SlideShare uma empresa Scribd logo
1 de 35
DR DHANESH KUMAR
19-03-2016
PRINCIPLES OF CPB
What is It ?
 Temporary mechanical circulatory support to
the stationary heart and lungs
 Heart and Lungs are made “functionless
temporarily” , in order to perform surgeries
History
 First open cardiotomy (Apr 5, 1951)
 First successfulOHS (Sep 2, 1952)
 Dr. F John Lewis
 ASD closure using hypothermia and inflow occlusion
 First successfulOHS using CPB (by JohnGibbon May 6, 1953)
 ASD closure
 High mortality rate
 VSD closure by azygos flow concept (controlled cross-
circulation) (Dr C.Walton Lillehei Mar 26, 1954)
 DeWall-Lillehei helix bubble oxygenator (May 1955)
 Beginning in a large series of patients
 Method of choice worldwide for OHS
 Rotating Disk oxygenator
 Developed by Dr Fredrick Cross and Earl Kay in 1962
 Used for early OHS in USA
 Membrane oxygenator
 Developed in 1950s-1970s; but initially not frequently
used
 In the mid-1980s, microporous designs; frequently
used.
 Hemodilution
 Major technologic advance in CPB
Cardiopulmonary Bypass
 Goals
1. Still, bloodless heart for cardiac surgery
2. Replacement of cardiac and pulmonary
function
Functions of CPB
• Respiration
 Ventilation
 Oxygenation
• Circulation
 Venous drainage (by gravity, centrifugal pump,
or negative pressure)
 Arterial inflow
• Temperature regulation (hypothermia)
 Low blood flow -> decreased blood trauma
 Decreased body metabolism
Components of CPB
 Total CPB
 Partial CPB
 Integral Components of Extracorporeal Circuit
 Pumps
 Oxygenator
 Heat exchanger
 Arterial filter
 Cardioplegic delivery system
 Cannulae (aortic; arterial; vena caval)
 Suction and vent
Basic CPB circuit with oxygenator and
centrifugal pump
Typical CPB Circuit
Pumps
 Two principal types
 Displacement pumps
 Roller pump
 Non occlusive roller pumps
 Rotatory pumps
 Radial (centrifugal) pumps
 Axial pumps (Archimedes’ screw)
 Diagonal pumps
Impeller PumpRoller Pump Centrifugal Pump
Pumps
Centrifugal pumps > Roller pumps
 Long-term CPB
 Ventricular assistance
 Neonatal ECMO
 Centrifugal pumps
 Biomedicus Biopump (Medtronic Inc)
 Sarns/3M centrifugal pump (Terumo)
 Levitronix CentriMag blood pump
 LVAD, RVAD, BiVAD
 BiVAD + oxygenator in RVAD = ECMO
Pulsatile Perfusion
 Significant physiologic advantages
• Diastolic run-off
• Stimulation of the endothelium
 Problem
• Noncompliant high resistance CPB circuit
• High flow with resultant shear stress
 Hemolysis
• Possible with roller pump and diagonal pump, but not with
centrifugal pump
• Requires larger bore arterial cannulas
 Alternative method for generating pulsatile flow in high-risk patients
• Use of IABP during CPB
• Additional cost and invasiveness
Oxygenator
 Limited reserve for gas transfer vs. natural lung
• Much smaller surface
• Limited by diffusion
 Types of oxygenator
• Disk oxygenator
• Bubble oxygenator
• Membrane oxygenator
 Maximum oxygen transfer
• Less than 25% that of normal lung
• Proportional to pO2 difference and surface area,
inversely to diffusion distance
Disk or bubble oxygenator
 Direct contact oxygenators
• Bubbles in direct contact with blood
• Increasing cellular trauma
Bubble oxygenator
 Bubble oxygenator
• Larger bubbles improve removal of CO2
• Smaller bubbles are very efficient at oxygenation but poor in CO2 removal
• Larger the No. of bubbles, Greater the efficiency of the oxygenator
Bubble Oxygenator
 Advantage
 Easy to assemble
 Relatively small priming volume
 Deforming the frothy blood
 Low cost
 Disadvantages
 Micro emboli
 Blood cell trauma
 Destruction of plasma protein
 Excessive removal of CO2
 Deforming capacity exhausted
Membrane Oxygenator
 Characteristics
 Gas exchange across a thin membrane
 No direct contact with blood and no defoamer; more physiologic
 Minimal blood damage
 Two types
 Solid type (Silicone)
 Microporous type (polypropylene)
 0.3-0.8-micron pores
 Most popular design = hollow fibers (120-200 microns)
Membrane Oxygenator
 Microporous / Hollow fibers
Microporous (Polypropylene) Membrane
Oxygenator
 Currently predominant design used forCPB
 Micropores
 Less than 1.0 um in diameter
 Initially porous, but plasma protein coating the membrane-gas
interface
 Surface tension of blood prevent gas leakage into the blood phase
 Conduit for O2 and CO2 exchange
 Problems
 Plasma leakage and membrane wet at use of period > 24 hours
Silicone Membrane Oxygenator
 True membrane oxygenator
 Silicone polymer
 Improved biocompatibility -> long-term support
 1980s to mid-1990s
 Still the membrane of choice for long-term procedures
 ECMO
 Problems
 Gas exchange inferior to polypropylene (microporous) oxygenator
 Need greater surface area and larger prime volume
 Difficult in manufacturing and quality control
New Generation Membrane Oxygenator
 Silicone polymer
 A continuous sheet of silicone membrane rolled into
a coil
 Manufactured by Medtronic Cardiopulmonary Inc.
 Membrane surface area + 0.6-4.5 sq.m
 Most common use for ECLS/ECMO
Heat Exchanger
 Integrated into oxygenator for warming and cooling
 Exchange surface made of
 Stainless steel, aluminum, or polypropylene
 Counter-current mechanism
 Temperature difference between waterside and blood side
 Historic reports : maximum difference of 10 °C
 Recent recommendation : 6 °C and longer rewarming
times
 To improve neurocognitive outcome
 Hyperthermic circulatory temperature
 Blood damage (protein denaturation)
 Limit absolute maximum temperature (42 °C) in blood
Filters and Bubble Traps
 In the circuit, micro emboli are monitored by
arterial line ultrasound or monitoring screen
filtration pressure.
 Depth filters consist of porous foam, have a
large, wetted surface and remove micro
emboli by impaction and absorption
 Screen filters are usually made of woven
polyester or nylon thread.
Tubing
 Medical grade Polyvinyl Chloride (PVC)
tubing
 It is flexible, compatible with blood, inert,
nontoxic, smooth, nonwettable, tough,
transparent, resistant to kinking and collapse
 Can be heat sterilized
 The Duraflo II heparin coating ionically
attaches heparin to a quaternary ammonium
carrier (alkylbenzyl dimethyl - ammonium
chloride), which binds to plastic surfaces.
Perfusion Monitors and
Sensors
 A sensor with alarms on the venous reservoir and
a bubble detector on the arterial line are
desirable safety devices.
 Flow-through devices are available to
continuously measure blood gases,
hemoglobin/hematocrit , and some electrolytes
 Temperatures of the water entering heat
exchangers
Circuits
 Venous drainage by gravity into oxygenator
 Height difference between venae cavae and oxygenator > 20-
30 cm
 Mechanical suction Not desirable
 Entrain air
 Suck the vena cava walls against the cannula orifices
 Arterial blood return to the systemic circulation under pressure
Arterial Return
 Ascending aorta just proximal to innominate A
 Femoral artery access in
• Dissecting aortic aneurysm (0.2-3%)
• Reoperation
• Emergency
• MICS
 Problems of femoral cannulation (more than ascending aorta
cannulation)
• Sepsis
• Pseudoaneurysm
• lymphatic fistula
 Arterial cannula
• The narrowest part of CPB circuit
• As short as possible
• As large as the diameter of vessel permits
 < 100 mmHg in full flow
Arterial Cannula
 Straight/Angled cannula
• Minimize risk of dislodgement of atheroma in the
ascending Aorta or Arch
 Axillary –subclavian artery, innominate artery, LV
apex
• In special circumstances
• Limitations and more complications
 Complication: Dissection of aorta
• All sites of arterial cannulation
• Prompt recognition and surgical correction
• TEE helpful for diagnosis
Size of venous cannula
Adult Children
 SVC (1/3 of total flow) 28 24
 IVC (2/3 of total flow) 36 28
 Example: 1.8 m2 patient
 Total flow 5.4 l/min
 SVC 1.8 l/min, IVC 3.6 l/min
 SVC > 30 Fr, IVC > 34 Fr : Single cannula > 38 Fr
 36-51 Fr cannula required.
Prime Fluid
 Ideally close to ECF
 Whole blood not used
• Homologous blood syndrome
• Postperfusion bleeding diathesis
• Incompatibility reaction
• Demand on blood banks
 Advantages of hemodilution
• Lower blood viscosity
• Improve microcirculation
• Counteract the increased viscosity by hypothermia
 Risk of hemodilution
• Decreased viscosity : SVR decreased
• Low oncotic pressure
• O2 carrying
• Coagulation factor
Principles of CPB
Principles of CPB
Principles of CPB

Mais conteúdo relacionado

Mais procurados

Pulsatile vs non pulsatile perfusion
Pulsatile vs non pulsatile perfusionPulsatile vs non pulsatile perfusion
Pulsatile vs non pulsatile perfusionNahas N
 
Basic Heart-Lung Machine in Cardiac Surgery
Basic Heart-Lung Machine in Cardiac SurgeryBasic Heart-Lung Machine in Cardiac Surgery
Basic Heart-Lung Machine in Cardiac SurgeryJenphop Khunjorn
 
Pediatric cardiopulmonary bypass
Pediatric cardiopulmonary bypassPediatric cardiopulmonary bypass
Pediatric cardiopulmonary bypasskp gourav
 
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.karthi murugan
 
Cardiopulmonary bypass
Cardiopulmonary bypassCardiopulmonary bypass
Cardiopulmonary bypassAbeer Nakera
 
Cardiopulmonary Bypass
Cardiopulmonary BypassCardiopulmonary Bypass
Cardiopulmonary BypassAllaa Subhi
 
Basic principles of myocardial proctection
Basic principles of myocardial proctectionBasic principles of myocardial proctection
Basic principles of myocardial proctectionRaja Lahiri
 
Priming fluid and hemodilution
Priming fluid and hemodilutionPriming fluid and hemodilution
Priming fluid and hemodilutionManu Jacob
 
History of cardiopulmonary bypass
History of cardiopulmonary bypass History of cardiopulmonary bypass
History of cardiopulmonary bypass Manu Jacob
 
emergency echo in critically ill patients.ppt
emergency echo in critically ill patients.pptemergency echo in critically ill patients.ppt
emergency echo in critically ill patients.pptShivani Rao
 
8.myocardial protection during cpb
8.myocardial protection during cpb8.myocardial protection during cpb
8.myocardial protection during cpbManu Jacob
 
Anticoagulation and haemostasis during cardiopulmonary bypass
Anticoagulation and haemostasis during cardiopulmonary bypassAnticoagulation and haemostasis during cardiopulmonary bypass
Anticoagulation and haemostasis during cardiopulmonary bypassDhritiman Chakrabarti
 
Lactate and cardiopulmonary bypass
Lactate and cardiopulmonary bypass Lactate and cardiopulmonary bypass
Lactate and cardiopulmonary bypass Manu Jacob
 
Complicationsandsafetyduringcpb 180414072601
Complicationsandsafetyduringcpb 180414072601Complicationsandsafetyduringcpb 180414072601
Complicationsandsafetyduringcpb 180414072601Manu Jacob
 

Mais procurados (20)

IABP
IABPIABP
IABP
 
Pulsatile vs non pulsatile perfusion
Pulsatile vs non pulsatile perfusionPulsatile vs non pulsatile perfusion
Pulsatile vs non pulsatile perfusion
 
VAD
VADVAD
VAD
 
Basic Heart-Lung Machine in Cardiac Surgery
Basic Heart-Lung Machine in Cardiac SurgeryBasic Heart-Lung Machine in Cardiac Surgery
Basic Heart-Lung Machine in Cardiac Surgery
 
Pediatric cardiopulmonary bypass
Pediatric cardiopulmonary bypassPediatric cardiopulmonary bypass
Pediatric cardiopulmonary bypass
 
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.
Hypothermia, DHCA, RCP, ACP,Oxygen consumption,Cooling, Rewarming.
 
Cardiopulmonary bypass
Cardiopulmonary bypassCardiopulmonary bypass
Cardiopulmonary bypass
 
Cardiopulmonary Bypass
Cardiopulmonary BypassCardiopulmonary Bypass
Cardiopulmonary Bypass
 
Basic principles of myocardial proctection
Basic principles of myocardial proctectionBasic principles of myocardial proctection
Basic principles of myocardial proctection
 
INTRA AORTIC BALLON PUMP (IABP)
INTRA AORTIC BALLON PUMP (IABP)INTRA AORTIC BALLON PUMP (IABP)
INTRA AORTIC BALLON PUMP (IABP)
 
IABP chetan
IABP chetanIABP chetan
IABP chetan
 
Basics of cpb
Basics of cpbBasics of cpb
Basics of cpb
 
Priming fluid and hemodilution
Priming fluid and hemodilutionPriming fluid and hemodilution
Priming fluid and hemodilution
 
History of cardiopulmonary bypass
History of cardiopulmonary bypass History of cardiopulmonary bypass
History of cardiopulmonary bypass
 
emergency echo in critically ill patients.ppt
emergency echo in critically ill patients.pptemergency echo in critically ill patients.ppt
emergency echo in critically ill patients.ppt
 
8.myocardial protection during cpb
8.myocardial protection during cpb8.myocardial protection during cpb
8.myocardial protection during cpb
 
Anticoagulation and haemostasis during cardiopulmonary bypass
Anticoagulation and haemostasis during cardiopulmonary bypassAnticoagulation and haemostasis during cardiopulmonary bypass
Anticoagulation and haemostasis during cardiopulmonary bypass
 
Lactate and cardiopulmonary bypass
Lactate and cardiopulmonary bypass Lactate and cardiopulmonary bypass
Lactate and cardiopulmonary bypass
 
Complicationsandsafetyduringcpb 180414072601
Complicationsandsafetyduringcpb 180414072601Complicationsandsafetyduringcpb 180414072601
Complicationsandsafetyduringcpb 180414072601
 
Priming and Hemodilution
Priming and HemodilutionPriming and Hemodilution
Priming and Hemodilution
 

Semelhante a Principles of CPB

oxygenators-copy-200308141605.pdf
oxygenators-copy-200308141605.pdfoxygenators-copy-200308141605.pdf
oxygenators-copy-200308141605.pdfMOHAMEDISMAILK2
 
principles of cardiopulmonary bypass
principles of cardiopulmonary bypassprinciples of cardiopulmonary bypass
principles of cardiopulmonary bypassIda Simanjuntak
 
ppt39sak23-171123100040.pdf
ppt39sak23-171123100040.pdfppt39sak23-171123100040.pdf
ppt39sak23-171123100040.pdfvegadof539
 
Cardio-Pulmonary Bypass: A Brief Overview
Cardio-Pulmonary Bypass: A Brief OverviewCardio-Pulmonary Bypass: A Brief Overview
Cardio-Pulmonary Bypass: A Brief OverviewAlanSeikka1
 
HEART LUNG MACHINE
HEART LUNG MACHINEHEART LUNG MACHINE
HEART LUNG MACHINEsathish sak
 
oxygenators-copy-200308141605.pptx
oxygenators-copy-200308141605.pptxoxygenators-copy-200308141605.pptx
oxygenators-copy-200308141605.pptxMOHAMEDISMAILK2
 
ECMO - extracorporeal membrane oxygenation
ECMO - extracorporeal membrane oxygenationECMO - extracorporeal membrane oxygenation
ECMO - extracorporeal membrane oxygenationprapulla chandra
 
ECMO - Part 1 by Dr.Tinku Joseph
ECMO - Part 1 by Dr.Tinku JosephECMO - Part 1 by Dr.Tinku Joseph
ECMO - Part 1 by Dr.Tinku JosephDr.Tinku Joseph
 
heart-lung-machine-pump.ppt
heart-lung-machine-pump.pptheart-lung-machine-pump.ppt
heart-lung-machine-pump.pptssuser1ecccc
 
ecmofinal-160719115713-converted.pptx
ecmofinal-160719115713-converted.pptxecmofinal-160719115713-converted.pptx
ecmofinal-160719115713-converted.pptxRANJANEEMUTHU1
 
Heart lung by pass unit
Heart lung by pass unitHeart lung by pass unit
Heart lung by pass unitIzzad Samir
 
Cardiac surgeries
Cardiac surgeriesCardiac surgeries
Cardiac surgeriesAmruta Pai
 
cardiopulmonary bypass
cardiopulmonary bypasscardiopulmonary bypass
cardiopulmonary bypassAkash Kanojia
 

Semelhante a Principles of CPB (20)

Unit 1.pdf
Unit 1.pdfUnit 1.pdf
Unit 1.pdf
 
oxygenators-copy-200308141605.pdf
oxygenators-copy-200308141605.pdfoxygenators-copy-200308141605.pdf
oxygenators-copy-200308141605.pdf
 
Sinz cpb
Sinz cpbSinz cpb
Sinz cpb
 
principles of cardiopulmonary bypass
principles of cardiopulmonary bypassprinciples of cardiopulmonary bypass
principles of cardiopulmonary bypass
 
Ecmo
EcmoEcmo
Ecmo
 
ppt39sak23-171123100040.pdf
ppt39sak23-171123100040.pdfppt39sak23-171123100040.pdf
ppt39sak23-171123100040.pdf
 
Adult ecmo
Adult ecmo Adult ecmo
Adult ecmo
 
Cardio-Pulmonary Bypass: A Brief Overview
Cardio-Pulmonary Bypass: A Brief OverviewCardio-Pulmonary Bypass: A Brief Overview
Cardio-Pulmonary Bypass: A Brief Overview
 
HEART LUNG MACHINE
HEART LUNG MACHINEHEART LUNG MACHINE
HEART LUNG MACHINE
 
Ecmo
EcmoEcmo
Ecmo
 
ECMO in Critical Care
ECMO in Critical CareECMO in Critical Care
ECMO in Critical Care
 
oxygenators-copy-200308141605.pptx
oxygenators-copy-200308141605.pptxoxygenators-copy-200308141605.pptx
oxygenators-copy-200308141605.pptx
 
ECMO - extracorporeal membrane oxygenation
ECMO - extracorporeal membrane oxygenationECMO - extracorporeal membrane oxygenation
ECMO - extracorporeal membrane oxygenation
 
ECMO - Part 1 by Dr.Tinku Joseph
ECMO - Part 1 by Dr.Tinku JosephECMO - Part 1 by Dr.Tinku Joseph
ECMO - Part 1 by Dr.Tinku Joseph
 
heart-lung-machine-pump.ppt
heart-lung-machine-pump.pptheart-lung-machine-pump.ppt
heart-lung-machine-pump.ppt
 
ecmofinal-160719115713-converted.pptx
ecmofinal-160719115713-converted.pptxecmofinal-160719115713-converted.pptx
ecmofinal-160719115713-converted.pptx
 
Heart lung by pass unit
Heart lung by pass unitHeart lung by pass unit
Heart lung by pass unit
 
Cardiac surgeries
Cardiac surgeriesCardiac surgeries
Cardiac surgeries
 
cardiopulmonary bypass
cardiopulmonary bypasscardiopulmonary bypass
cardiopulmonary bypass
 
Cardiopulmonary bypass
Cardiopulmonary bypassCardiopulmonary bypass
Cardiopulmonary bypass
 

Mais de Dhanesh Bhardwaj

Mais de Dhanesh Bhardwaj (20)

Mechanical Circulatory Support
Mechanical Circulatory SupportMechanical Circulatory Support
Mechanical Circulatory Support
 
Carcinoma lung
Carcinoma   lungCarcinoma   lung
Carcinoma lung
 
Acute rheumatic fever
Acute rheumatic feverAcute rheumatic fever
Acute rheumatic fever
 
Ventricular Septal Defect
Ventricular Septal DefectVentricular Septal Defect
Ventricular Septal Defect
 
Tetrology of Fallot
Tetrology of FallotTetrology of Fallot
Tetrology of Fallot
 
Sternal/ Chest wall deformities and Tumors
Sternal/ Chest wall deformities  and TumorsSternal/ Chest wall deformities  and Tumors
Sternal/ Chest wall deformities and Tumors
 
Shock and mods
Shock and modsShock and mods
Shock and mods
 
Mitral stenosis
Mitral stenosisMitral stenosis
Mitral stenosis
 
Ecg basics and interpretation
Ecg basics and interpretationEcg basics and interpretation
Ecg basics and interpretation
 
Discuss thoracic incisions(1) copy
Discuss thoracic incisions(1)   copyDiscuss thoracic incisions(1)   copy
Discuss thoracic incisions(1) copy
 
Atrial septal defect
Atrial septal defectAtrial septal defect
Atrial septal defect
 
Anatomy of right atrium
Anatomy of right atriumAnatomy of right atrium
Anatomy of right atrium
 
Thoracic dnb exam
Thoracic dnb examThoracic dnb exam
Thoracic dnb exam
 
Evaluation of cyanotic child &amp; management of cyanotic
Evaluation of cyanotic child &amp; management of cyanoticEvaluation of cyanotic child &amp; management of cyanotic
Evaluation of cyanotic child &amp; management of cyanotic
 
Carcinoma lung
Carcinoma   lungCarcinoma   lung
Carcinoma lung
 
AHA/ACC guidelines
AHA/ACC  guidelinesAHA/ACC  guidelines
AHA/ACC guidelines
 
AGT notes
AGT notesAGT notes
AGT notes
 
Hypertrophic obstructive cardiomyopathy
Hypertrophic obstructive cardiomyopathyHypertrophic obstructive cardiomyopathy
Hypertrophic obstructive cardiomyopathy
 
Myocardial Protection
Myocardial ProtectionMyocardial Protection
Myocardial Protection
 
Aortic dissection
Aortic dissectionAortic dissection
Aortic dissection
 

Último

Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...narwatsonia7
 
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...Taniya Sharma
 
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...vidya singh
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...chandars293
 
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiRussian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiAlinaDevecerski
 
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Dehradun Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...tanya dube
 
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...chandars293
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...aartirawatdelhi
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escortsvidya singh
 
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Dipal Arora
 
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...Genuine Call Girls
 
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...astropune
 
Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 9332606886  Meetin With Bangalore Esc...Bangalore Call Girls Nelamangala Number 9332606886  Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Esc...narwatsonia7
 

Último (20)

Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
 
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
 
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
 
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
 
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiRussian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
 
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Dehradun Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Dehradun Just Call 9907093804 Top Class Call Girl Service Available
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
 
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
 
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
 
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
 
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
 
Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 9332606886  Meetin With Bangalore Esc...Bangalore Call Girls Nelamangala Number 9332606886  Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Esc...
 

Principles of CPB

  • 2. What is It ?  Temporary mechanical circulatory support to the stationary heart and lungs  Heart and Lungs are made “functionless temporarily” , in order to perform surgeries
  • 3. History  First open cardiotomy (Apr 5, 1951)  First successfulOHS (Sep 2, 1952)  Dr. F John Lewis  ASD closure using hypothermia and inflow occlusion  First successfulOHS using CPB (by JohnGibbon May 6, 1953)  ASD closure  High mortality rate  VSD closure by azygos flow concept (controlled cross- circulation) (Dr C.Walton Lillehei Mar 26, 1954)
  • 4.  DeWall-Lillehei helix bubble oxygenator (May 1955)  Beginning in a large series of patients  Method of choice worldwide for OHS  Rotating Disk oxygenator  Developed by Dr Fredrick Cross and Earl Kay in 1962  Used for early OHS in USA  Membrane oxygenator  Developed in 1950s-1970s; but initially not frequently used  In the mid-1980s, microporous designs; frequently used.  Hemodilution  Major technologic advance in CPB
  • 5. Cardiopulmonary Bypass  Goals 1. Still, bloodless heart for cardiac surgery 2. Replacement of cardiac and pulmonary function
  • 6. Functions of CPB • Respiration  Ventilation  Oxygenation • Circulation  Venous drainage (by gravity, centrifugal pump, or negative pressure)  Arterial inflow • Temperature regulation (hypothermia)  Low blood flow -> decreased blood trauma  Decreased body metabolism
  • 7. Components of CPB  Total CPB  Partial CPB  Integral Components of Extracorporeal Circuit  Pumps  Oxygenator  Heat exchanger  Arterial filter  Cardioplegic delivery system  Cannulae (aortic; arterial; vena caval)  Suction and vent
  • 8. Basic CPB circuit with oxygenator and centrifugal pump
  • 10. Pumps  Two principal types  Displacement pumps  Roller pump  Non occlusive roller pumps  Rotatory pumps  Radial (centrifugal) pumps  Axial pumps (Archimedes’ screw)  Diagonal pumps
  • 11. Impeller PumpRoller Pump Centrifugal Pump Pumps
  • 12. Centrifugal pumps > Roller pumps  Long-term CPB  Ventricular assistance  Neonatal ECMO  Centrifugal pumps  Biomedicus Biopump (Medtronic Inc)  Sarns/3M centrifugal pump (Terumo)  Levitronix CentriMag blood pump  LVAD, RVAD, BiVAD  BiVAD + oxygenator in RVAD = ECMO
  • 13. Pulsatile Perfusion  Significant physiologic advantages • Diastolic run-off • Stimulation of the endothelium  Problem • Noncompliant high resistance CPB circuit • High flow with resultant shear stress  Hemolysis • Possible with roller pump and diagonal pump, but not with centrifugal pump • Requires larger bore arterial cannulas  Alternative method for generating pulsatile flow in high-risk patients • Use of IABP during CPB • Additional cost and invasiveness
  • 14. Oxygenator  Limited reserve for gas transfer vs. natural lung • Much smaller surface • Limited by diffusion  Types of oxygenator • Disk oxygenator • Bubble oxygenator • Membrane oxygenator  Maximum oxygen transfer • Less than 25% that of normal lung • Proportional to pO2 difference and surface area, inversely to diffusion distance
  • 15. Disk or bubble oxygenator  Direct contact oxygenators • Bubbles in direct contact with blood • Increasing cellular trauma
  • 16. Bubble oxygenator  Bubble oxygenator • Larger bubbles improve removal of CO2 • Smaller bubbles are very efficient at oxygenation but poor in CO2 removal • Larger the No. of bubbles, Greater the efficiency of the oxygenator
  • 17. Bubble Oxygenator  Advantage  Easy to assemble  Relatively small priming volume  Deforming the frothy blood  Low cost  Disadvantages  Micro emboli  Blood cell trauma  Destruction of plasma protein  Excessive removal of CO2  Deforming capacity exhausted
  • 18. Membrane Oxygenator  Characteristics  Gas exchange across a thin membrane  No direct contact with blood and no defoamer; more physiologic  Minimal blood damage  Two types  Solid type (Silicone)  Microporous type (polypropylene)  0.3-0.8-micron pores  Most popular design = hollow fibers (120-200 microns)
  • 20. Microporous (Polypropylene) Membrane Oxygenator  Currently predominant design used forCPB  Micropores  Less than 1.0 um in diameter  Initially porous, but plasma protein coating the membrane-gas interface  Surface tension of blood prevent gas leakage into the blood phase  Conduit for O2 and CO2 exchange  Problems  Plasma leakage and membrane wet at use of period > 24 hours
  • 21. Silicone Membrane Oxygenator  True membrane oxygenator  Silicone polymer  Improved biocompatibility -> long-term support  1980s to mid-1990s  Still the membrane of choice for long-term procedures  ECMO  Problems  Gas exchange inferior to polypropylene (microporous) oxygenator  Need greater surface area and larger prime volume  Difficult in manufacturing and quality control
  • 22. New Generation Membrane Oxygenator  Silicone polymer  A continuous sheet of silicone membrane rolled into a coil  Manufactured by Medtronic Cardiopulmonary Inc.  Membrane surface area + 0.6-4.5 sq.m  Most common use for ECLS/ECMO
  • 23. Heat Exchanger  Integrated into oxygenator for warming and cooling  Exchange surface made of  Stainless steel, aluminum, or polypropylene  Counter-current mechanism  Temperature difference between waterside and blood side  Historic reports : maximum difference of 10 °C  Recent recommendation : 6 °C and longer rewarming times  To improve neurocognitive outcome  Hyperthermic circulatory temperature  Blood damage (protein denaturation)  Limit absolute maximum temperature (42 °C) in blood
  • 24. Filters and Bubble Traps  In the circuit, micro emboli are monitored by arterial line ultrasound or monitoring screen filtration pressure.  Depth filters consist of porous foam, have a large, wetted surface and remove micro emboli by impaction and absorption  Screen filters are usually made of woven polyester or nylon thread.
  • 25. Tubing  Medical grade Polyvinyl Chloride (PVC) tubing  It is flexible, compatible with blood, inert, nontoxic, smooth, nonwettable, tough, transparent, resistant to kinking and collapse  Can be heat sterilized  The Duraflo II heparin coating ionically attaches heparin to a quaternary ammonium carrier (alkylbenzyl dimethyl - ammonium chloride), which binds to plastic surfaces.
  • 26. Perfusion Monitors and Sensors  A sensor with alarms on the venous reservoir and a bubble detector on the arterial line are desirable safety devices.  Flow-through devices are available to continuously measure blood gases, hemoglobin/hematocrit , and some electrolytes  Temperatures of the water entering heat exchangers
  • 27. Circuits  Venous drainage by gravity into oxygenator  Height difference between venae cavae and oxygenator > 20- 30 cm  Mechanical suction Not desirable  Entrain air  Suck the vena cava walls against the cannula orifices  Arterial blood return to the systemic circulation under pressure
  • 28.
  • 29. Arterial Return  Ascending aorta just proximal to innominate A  Femoral artery access in • Dissecting aortic aneurysm (0.2-3%) • Reoperation • Emergency • MICS  Problems of femoral cannulation (more than ascending aorta cannulation) • Sepsis • Pseudoaneurysm • lymphatic fistula  Arterial cannula • The narrowest part of CPB circuit • As short as possible • As large as the diameter of vessel permits  < 100 mmHg in full flow
  • 30. Arterial Cannula  Straight/Angled cannula • Minimize risk of dislodgement of atheroma in the ascending Aorta or Arch  Axillary –subclavian artery, innominate artery, LV apex • In special circumstances • Limitations and more complications  Complication: Dissection of aorta • All sites of arterial cannulation • Prompt recognition and surgical correction • TEE helpful for diagnosis
  • 31. Size of venous cannula Adult Children  SVC (1/3 of total flow) 28 24  IVC (2/3 of total flow) 36 28  Example: 1.8 m2 patient  Total flow 5.4 l/min  SVC 1.8 l/min, IVC 3.6 l/min  SVC > 30 Fr, IVC > 34 Fr : Single cannula > 38 Fr  36-51 Fr cannula required.
  • 32. Prime Fluid  Ideally close to ECF  Whole blood not used • Homologous blood syndrome • Postperfusion bleeding diathesis • Incompatibility reaction • Demand on blood banks  Advantages of hemodilution • Lower blood viscosity • Improve microcirculation • Counteract the increased viscosity by hypothermia  Risk of hemodilution • Decreased viscosity : SVR decreased • Low oncotic pressure • O2 carrying • Coagulation factor

Notas do Editor

  1. University of Minesta hospital; Thomas Jefferson University hospital in Philadelphia; 18-yr-old woman; Oxford univesity, physics, architec;
  2. University of Minesta hospital; Thomas Jefferson University hospital in Philadelphia; 18-yr-old woman; Oxford univesity, physics, architec;