortic Cross-clamping is placed in the ascending aorta?
Aortic Cross-clamping separates coronary perfusion from systemic circulation
This causes cessation of coronary perfusion
Prevents blood regurgitation through aortic valve
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass initiation & Aortic Cross-clamping, what happens next?
Cardioplegia administered
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass initiation & Aortic Cross-clamping, Cardioplegia administered. What’s an important consideration in pts with aortic insufficiency?
The cardiac protection provided by antegrade cardioplegia may not provide sufficient protection to the heart
Retrograde cardioplegia would also likely be used
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
How is Cardioplegia administered?
Given every 15-20 minutes
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: When Cardioplegia is administered, Aortic insufficiency may reduce cardiac protection
True
Antegrade cardioplegia must be combined with Retrogade cardioplegia in Aortic insufficiency
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: During bypass and depending on the institution, the anesthesia provider doesn’t have much responsibility in regards to maintaining hemodynamics
True
The perfusionist will be the primary monitor of pump flow and MAP and treating them accordingly
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, while it isn’t our responsibility per se to manage hemodynamics, we should stay vigilant to:
MAPs,
especially if they are consistently low or high
Because the perfusionist may need support in managing them in the form of either a vasopressor infusion, or narcotics, benzos and muscle relaxants
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, we will also collaborate with the perfusionist to make sure that arterial blood gas values are within normal ranges. Why is this important?
CO2 can be reduced by increasing the fresh gas flow on the bypass machine
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, we will also monitoring urine output, ensuring that it stays at a minimun of?
0.5 ml/kg/hr
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
In general, bypass time is the time used to prepare for:
Weaning and coming off pump
So ensuring that all iV push drugs are refilled,
Infusions are primed and ready to go,
Charting is kept up to date,and
Any other preparatory work that’s needed
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, assess for adequate depth of anesthesia by monitoring for:
Shivering
Breathing
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, Assess temperature for adequate systemic hypothermia by monitoring for:
Core vs Shell temperature
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, patient must be rewarmed. Deciding the appropriate time to rewarm is important. Why is that?
Adequate time must be given to the process
Rewarming too fast can have a negative effect, including neurologic complications
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, Air must be evacuated from the heart and any bypass grafts. Why is that important?
To reduce the chance of entry into systemic circulation
Especially during valvular repair surgeries, where the heart is actually openned
WEANING FROM BYPASS
Air going down into the coronary arteries can also cause:
Dysrhythmias
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, Air must be evacuated from the heart and any bypass grafts. Which imaging technique can assist with this?
TEE
Heart allowed to beat after air removed
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, the aortic cross-clamp must be removed from the aorta. Why?
So that blood has a clear path from the left side of the heart into systemic circulation
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, lung ventilation must be resumed. When?
When pulmonary blood flow commences
Ventilation will also aid in air evacuation
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, and while lung ventilation is resumed, what would be the benefit of using Valsalva maneuver?
Removes air from lungs
Aids in filling cardiac Chambers
Recruits atelectatic alveoli
WEANING FROM BYPASS - REWARMING
Rewarming must occur gradually. The gradient between arterial outlet and venous inflow should be no more than?
10° C
WEANING FROM BYPASS - REWARMING
During rewarming, the gradient between arterial outlet and venous inflow should be no more than 10° C. Why is that crucial?
Prevents cerebral overheating
Prevent gas bubble (gasious emboli) formation.
Gasious emboli start to form because the gas solubitlity will decrease with increase temeperatures
WEANING FROM BYPASS - REWARMING
During rewarming, why should surgical teams limit arterial outlet blood temperatures to less than 37 degrees C?
To avoid cerebral hyperthermia
Research has also notes that arterial outlet blood temperatures underestimate cerebral temperature
Limit arterial outlet blood temperatures to less than 37 C
WEANING FROM BYPASS - REWARMING
What happens if patient temperature not adequate prior to conduction?
Fibrillation can occur
WEANING FROM BYPASS - REWARMING
The rewarming phase is the most critical time for AWARENESS/RECALL. Why is that?
Potentiation of anesthetic effect due to hypothermia dissipates