Complicationsandsafetyduringcpb

1. Safety during CPBSafety during CPB
Manu Jacob
Perfusionist
KMCT MCH

2. Bypass safetyBypass safety
Concept of safety is subjective.
Fatal perfusion accidents occurred 1/1800
cases.(1981)
Serious incident 1/130 procedures (1981)
With better saftey features and perfusion
techniques standards has improved
considerably.

3. Organizational aspectsOrganizational aspects
Most important and fundamental aspect of
cardiac surgery.
Describes the quality required of the unit
members and their responsibilities.
Describes the components required for an
open-heart unit.
Emphasizes team work.
Emphasizes co-operation,co-ordination
and effective communication.

4. Perfusion department safetyPerfusion department safety
organizationorganization
 Establishment of equipment records:
1. Identification and location of each
individual device.
2. Record of maintenance and repair of
each device.
3. Establishment of routine preventive
maintenance protocols.
 Faults book

5. Perfusion protocolPerfusion protocol
 Establish agreed protocols to be followed by all
perfusionists
1. Basis for selction of equipments
2. Pre-operative machine checks
3. Priming solutions and techniques
4. Case record which should include
a) patient statistics
b) equipments used
c) fluids and drugs used.
d) measured parameters.
e) frequency of entries.

6. Perfusion protocol contd.,Perfusion protocol contd.,
 Pre-bypass check list.
 Basic guideline for perfusion
management
1. Blood flows
2. Pressure limits
3. Fluid replacements
4. Blood gas and electrolyte limits
5. Anticoagulation and temperature control

7. Perfusion protocol contd.,Perfusion protocol contd.,
 Procedures to be followed in the event
of equipment failure
1. Electrical power
2. Mechanical pump failure
3. Reservoir failure
4. Gas supply failure
5. Temperature control
6. Circuit rupture

8. Perfusion protocol contd.,Perfusion protocol contd.,
 Team responsibility and communication
1. Establish agreed areas of responsibility
and systems of communication
2. Establish a procedure in the event of
failure
 Establish protocol for cleaning and
decontamination of all non-disposable
equipments.

9. Patient specific safety protocolsPatient specific safety protocols
 Identification of patient
1. Patient statistics
2. Diagnosis
3. Pre-operative
haematology,biochemistry,drug
theraphy
4. Cardiac investigative results
5. Proposed opertation

10. Patient specific protocols contd.,Patient specific protocols contd.,
 Selection of equipment according to
protocol
 Machine checks
a) Availability of alternate systems
b) Calibration checks
c) Occlusion checks
 Circuit components
a) Sterility b) visual check for defects
c) Availability of alternatives

11. Protocol contd.,Protocol contd.,
Prime according to protocol
Double check all fluids and drugs
Institute case record
Ensure record of identification data on
equipment and fluids used
Follow protocols for cleaning and
decontamination.

12. Accidents OR Mishaps In PerfusionAccidents OR Mishaps In Perfusion
Occasional
Often
TWO Categories:
Human error
Equipment failuresTerumo conf.Dubai June 2002

13. Human errorHuman error
Inadequate knowledge
Carelessness
Overconfidence
Poor investigations
Poor communications

14. Human errorHuman error
Critical situation
Odd times
Poor medical ethics
interdepartmental politics or ego
Untidiness or disorganized setups

15. Non-human elementsNon-human elements
Mechanical defects
Environmental factors
Lighting conditions

16. Human factors of accidentsHuman factors of accidents
Adventurous spirit
Inadequate training
Negligence and irresponsibilities
Fatigue
Stress
Impatience
Carlessness
The ageing process

17. Equipment failuresEquipment failures
Equipment failures:
Attention, resolve at the earliest
Failure attracts the attention of many
Too many opinions
Confusion - Perfusionist - Diversion

18. Accidents only to medical field?Accidents only to medical field?
Common to any given speciality.
More common in teaching institutions
Interns and Students
Does not spare even the most
experienced and in the hands of
observers.

19. TO Err is human
Acceptance gains knowledge
Denial fools self
Knowledge gets ignored

20. Reduced oxygenationReduced oxygenation
Most frequent incident
Gas delivery system may develop leak or
blockage.
Forgetting to turn on the gas before going
on cpb
Gas line not connected to oxygenator.
Defective oxygenator
Blood flows more than the rated flow

21. Arterial line air embolismArterial line air embolism
Most sudden and distressing incident
during CPB.
Mostly occurs due to non usage of safety
devices
Level alarm is a usefull aid but not a
substitue for proper vigilance.
The use of arterial filter and bubble traps.

22. Other perfusion related causesOther perfusion related causes
of gross air embolismof gross air embolism
 Oxygenator related.
1. Break in the integrity of oxygenator
connections
2. Detachment of oxygenator from holder
3. Non-venting of oxygenator
4. Clotted oxygenator

23. Pump related causes of grossPump related causes of gross
air embolismair embolism
runaway arterial pump head.
Reversal of arterial pump
Occluded line proximal to arterial pump
head.
Reversal of vent pump
Ruptured pump boot due to
overocclussion.
Foreign bodies entering pump head.

24. Cardiotomy reservoir relatedCardiotomy reservoir related
Production of positive pressure at the
input to the reservoir.
Air forced back up an arterial filter purge
line
Air forced back along vent system through
a non-occlusive pump
Large amount of air entrained in the
cardiotomy reservoir

25. Management of gross airManagement of gross air
embolismembolism
Prevention is the best form management.
Guidelines and procedures should be
setup and practiced by perfusionist.
Stop arterial pump immediatley.
Clamp venous line.
Place patient in a steep head down
position.
Cannula removed and circuit purged of
air.

26. Management of air embolismManagement of air embolism
contd.,contd.,
Arterial line is connected to venous
cannula to facilitate retrograde perfusion.
Start flow at 1 to 2lts/mt with flow
directed up the SVC.
Try to cool the patient to 20 degrees.
Suction system is to retrieve blood from
aortotomy.
Anesthetist exerts pressure on carotids.

27. Air embolism contd.,Air embolism contd.,
Retrograde perfusion is continued until
the arterial system is cleared of air.
Standard bypass is resumed with
hypothermia.
Air from the coronary system is also
removed by pharmocological elevation of
perfusion pressure.
Dexamethasone and thiopentone are
administered.

28. Contd.,Contd.,
Rewarming accomplished slowly to core
temp of 35 deg and bypass discontd.
Patient ventilated on 100% oxygen
Deep barbiturate anesthesia may be
useful.
Hyperbaric treatment is useful with good
results especially within 48 hrs of injury.
Mean arterial pressure at 100 to 130
mmhg

29. How to avoid accidents?How to avoid accidents?
Sound Knowledge
Regular updates
Regular Maintenance of equipments.
Build up of trust and team spirit

30. How to avoid accidents? Contd.,How to avoid accidents? Contd.,
Follow the standards of perfusion
Good data management
Check list and double check
Reconfirmation of settings
Vigilant always
Never be overconfident

31. Contd.,Contd.,
Good communication
Sharpness in sight, hearing and
reasoning
Engage all the saftey gadgets on the
HLM
Widens the saftey window
Machines have alarm, alert
 and auto shut off

32. Contd.,Contd.,
Saftey gadgets gives relaxation to the
operating perfusionist
Keep the safe timing limits
Develop good organising skills
Methodic approach

33. Standards to followStandards to follow
Document all the vital parameters,
history of the Patient
Appropriate the equipment selection
and the disposables as per the
patients need
Never go with blind approaches

34. DrugsDrugs
Always read the drug label
Never follow the color or shape of the
vial or container
May lead to increase in Morbidity and
mortality

35. Overcoming accidentsOvercoming accidents
Learning
◦ An ongoing process
◦ Universal
◦ No age limit
◦ Do not deny the opportunity
Dedicate your time and age for
achievements.

36. Ultimate goalUltimate goal
Save the life inspite of all the odd
situations
Prevent the re-occurrence
Draft protocols and applications
Be committed to the profession

37. Contd.,Contd.,
Do not work for rewards alone
Earn the confidence of the team
Knowledge, hard work and efficiency
Earns a better living
Terumo conf.Dubai June 2002

38.  Sincereity, punctuality, honesty, vigilance, dedication, thorough knowledge and
good communication
 Earns a good professional
 Terumo conf.Dubai June 2002

39. Constant updateConstant update
Text books
Media
CME
Conferences National, International
Medical exhibitions
Help to develop the management
skills of the perfusionist

40. Worldwide experience shows :
Human errors > 90%
Equipmental errors <10%

41. Perfusion management andPerfusion management and
perfusion systemsperfusion systems
inspite of advanced technologies,
monitoring the adequacy of perfusion is
not reliable.
Oxygen delivery to the vital organs
depends on multi-faceted interaction of
perfusion conditions.
There are no easily measured indicators of
adequacy avilable to us in OT

42. Perfusion systemsPerfusion systems
the CPB machine,patient and perfusionist
constitute a system.
Systems performance is a science
employed by diverse agencies such as
atomic energy commission and NASA.
From the perfusionist point of view it is
important that the fundamental priciples
of system performance are recoganised.

43. Perfusion system contd.,Perfusion system contd.,
 An FDA sponsored study identified four
broad areas as the cause of
unsatisfactory perfusion.
1. Inadequacy of current perfusion
management technique.
2. Pre-bypass pathalogical problems in
patient
3. Bypass device inadequacy or failure
4. User error-accounts 80% of all errors.

44. Safety for the perfusionistSafety for the perfusionist
Awareness of safety factors related to
hepatitis B infection and HIV has
prompted concern among the team.
Protection of health care staff is the
responsibility of management to help in
the vaccination
Avoidance of skin, mucus membrane and
skin puncture contact with affected blood.