Perfusion Safety, cardioplegia delivery management

Ns. Ida Tiur Simanjuntak. S.KepNational Cardiovascular Centre Harapan Kita Jakarta

TAPS Thailand, 2010

Perfusion safety ???

Safety is a committed respect for human lives

in which we have responsibility (Reed, 1988)

Perfusion safety

• Absence of structural and functional damage after cardiopulmonary bypass

• Protect life and talent and avoid negative social and economical consequences

• Avoid feeling of personal guilt and maintain team’s reputation

Cardioplegia

paralysis of the heart, as may be done electively in stopping the heart during cardiac surgery, cardioplegia may be done using chemicals or electrical stimulation(The American Heritage, Medical Dictionary, 2007)

The problems had reported in case management cardioplegia delivery

• Failure to add a sufficient amount of Potassium is the most common error when preparing cardioplegia solutions

• The heating cooling unit may fail and cardioplegia may not be delivered at the right temperature.

• A simple test is to feel the cardioplegia line during delivery. It should be at the temperature during delivery and also a mist must form if giving cold cardioplegia and if using metallic direct cardioplegia cannulae the handle must cool.

(Patient Management & Perfusion Technique, The Regents of the University of Michigan, 2009)

Safety management of cardioplegia delivery

1. Cardioplegia solution

2. Cardioplegia delivery circuit

3. Cardioplegia delivery technique

I. Cardioplegia solutions

• Preparing cardioplegia solutions• Cardioplegia solution label expired date

Check boxes are provided to indicate which solution has been prepared.  • Two perfusionist check when add the CPG into the solutions• Blanks are also provided for the initials of the preparer as well as the time

and date of preparation. 

Perfusion Safety…

Content of Cardioplegia Concentrate

• 20 ml (1 ampoule) of DBL Cardioplegia Concentrate contains:

Magnesium chloride 16 mmolPotassium chloride (KCl) 16 mmolProcaine hydrochloride 1 mmol

High potassium cardioplegia solution (H):DBL Cardioplegia Concentrate 2 ampoulesSodium Bicarbonate 30 mmolAsering Solution 500 ml

Low potassium cardioplegia solution (L):DBL Cardioplegia Concentrate 1 ampouleSodium Bicarbonate 30 mmolAsering Solution 500 ml

II. Cardioplegia circuit

• Cardioplegia Roller Pump Calibration– The cardioplegia roller pump should be calibrated prior to the initiation of

CPB.

• Refer to 4:1 Cardioplegia roller pump Calibration Chart below and find the appropriate stroke volume for the prescribed 4:1 cardioplegia pump boot.

Cardioplegia Set 4:1 Cardioplegia Boot Diameters Stroke Volume/Revolution

MUF/4:1 CP Set 3/32” & 3/16” 10 ml

Non MUF 4:1 CP Set 3/32” & 3/16” 10 ml

Perfusion Safety…

calibration

PRESSURE PUMP

Perfusion Safety…

III. Cardioplegia delivery technique

A. Flow Antegrade cardioplegia

• aortic root to the coronary ostia • flow 250-350 ml/min

conditions that influence the flow of cardioplegia delivery :Low flow (below therapeutics dose) :

– Severe widespread coronary artery disease– Small patient– Intimal infusion

High flow (above therapeutics dose) :– Large patient– Aortic incompetence– Crossclamp malposition

Cont…..

Retrogade cardioplegia

• Coronary sinus via a retrograde catheter • Flow 200 ml/min

conditions that influence the flow of cardioplegia delivery :

Low flow (below therapeutics dose) : Overinflated baloon Too deep insertion of cannula into coronary sinus Rotation of heart

High flow (above therapeutics dose): Inadequate cardioplegia distribution (severe stenosis) Leakage of blood around inadequately filled balloon Ruptured coronary sinus

B. Pressure

Antegrade :

• Aortic root pressure : 50-90 mmHg

• High pressures (>100 mm Hg) cause difficulty with visualization and may lead to myocardial edema.

• Low delivery pressures (<50 mm Hg) will result in inadequate myocardial

perfusion or left ventricular distention due to aortic valve incompetence

(Young JN, Choy IO. Aortic root pressure monitoring during antegrade cardioplegia administration.

Ann Thorac Surg 1996;62:1213–4)

Retrograde :

• Coronary sinus pressures : 28 - 50 ml.

• Keep coronary sinus pressures mid 30 mmHg as too low pressures may compromise cardioplegia distribution, while too high pressures may rupture the coronary sinus

• Additionally, delivery of retrograde cardioplegia takes longer compared to antegrade delivery because of lower flow rates and pressures employed to prevent the development of myocardial edema and coronary sinus injury (antegrade cardioplegia is delivered at systemic pressures).

•  Because of this, many surgeons advocate initiating cardiac arrest with a single dose of antegrade cardioplegia, followed by interval dosing of retrograde cardioplegia.

C. Volume

• Induction dose : 20ml / kgBW for 4 minutes• Maintenance dose : 10ml / kgBW for 2 minutes

D. Temperature

• Check the heat exchanger and the ice

• Cardioplegia solution temperature is controlled with a dual cooler/heater unit. 

• The cooler portion of the unit is set at 4oC for cold cardioplegia delivery. 

Perfusion Safety…

Giving Methods Cardioplegic Solutions

Crystalloid cardioplegia

• More likely to be used in pediatric where cross-clamp time of less than 1 hour

• Simple circuit and low cost• Less oxygen carrying• When given in large amounts of risk for hemodelution

Blood Cardioplegia

• advantage of blood cardioplegia is the blood oxygen carrying capacity greater than crystaloid,

• Natural buffers hemoglobin

• Is a metabolic substrate carrier and free radical scavengers of natural

• oncotic also increase, preventing edema myocardia

• In some references mention that the blood kardioplegia more effective on long cross-clamping conditions (> 1 hour)

• Need Potassium is higher than the cristaloid because it will mix with blood. Usually the ratio is 4:1 (that is usually used in the protocol harkit)

Mechanism of myocardial protection with Cardioplegia

• Mechanical arrest (potassium-induced) will reduce oxygen consumption • Hypothermia will reduce consumption • Aerobic metabolism can be maintainted with oxygenated cardioplegia

• Given just prior to the removal of the aortic cross clamp. • "Hot Shot" is delivered retrograde at 150 - 200 ml/min at a

temperature of 32 - 37oC. • Total dose of 30 ml/kg is ideally delivered over a 2 - 4

minute

Hot Shot

Conclusions…

Cardioplegia delivery management :

1.Check the cardioplegia solutions

2.Check the cardioplegia circuit

3.Check when cardioplegia is delivery

SO……

IF WE GIVE THE GOOD CARDIOPLEGIA SOLUTIONS WITH THE GOOD CARDIOPLEGIA

DELIVERY MANAGEMENT,,HOPE THE OUTCOMES OF PATIENT WILL BE GOOD TOO…..

Perfusion safety…

safe for the patient and safe for our team…

THANK YOU……