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
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
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
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.