CPB

[ Cardiopulmonary Bypass ]
HISTORY - Father of HLM- Dr. John Gibbon
1937-First successful demonstration of artificial heart
and lungs.
Maintained cat’s circulation on CPB.
1953-Cecelia Bavolek first patient to undergo open heart
surgery using CPB to repair an ASD.
Definition – CPB is a form of extracorporeal circulation.
Temporarily takes over the function of heart and lungs
during surgery, maintain the circulation of blood and the
oxygen content of body.
Goals of CPB –Oxygenation and carbon dioxide elimination.
 Circulation of blood.
 Temperature regulation.

Principle of CPB- Venous return is drained by gravity into the reservoir by

cannula placed in RA or SVC,IVC then pump through oxygenator, return into
patient’s arterial system by cannula in ascending aorta.

Indications of CPB- procedures require temporary cessation of heart’s function

and bypassing of heart and lungs to facilitate surgical repair.

CABG
Valve replacement or repair
Congenital heart defects
Aortic aneurysm repair
Heart transplantation
C0MPONENTS OF CIRCUIT

Pump
Oxygenators
Reservoir
Custom pack
Cardioplegia delivery system
Cannulas
Heat exchanger
Hemofilter
Roller pump
PUMP
Centrifugal pump
Axial pump

ROLLER PUMP – consists of rollers [usually two] positioned on

the end of a rotating arm, forward flow is induced by rollers
compressing tubing mounted in U shape raceway.
Flow rate depends on- diameter of tubing
diameter of raceway
rotation rate of impellers
CENTRIFUGAL PUMP

It consists of vane less rotor cones capable of spinning at high

velocity mounted in a clear plastic housing ,causing circular
motion of blood.
Non occlusive
Preload and afterload dependent.
Flow meter probe must be placed to arterial line to determine
pump flow.
 AXIAL PUMP
New generation of rotary pump consists of
impellers driven by electric motor to generate
axial flow by rotating blood internal impeller.
Provide both continuous and pulsatile flow
RPM- upto15000
Used in pediatric ECMO and ventricular assisted
devices
 OXYGENATORS
Ideal oxygenator – excellent gas exchange.
minimum blood trauma.
small prime volume
minimal failure incidents,
easily assembled and safety

Function- gas exchange and heat exchange

 BUBBLE OXYGENATOR

Divided into two sections- mixing chamber

reservoir

Advantage- low resistance to flow

low pressure drop

Disadvantage- direct contact between blood and air that

permits to formation of gas emboli.
MEMBRANE OXYGENATOR
Membrane consists of plastic housing made of polycarbonate
which contains gas exchange membrane and water circuit.
TYPES- hollow fiber membrane
flat sheet membrane
Integrated arterial filter with self vent technology
HOLLOW FIBER- most commonly used.
gas exchange occur by diffusion
Pressure in blood side always exceed to pressure in gas side to
prevent formation of gas emboli.
 FLAT SHEET MEMBRANE

Membrane is flat sheet which folded to create plates that

separate blood compartment from gas compartment .
Have larger surface area and demand greater prime volume.

INTEGRATED ARTERIAL
New generation of hollow fiber oxygenator with integrated
arterial filter.
Has a screen filter surrounds hollow fiber layer of oxygenator
to trap and remove particulate and air emboli from blood
before return to arterial line.
TRUE MEMBRANE
Non- porous membrane
Manufactured by coiling silicone rubber sheets in a cyclindrical
fashion.
Gas transfer depend upon – permeability of membrane
driving pressure of gas
diffusion distance

Used in ECMO
RESERVOIR
FUNCTION- defoaming ,filtration, temporary store blood
TYPES- soft shell
hard shell

SOFT SHELL- has advantage of increase and reduce it’s size

according to amount of blood
Blood enter through inlet port passes through micro screen and
aspirate from outlet port
Don’t have air spaces that prevets accidental delievery of air to the
patient.
HARD SHELL RESERVOIR
Hard shell container made up of polycarbonate ,contain
integral filter mechanism

Venous blood passes -defomer [polyurethane foam]

 Depth filter [polyester or dacron]
 Screen filter[polyester or polypropylene]

 ADVANTAGE- easy volume measurement, larger capacity, easy to prime,

permit suction of VAVD.

 DISADVANTAGE-micro air bubbles

 Increased activation of blood elements.
 CUSTOM PACK
SURGEON PACK-AV loop with filter line.
suction line
connector- straight or Y connector with luerlock

PERFUSION PACK- Pump head

Gas line filter
purge line with one way valve
qucik prime line.
 Tubing
Components of CPB circuit interconnected by series of tubes
made of PVC or silicone.
Latex rubber generates more hemolysis than PVC.
Silicone produce less hemolysis, but release more particles
than PVC.
Because of durability of PVC’s and accepted hemolysis rate,
PVC used for tubing.
Heparin coated tube give higher level of bicompatability,
decrease inflammatory response and inhibit and platelets
activity.
 Suckers and Vents
Suckers: allow to salvage blood from operative field to be
returned to the circuit by reservoir.
Vent : used for venting left heart.

Common site for placing vent:

Aortic root
RSPV (Right superior Pulmonary vein)
Left Ventricular Apex
Pulmonary artery, LA or LV
Reasons for venting Heart
Prevent distension of heart
Reduce myocardial re-warming
Improve surgical exposure
Create dry surgical field

Complications:
Damage to LV wall due to excessive suction
May introduce air into left heart and carries risk of systemic
air embolism
CARDIOPLEGIA DELIVERY SYSTEM

The CDS designed to deliver cardioplegia solution to the

heart, arresting myocardial activity and protect the
myocardium during cardiac surgery .

COMPONENTS- Cardioplegia pump

heat exchanger
mixing system
pressure monitoring line
Delivery line and cannula
 Type of CPG

Cold crystalloid CPG:

Consist only crystalloid solution with K+, Mg2+, Procaine
Initial dose- 20 to 30 mEq/L.
Maintenance dose- 5 to 10 mEq/L.
Disadvantage: Myocardial edema activation of platelets, leucocytes

Cold blood or warm blood CPG:

Consist of both blood and crystalloid St. Thomas- 4:1 (25 min); Del Nido-
1:4 (90 min)
Dose: 20x weight Of patient
Advantage: limit of myocardial injury, reduce edema, contain free radical
scavengers.
 CARDDIOPLEGIA
CLASSIFICATION
1. Intracellular
St. Thomas
Del Nido
Custodial (histidine, tryptophan, ketoglutarate)
2. Extracellular
Cold
Warm
Tepid
Del Nido cardioplegia solution
Mannitol 20 %, 16.3 ml
MgSO4 50 %, 4 ml
NaHCO3 8.4 %, 13 ml
K+Cl (2mEq/ml) 13 ml
Lignocaine 2 %, 6 ml
St. Thomas’ Hospital cardioplegia solution No. 2
Na+ 110 mmol/L
Cl- 160 mmol/L
K+ 16 mmol/L
Ca2+ 2.4 mmol/L
Mg2+ 32 mmol/L
HCO3- 10 mmol/L
Canulation
Cannulas are used to connect the patients circulation to
extracorporeal circuit.
There are 3 types of canulation involved in CPB arterial.
Arterial cannula
Venous cannula
Cardioplegia cannula

Arterial Cannulation: used to deliver oxygenated blood to systemic

circulation.
During CPB: means arterial pressure (MAP)- 60-100 mmHg arterial
line pressure <300 mmHg.
Causes of high arterial line pressure:
kink in aortic cannula
Cannula too small
Improper positioned
Aortic dissection
Cross clamp too near to cannula

Common site- Ascending aorta

Alternative- Femoral artery
Axillary/ subclavian artery
Innominate artery
Type of arterial cannula- straight tip
curved tip

COMPLICATION- Aortic dissection

bleeding
embolism
VENOUS CANNULATION
Drain deoxygenated blood from venous system to CPB machine.
Venous line pressure= 0-20mmHg , VAVD = -40mmHg

Common site – RA
SVC, IVC

Cannula type- single stage

two –stage
separate SVC and IVC cannula.
COMPLICATION- Air embolism
Low cardiac output
Artial dysrhytmia
Bleeding

CAUSES OF POOR VENOUS RETURN- Inadequate size of cannula

Inadequate perfusion pressure
Kink
Air lock
Inadequate height of patient
Reduced venous volume
CARDIOPLEGIA CANNULATION
Deliver cardioplegia solution to arrest and protect the heart
during surgery.

Type of cannula- Antegrade cannula

Retrograde cannula
Ostial perfusion cannula
Route: 100 to 150 ml per BSA, line pressure- 125-250, aortic
root pressure- 40-50mmHg
Antegrade: CPG given in aortic root or directly into coronary
ostia in normal direction of blood flow
Also given coronary graft- saphenous vein graft.
Ostial perfusion cannula: Right CA pressure not greater than
100 mmHg LCA pressure not greater than 200mmHg.
Aortic insufficiency- direct ostial cannulation.
E.g. Aortic valve replacement
Retrograde- CPG given in coronary sinus in reverse direction
has balloon near its tip when inflated pressure backward flow
of CPG 100 to 200 ml/min, pressure- 30-50mmHg.
Complications- coronary sinus injury
Inadequate myocardial protection
Aortic dissection

Heat exchanger: facilitate management of patient’s blood

temperature.
the heat exchanger maybe used to reduce the
temperature of blood on initiation of CPB and then to warm the
blood before the termination of CPB.
reduces the temperature of cardioplegia blood to
the require level.
Hemofilter
It is a device used in CPB circuit for ultrafication.
Removes excess water, electrolytes, inflammatory mediator and small
molecules from the blood during or after bypass.
It connected to venous line or arterial line of CPB circuit.
Blood flow passed through hemo filter membrane
Filtrate (water, electrolyte toxins) collected separately
Blood is returned back into CPB circuit

Ultra filtration: 1. CUF

2. MUF
3. SMUF
4. Dilution Ultra filtration 5. Pre CPB ultra filtration
Conduct of bypass in adult
Pre Bypass
Collect patient data: height, weight, haemoglobin to
calculate BSA, flow, CPBHCT.
CPB HCT: patient blood volume x Pre CPBHCT
total volume (Pt. volume +Prime volume)
Blood volume= wt. x wt. factor
Adult male= 70 ml/Kg
Adult female= 60 ml/Kg
Pediatric= 85 ml/Kg
Transfused blood volume=
desired HCT(Pt. volume+ Prime volume)-(HT 1xPt.
volume)
HTTBV
HT1: patient HCT before bypass
HTTBV : 60 or 40
Check for patient blood arrive on time
After calculation of BSA, now we decide, oxygenator (adult)
sorine inspire with integerated arterial filter.
[Maximum capacity: 7L]
Custom pack [adult]
 Cardioplegia delivery system (adult)
Cannula : Aortic- according to flow
Venous- SVC: angled metallic cannula with wire
reinforced
 IVC: straight cannula with wire reinforced
Vent: LV vent
Antegrade CPG needle, 14 fr, 16 fr
Retrograde CPG cannula , ostial perfusion cannula if
required
flexible sucker
Hemofilter set (adult)
Assembling of circuit
 Place venous reservior after orienting it on its holder, attach quick prime line
 Remove vent port cap
 Connect the gas line to the oxygenator
 Connect pump head (oxygenator, outlet reservior)
 Connect the AV loop
 Connect recirculation line to recirculation port on venous inlet
 Connect the suction or vent required
 Connect arterial filter purge line
 Connect cardioplegia delivery system, purge line
 Pressure line of cardioplegia and oxygenator
 Check for all the 3 way connections

 After assembling, inside OT, on machine and connect the gas line (O 2, air)
 Prepare cardioplegia with name, date and attach to the line. Connect water lines to oxygenator
and cardioplegia.
Priming the circuit
Plasmolyte A used (crystalloid)
Fill the reservior with quick prime line
Recirculation line open (R-oxy) which prime the oxygenator.
Prime AV loop by unclamping the venous and arterial line.
Then, prime cardioplegia delivery system, vent, sucker.
Occulsion Setting
Set the occulsion of roller pump
Advance a column of priming 30 cm above the level of pump
in arterial line placed vertically.
Adjust the roller occulsion against backing plate to allow
slight drop 1cm/min.
Other method: clamp arterial line.
Turn pump carefully pressure 300mmHg
Observe rate of pressure drop
Adjust the occulsion until drop off pressure over the lower
260-280 mmHg (approx in 10sr)
Suction pump
Clamp placed on tubing on the inlet slide of sucker roller
pump, gradually occlude until the tube collpased
Decrease occulsion until the vaccum is cleared.
The occulsion setting again increased, until the vaccum is
drawn and held.

Excessive occulsion- increase hemolysis, increase tube

installation, excessive tubing wear
Too little occulsion- rapid backflow of blood- hemolysis also
decrease forward flow to the patient.
Calibrate the pressure line in the transducer
Connect the hemofilter set
Administer anticoagulant (3-4 Vper ml of priming) and
antibiotic
Heat temp. probe connected to machine (reservoir)
Level sensor positioned
Pre bypass checklist
Back-up power available
Hand cranks available
Oxygenator preferibly place on holder and secure
Water lines connected
Gas line connected and not leaking
Sucker and vent in proper direction
Occlusion set
Pressure transducers calibrated
Level sensor operable
Supply and back-up components available.
Line divide
Line connects between table line and pump line.
Increase flow speed fast ciculating the priming solution, make
sure no bubble present.
Then recirculation is closed, pump stopped and venous line
clamped. CPG line- flesh check for ACT
ACT>200 – cannulation started
ACT>300 – pump sucker on
 Aortic cannulation: by advancing pump (150-250 ml/min) cannula is connected to patient.
 Check for B.P. line pressure (less than 100mmHg)
 Oscillation
 Resistance
 Occulsion test by surgeon

 Venous cannulation: SVC cannulated – half venous open – IVC cannulated.

 Antegrade cardioplegia needle cannulated- root vent on.
 ACT> 480 sec
 Oxygen on
 Venous tube open- flow increased
 Check venous reservoir level
 Line pressure
 Perfusion pressure
 Colour difference

 Full flow and full bypass achieved

 Start cooling the patient
 flow 0.5, AC clamp- cardioplegia start root vent off- full flow (pressure decrease)
note volume of CPG given.
CPG dose – 20 ml/Kg
Remind the surgeon about CPG time at 20 min
Correct the ABG parameters in between bypass
In case of retrograde priming- after SVC and aortic
cannulation, hemofilter on and CUF started to remove the
fluid
Check ABG and ACT after 3-5 min of CPG antegrade (150-200
mmHg) administration.
Retrograde CPG- retrograde pressure (25-40 mmHg) time
and dose monitored
Drugs given- Taxid, hemostat, methylpred, mannitol, Adr, Noradr,
NTG, sodium, K+Cl-, sodium nitroprusside, SBC, Insulin, lasix etc.
Tranexamic acid/ Taxid- antifibrolytic prevent the breakdown of
blood clots to control excessive bleeding
Reduce blood loss and blood transfusion

Aminocarpic acid/hemostat: used to treat acute bleeding

disorders (antifibrolytic)
Methylprednisolone: (corticosteroid) reduce the inflammatory
reaction during and after CPB.
Mannitol: osmotic diuretic. It improves renal blood flow,
minimises extra vascular fluid shifts, protect kidney.
SBC: primarily to buffer metabolic acidosis, which can occur
during prolong CPB, prevent or reduce AKI.
Lasix/ furosemide: loop diuretic treats edema and high BP.
Insulin: manage hyperglycemia
Noradr- used as vasopressors to maintain blood pressure
Treat- hypotension
NTG[Vasodilator]: manage systemic or pulmonary
hypertension.
Improve blood flow to heart muscle
Improve cardiac output, reduce work load.
Sodium nitroprusside: vasodilator ,treat hypertension
Weaning off and termination from bypass:
 Re warming the patient (gradient 8-10 oC)
 Patient position on OT table is neutral vent sites, purge and sampling line is closed.
 Heart de0aired by filling blood
 Flow decrease gradually and then pump of CVP-5-15, MAP- 70-100.
 Off pump-start gas flow
 MUF started- stop after desired volume is excreted
 LV vent removed and drain blood from it
 Remove venous cannula both from IVC and SVC and drain blood from them. (heart eject by partially
clamp VC)
 Protamine given (root vent off)
 Continue load the patient by blood
 All blood in
 Continue flushing to prevent clotting of aortic cannula flow 0.5, AC clamp removed
 Stop flush- aortic cannula out- drain blood from aortic cannula.
 Last suction and off pump completely
 Check for urine output, patient blood gas and electrolytes are normal
Complication Description Correction / Management

Switch to hand-crank (manual mode), replace or

Pump Failure (roller or centrifugal) Malfunction of roller or centrifugal pump
repair pump, standby pump

Replace oxygenator (if possible), initiate

Oxygenator Failure Inadequate gas exchange or oxygenator leak/clot
emergency bypass circuit

Straighten tubing, reposition clamps, replace

Tubing Kinks or disconnections Bending of tubing obstructing flow
tubing if persistent

Clamp proximal and distal ends, replace affected

Tubing Rupture Leak or burst in CPB tubing
section immediately

Stop pump, place patient in Trendelenburg,

Air Embolism Air enters circulation due to suction or circuit error
aspirate air, consider hyperbaric O₂

Use backup unit, manually control patient

Heater-Cooler Unit Malfunction Inadequate temperature regulation
warming/cooling

Replace filter immediately, ensure proper

Arterial Line Filter Blockage Clot or debris blocks arterial filter
anticoagulation

Inaccurate or absent readings from pressure Check transducer connections, zero the system,
Pressure Monitoring Failure
transducers replace faulty components

Low volume or air in venous reservoir leading to Replenish volume, stop suction, close venous line
Reservoir Issue (Low volume/ collapse)
air entrainment until air is cleared

Inspect line, straighten or reposition tubing, check

Venous Line Kinks / Obstruction Reduced venous return due to kink or clamp
cannula position