Sultanate of Oman Ministry of Health

The Royal Hospital Department of National Heart Centre

Pediatric Cardiopulmonary Bypass

Practice Guideline
Document 1.0

Version 1: Revision 0

Date Effective: 28th April 2019

Review Date: 28th April 2020

Authors

Victoria Harris, BSc, CPC, ACP and

Maria Al Bulushi, BSc, CCP

Approved

Saleh Badwi Al Harthy, BSc, CCP

Chief Perfusionist

1
 Table of Contents

Page
Patients calculated blood flow …………………………………………………………………………………………….4
Equipment Selection…………………………………………………………………………………….………………………4
Oxygenator Selection…………………………………………………………………………………………4
Venous Reservoir……………………..…………………………………………………………..……………4
Tubing Pack Selection…………………………………………..…………………………………………….5
Boot Pump…………………………………………………………..…………………………………………….5
Centrifugal Pump………………………………………………….……………………………………………5
Arterial Line Filter…………………………………………….………………………….…………………….5
Hemoconcentrator…………………………………………….…………………………………..………….6
Cardioplegia……………………………………………………………………………………………………….6
Priming volumes ………………………………………………………………………………………………………………....7
Arterial Cannulas………………………………………………………………………………………….………………………8
Venous Cannulas………………………………………………………………………………………………………………….9
Predicated HCT/Hb on CPB ……………………………………………………………………………………………….10
Medication – Prime Components……………………………………………………………..………………………..11
Medication – Group A, added to CPB circuit
RX5 ¼ x ¼” tubing pack………………………………………………………………………….…………..……13
Maquet ¼ x 3/8”tubing pack………………………………………………………………………..…………14
RX1540 3/8 x 3/8 tubing pack……………………………………………………………………….………..14
Inspire/RX25 3/8 x ½ tubing pack……………………………………………………………………..…….15
Medication – Group B, administered during CPB………………………………………………………………..16
Medication – Group C, administered under direction of surgeon/anesthesiologist…………....17
Assembly of Circuit…………………………………………………………………………………………….……………….18
Safety Devices………………………………………………………………………………………………..…………………..19
Alarm Settings…………………………………………………………………….………………………………………………20
CPB Monitoring Devices………………………………………………………………………………………….………….21
Charting……………………………………………………………………………………………………………….…………….21
Communication………………………………………….………………………………………………………………………22
Anticoagulation………………………………………………………………………………………………………………….22
Arterial Line Test ……………………………………………………………………………………………………….………23
Initiation of CPB…………………………………………………………….……………………………………………………23
Initiation of CPB in cyanotic patients…………………………………………….……………………………………24
Arterial Line Pressure………………………………………………………………………………………………………….25
Patient Blood Pressure Maintenance………………………………………………………………….………………25
Vacuum Assisted Venous Drainage (VAVD)…………………………………………………………………………27
Cardioplegia ………………………………………………………….…………………………………………………………..28
DHCA…………………………………………………………………………………………..……………………………………..31
Antegrade cerebral perfusion……………………………………………………………….……………………………32
Lower Body Perfusion……………………………………………………………………………………………………..….32
ABG Management………………………………………………………………………………………..…………………….33
Re-warming…………………….………………………………………………………………………………………………….34
X-Clamp Removal ……………………………………………………………………………….……………………………..34
Termination of CPB………………………………………………………..…………………………………………………..34
Modified Ultra filtration (MUF)…………………………………………………..………………………………………35

2
Circuit Volume………………………………………………………………………………….…………………………….….38
Protamine…………………………………………………………………………………………………………………………..38
Circuit Disposal…………………………………………………………………………………………………………………38
Roles and Responsibilities…………………………………………………………………………………………………..39
On-Call Perfusionist…………………………………………………………………………………….………………………40
Emergency Overnight Set-up………………………………………………………………………..…………………….40
Standby CPB set-up…………………………………………………………………….………………………………………41

Perfusion Agreement.……………………………………………………………………………………….………..………42
Cardiac Agreement……..…………………………………………………………………………………………...………..43
Cardiac Anesthesia Agreement ..………………………………………………………………………………..………44

References……………………………………………………………………………………………………………….…………45
Appendix ………………………………………………………………………………………………………………..………….46

3
Equipment Selection Criteria

All perfusionists should be familiar with the function and operation of CPB equipment for the safe
practice of perfusion. All equipment is selected based on the manufactures published performance
profiles with respect to blood flow rate (as per tables 2-9), the patient's requirement for bypass
during rewarming and at normothermia.

The oxygenator, tubing pack, boot pump, hemocentrator and all cannulas are selected based on
the equipment selection criteria column below (orange).

Table 1. Patient's Maximum Potential Blood Flow

Weight Age Equipment Selection Range on

Oxygenator
(kg) (approx) Criteria CPB
0-3 Neonate (0-30 days) 150mls/kg 120 - 175 Terumo RX5
3.1-8 1 month – 6 months 130mls/kg 120 - 175 Terumo RX5
8.1-12.0 6 months - 1 year 120mls/kg 100 - 150 Terumo RX5
12.1-20 1 year - 5 years 100mls/kg 100 - 120 Quadrox-I Pediatric
20-28 5 years + 2.5L/m2/min 2.5-2.6L/m2/min Quadrox-I Pediatric
28+ 10 years + 2.4L/m2/min 2.4L/m2/min Terumo RX15(40)

Table 2. Oxygenator Selection Guideline

Priming
Maximum
Oxygenator Volume
Flow (L/min)
(mls)
Terumo RX5 43 1.5
Maquet Quadrox-I 81 2.8*
Pediatric
Terumo RX15 (40) 135 5.0
Sorin Inspire 6 184 6.0
Terumo RX25 250 7.0
* Sorin Dideco D736 arterial filter in infant tubing pack rated flow 2.5LPM

Alternative oxygenators may be used if in stock and the perfusionist is familiar with the equipment

Table 3. Venous Reservoir

Low level alarm Maximum storage

Reservoir
point (mls) capacity (mls)
Terumo RX5 35 1000
Maquet Quadrox-I Pediatric 30 1700
VHK 31000
Terumo RX15 (40) 200 4000
Sorin Inspire 6 150
Terumo RX25 200 4000

4
Table 4. Tubing Pack Selection Guideline

Type 1/4 x 1/4 1/4 x 3/8 3/8 x 3/8 3/8 x 1/2

Blood Flow 0-1.5 1.5-2.8 less than 4.0 less than 7.0
(L/min)

Sorin tubing packs are coated with P.h.i.s.i.o based on a phosphorylcholine molecule to increase
the hemocompatibility. Improves platelet preservation, reduces activation of coagulation
factors, reduces inflammatory reactions and limits post operative bleeding.

Table 5. Pump Boot Selection Guideline

Type 1/4" Boot 3/8" Boot 1/2" Boot Centrifugal

Blood Flow Less than 1.5 Less than 6 Greater than 6 Greater than 6
(L/min)

All roller heads run anti-clockwise, each turn of the boot pump equates to the following volumes:
* 1/4" 13ml per revolution
* 3/8" 29ml per revolution
* 1/2" 48ml per revolution

Table 6. Centrifugal Pump

Priming Volume Max Blood Flow Inlet/Outlet

Centrifugal Pump
(mls) Rate (LPM) connection

Sorin Revolution 57 8 3/8

Table 7. Arterial Line Filters

Pore Size Inlet/Outlet Priming Volume Max Blood Flow

Filter
(μm) Connection (mls) Rate (LPM)

Sorin Dideco
40 1/4 40 2.5
D736

Baby Sherlock
40 1/4 35 3.2
Euroset
Sorin P.H.Y.S.I.O
40 3/8 195 8
D734

5
Table 8. Hemoconcentrator Selection Guide

Static Priming Surface Max Rated Blood Use with

Hemoconcentrator
volume (mls) Area (m2) Flow (mls/minute) circuit

1/4 x 1/4
Maquet BC 20 plus 17 0.22 100
1/4 x 3/8

3/8 x 3/8
Sorin DHF06 60 0.68 500
3/8 x 1/2

Table 9. Cardioplegia Selection Guide

Cardioplegia Device Static Priming Maximum Flow (mls)

Volume (mls)

Sorin CSC 14 30 2500

6
Table 10. Circuit Prime Volumes

Art
Oxygenator Pump Tubing Set Cardioplegia MUF H/C
Filter Total
Type mls mls Type mls Size mls Type mls Type mls (mls) Circuit volumes based on the
circuit diagrams and
143b 40 1/4 57 1/4 x 1/4 129 CSC 14 110 BC 20 20 500 following calculations:
Terumo RX5
1/8" = 2.5mls/foot
Quadrox-I 181c 40 3/8 81 1/4 x 3/8 215 CSC 14 110 BC 20 20 650 3/16 = 5.22mlks/foot
Pediatric 1/4" = 9.65mls/foot
Terumo 335e 195 3/8 81 3/8 x 3/8 355 CSC 14 110 DHF06 20 1125 3/8" = 21.7mls/foot
RX15 (40) 1/2" =38.61mls/foot
Sorin Inspire 434f 195 centrifugal 95 3/8 x 1/2 432 CSC 14 110 DHF06 20 1330
6 1 foot = 30cms
g
Terumo 550 195 centrifugal 95 3/8 x 1/2 432 CSC 14 110 DHF06 20 1450
RX25
b
static priming volume + min operating level +65mls (starting volume of 100mls in reservoir)
c
static priming volume + min operating level +70mls (starting volume of 100mls)
e
static priming volume + minimum operating level + 100mls (starting volume of 200mls)
f
static priming volume + minimum operating level + 100mls (starting volume of 250mls)
g
static priming volume + minimum operating level + 100mls (starting volume of 300mls)

7
Cannula Selection Guideline

The charts below are guidelines to cannula selection. Anatomical characteristics (e.g. LSVC,
small, large vessels) may result in deviations from this chart. Different cannula manufactures
(Medtronic versus Edwards) and characteristics (straight versus right angled) will result in
different flow dynamics based on wall thickness, resulting internal diameters (ID) and
cannula design (see appendix 2).

Cannula selection is subject of approval by consultant surgeon.

CPB flow on bypass is not an absolute value and is adjusted according to physiological and
surgical requirements. Appropriate blood flow rate is multifactorial for example blood flow
rate may be increased as a result of the flowing:

- Normothermia

- Rising lactate levels

- SVO2 less than 65%

- Low mean arterial blood pressure (see table 22)

- HCT less than 25%

- Below baseline cerebral saturation (NIRS)

- Absence of collateral circulation/ flooding at surgical field

Table 11. Arterial Cannulas (Medtronic DLP)

Cannula selection is based on flow (orange column), weights are approximate only and not
absolutes.

Arterial Rated Flow

Approx. Weight (kg)
(Fr) (mls)
6 Less than 400 Less than 2.6
8 400-700 2.6-5
10 700-1250 5-8
12 1250-2000 8-20
14 2000-2700 20-35
16 2700-3750 35-60
18 EOPA 3750-4750 60-85
20 EOPA 4750-5700 85

Note: Arterial line pressures of 250mmHg are acceptable at full flow. However, always
inform the surgeon of the exact number regardless. Cannulas flowing at the lower rated flow
with high line pressure may require manipulation from the surgeon for optimal location
within lumen.

8
Table 12. Venous Cannula Bicaval Straight Cannula (Medtronic DLP)

Cannula selection is based on flow (orange column), weights are approximate only and not
absolutes.

Rated Flow Weight

SVC (Fr) IVC (Fr)
(mls) (kg)
12 14 0-600 <4
14 16 600-950 4-7.5
16 18 950-1300 7.6-11
18 20 1300-1650 11.1-16.5
20 22 1650-2100 16.5-25
22 24 2100-2400 26-30
24 26 2400-3000 31-44
26 28 3000-3600 45-50

Table 13. Venous Cannula Bicaval Right Angle (Medtronic or Edwards)

Rated Flow
SVC (Fr) IVC (Fr) Weight (kg)
(mls)
10 12 600 Less than 4
12 14 600-950 4-7.5
12 16 950-1200 7.5-10
14 16 1200-1650 10-16.5
16 18 1650-2500 16.5-30
18 20 2500-3000 31-44
20 22 3000-3750 42-59
22 24 3750-4500 60+
24 28 4500-5500 70+
28 28 5500-6000 95+

Table 14 Venous Cannula Single Straight

Venous Rated Flow Weight

(Fr) (mls) (kg)
12
14 350
16 600 4
18 950 4-5
20 1300 6-9
22 1650 10-15
24 2100 16-25
26 2400 25-30
28 3000 30+
30 3600
32
34

9
Predicted HCT on Bypass

The following calculation will identify the patients predicted HCT on bypass and the
subsequent packed RBC volume required to obtain a HCT of 24% (Hb 7.2g/dL) on initiation.

Estimated HCT on CPB

1. Patient estimated blood volume (mls): EBVpt = Wt (kg) x Volaemia (see table 15)

2. Patient's estimated RBC volume (mls): ERBCVpt = EBVpt x HCTpt

3. Total CPB circulating blood volume (mls): TCPBCBV = EBVpt + Priming volume (PVcpb)

4. Estimated HCT on CPB: EHCTpump = (EBVpt x HCT) / (EBVpt + PVcpb)

RBC volume required for HCT of 24%

5. RBC estimated blood volume on CPB (mls): ERBCVcpb = TCPBCBV x 0.25

6. RBCadded = (ERBCVcpb- ERBCVpt ) ÷ 65

For example:

A 3kg patient, Hb 11.4 (x3 = approx HCT)

1. EBVpt : 3kg x 85 ml = 255mls

2. ERBCVpt = 255 x 0.34 = 86.7mls

3. TCPBCBV = 255 + 500 = 755mls

4. EHCTpump = (255 x 0.34)÷ (255+500) = 11.4%

5. ERBCVcpb = 755 x 0.24 = 181.2mls

6. RBCadded = (181.2-86.7) ÷ 65 = 145mls

Patients 10-20kg the perfusionist MUST discuss with cardiac surgeon and anesthesiologist
regarding blood product requirement. Asanguineous prime may be appropriate for non-
complex / short (less than 60 minutes) cases.

Table 15. Patient Blood Volume

Weight (kg) Volaemia (ml/kg)

Less than 10 85
11-20 80
21-30 75
31-40 70
Greater than 41 65

10
Medication – Prime Components

Plasmalyte A 148 – the main crystalloid priming component of the CPB circuit, an isotonic
solution containing potassium, sodium, magnesium, acetate, gluconate and chloride. Dose
ranges of 500-1500mls are used depending on circuit size selection and blood prime volume.

Albumin 20% - used to maintain colloid osmotic pressure (COP) and coats the circuit in order
to ameliorate blood contact activation. Dose 30g/L circuit prime, range 50-200ml depending
on circuit size selection and blood prime.

Heparin (1,000UI/ml, 10g/ml) green vial

Heparin (5,000UI/ml, 50g/ml) blue vial - circuit anticoagulation, dose ranges dependant on
circuit size selection, approximately 3UI/ml prime.

Mannitol 20% - osmotic diuretic with free radical scavenging properties, which has been
shown to reduce the extent of ischemic injury and improve the function of the myocardium.
Mannitol minimizes extra vascular fluid shifts, reduces positive fluid balance and improves
post operative renal function. Total dose of 0.75g/kg, half in prime and second on
rewarming, prior to x-clamp removal.

Sodium Bicarbonate 8.4% (1mEq/ml) – used to buffer acidic prime constituents. Dose
ranges of 2mls/100ml prime volume. Addition of NaHCO3 to buffer circuits often results in
elevated prime sodium levels in the neonatal circuit.

Calcium Chloride 10% - used to prevent hypocalcaemia upon initiation of CPB. Circuit prime
blood gas of Ca++: 0.7-1.0mmol/L is targeted. Dose is dependent on blood prime and
crystalloid volume.

Blood Prime - If an asanguineous (crystalloid) prime would result in excessive hemodilution

then the volume of PRBs necessary to achieve target HCT range should be added to prime.
Neonatal patients we aim for PRBCs less than 10 days old and all other pediatric patients 14-
28 days old.

11
Fresh frozen plasma (FFP) - Assist in the minimization of dilution to patients clotting factors,
whilst permitting maintenance of an appropriate colloid osmotic pressure (COP). Neonate
less than 30 days will receive 1 unit (150mls) in the CPB prime.

12
Group A: Medication added to Circuit Prime
All medication drawn up in an aseptic manner in syringes labeled with the name and dose.
Independent double checking of all medication shall be completed by two perfusionists’.

Table 16. Oxygenator: Terumo RX5 and ¼ x ¼ tubing pack

Drug Volume / Dose

Plasmalyte A 148 500 mls
*if blood products added removal of equivalent volume
Albumin 20% Blood Prime: 50mls
Crystalloid Prime: 100mls
Heparin (1,000UI/ml) 1000UI (10mg) + 500U post ZBUF (pre bypass ultrafiltration)
Green vial
Mannitol 20% 0.75g/kg
kg x 3.75 = Total dose (mls)
Total dose / 2 = Prime dose (mls)

Example
3 kg x 0.75 = 2.25g
2.25g ÷ 0.2g/ml = 11.25mls total

Sodium Bicarbonate 8.4% 15mEQ

(1mEq/ml) Circuit prime blood gas
Na no more than 10mmol/L different to patients pre bypass levels
HCO3 22-24, BE -2.25 to +2.5
Calcium Chloride 10% Blood Prime: 50mg/100mls RBC
1.36 mEq Ca++/ml Crystalloid:100mg
Circuit prime blood gas Ca++: 0.7-1.0mmol/L
Magnesium 50% 4mEq
4mEq/ml (1ml)
PRBC Target on CPB 24% (see calculation page 9)
FFP Neonate less than 30 days old = 1 unit FFP (150mls)

13
Table 17. Oxygenator: Maquet Quadrox pediatric and ¼ x 3/8 tubing pack

Drug Volume
Plasmalyte A 148 650 mls
*if blood products added removal of equivalent volume
Albumin 20% 100mls

Heparin (1,000UI/ml) 1500UI (15mg) + 500U post ZBUF (pre bypass ultrafiltration)
Green vial
Mannitol 20% 0.75g/kg
kg x 3.75 = Total dose (mls)
Total dose / 2 = Prime dose (mls)

Sodium Bicarbonate 8.4% 15mEQ

(1mEq/ml) Circuit prime blood gas
Na no more than 10mmol/L different to patients pre bypass
levels
HCO3 22-24, BE 0 to +4
Calcium Chloride 10% Blood Prime: 50mg/100mls blood
1.36 mEq Ca++/ml Crystalloid:100mg
Circuit prime blood gas Ca++: 0.7-1.0mmol/L
Magnesium 50% qEm6
4mEq/ml )qm1.5(
PRBC Target on CPB 24% (see calculation page 9)
FFP Neonate less than 30 days old = 1 unit FFP (150mls)

Table 18. Oxygenator: Terumo RX15(40) and 3/8 X 3/8 tubing pack

Drug Volume
Plasmalyte A 148 1125 mls
*if blood products added removal of equivalent volume
Albumin 20% 150mls

Heparin (5,000UI/ml) 3500UI (35mg)

Blue vial
Mannitol 20% kg x 3.75 = Total dose (mls)
Total dose / 2 = Prime dose (mls)
Sodium Bicarbonate 8.4% 40mEq
(1mEq/ml)
Calcium Chloride 10% Blood Prime: 50mg/100mls
1.36 mEq Ca++/ml Crystalloid:150mg
Circuit prime blood gas Ca++: 0.7-1.0mmol/L
Magnesium 50% 12mEq
4mEq/ml (3mls)
PRBC Target on CPB 24%
(see calculation page 9)
FFP n/a

14
Table 19. Oxygenator: Sorin Inspire/Terumo RX25 and 3/8 x 1/2 tubing pack

Drug Volume
Plasmalyte A 148 1300/1450mls
*if blood products added removal of equivalent volume
Albumin 20% 200mls (Hb less than 10g/L)

Heparin (5,000UI/ml) 5000UI (50mg)

Blue vial
Mannitol 20% kg x 3.75 = Total dose (mls)
Total dose / 2 = Prime dose (mls)
Sodium Bicarbonate 8.4% 50mls
(1mEq/ml)
Calcium Chloride 10% Blood Prime: 50mg/100mls
1.36 mEq Ca++/ml Crystalloid: 150mg
Circuit prime blood gas Ca++: 0.7-1.0mmol/L
PRBC Target on CPB 24%
(see calculation page 9)
FFP n/a

15
 Group B: Medication administered during CPB

All medication drawn up in an aseptic manner in syringes labeled prior to CPB, with name
and dose

Table 20 Group B: Medication administered during CPB

Drug Dose Comments

Plasmalyte A As required to maintain safe - Administered and calculated by
operating volume within reservoir perfusion
- Notify surgeon if excessive volume
requirement
Heparin Re-bolus prime heparin dose - Administered and calculated by
1000UI/ml perfusion
or - Notify anesthesia of dose given
5000UI/ml - ACTs to be monitored every 30 minutes
on CPB
- ACT >400 seconds
Sodium Bicarbonate Calculation guide: -Notify anesthesia of requirement and
8.4% (1mEq/ml) (0.3 x kg x BE) ÷ 2 dose given
Mannitol 20% Half dose 0.375g/kg -Administered and calculated by
perfusion
-Given during re-warming and/or pre x-
clamp removal (free radical scavenger)
Phenylephrine 0.5ml bolus -Maintain MAP as per policy guidelines
(10mcg/ml) (0.5mcg/ml) -Notify anesthesia of requirement
(consider constant infusion)
Calcium Chloride 10% As specified by anesthesia -Calculated by anesthesia
(100mg/ml) Calculation guide -Administered by perfusion OR
(130-current patient Ca++) x kg anesthesia
= mg -Administer with normal ECG,
Example -Warm patient (above 34 degrees)
130-90 = 40 -Reperfusion of 10 minutes
40 x 5kg = 200mg
Potassium Target-Current = Difference (mEq) -Calculated by perfusion and confirmed
(2mEq/ml) (Difference x kg) ÷ 5 with anesthesia
= mEq Administered by perfusion
Example -Administer with normal ECG,
4.5 - 3.5 = 1mmol/L -Warm patient (above 32 )
1 x 5kg = 5 ÷ 5 -Reperfusion of 10 minutes
= 1mEq
Albumin 5% As required - Administered by perfusion
(250ml) Patients Hb below 8g/L consider - Notify anesthesia
use in replacement of Plasmalyte A
PRBC see page 9 -Maintain HCT greater than 25% on CPB
-Termination of CPB HCT greater than
34% on complex neonates
FFP Multidisciplinary discussion Multidisciplinary discussion
Sodium Chloride 0.45% As required Administered and calculated by perfusion
Zero balance ultrafiltration (ZBUF) to
clear high potassium levels.

16
Table 21. Group C: Medication administered on the direction of surgeon or anesthetist

Drug Dose Comments

Cardioplegia Initial dose: Administered by perfusion
(see below) 40mls/kg at 4:1ratio under direction of surgeon
Subsequent doses:
20mls/kg at 4:1 ratio
Nipride Use as specified by anesthesia Calculated by Anesthesia

Insulin Use as specified by anesthesia Calculated by Anesthesia

2IU/ml
Cisatracurium Use as specified by anesthesia Calculated by Anesthesia

Midazolam Use as specified by anesthesia Calculated by Anesthesia

Potassium Chloride Use as specified by anesthesia Calculated by Anesthesia

(2mEq/ml)
Magnesium Sulphate Use as specified by anesthesia Calculated by Anesthesia

Fentanyl Use as specified by anesthesia Calculated by Anesthesia

Solu-medrol Use as specified by anesthesia Calculated by Anesthesia

17
Assembly of Circuit

All pediatric perfusionists are to set up the CPB circuit with the same configuration
illustrated below. Any decision to move away from this set-up must be planned and
discussed with the surgeon and anesthesiologist.

Flow probe
Venous saturation
probe

Bubble
sensor

Level
Alarm

The perfusionist shall wear a surgical mask and wash hands prior to aseptically setting up the
CPB machine. The sorin 3T water lines are connected to the oxygenator and blood
cardioplegia device for 5 minutes to check for water leaks/ integrity of fibers prior to
priming. Hands must be washed or hand sanitizer gel used after handling the heater-cooler
lines.

18
The reservoir /oxygenator shall be mounted on the heart lung machine approximately
30cms below the level of the OR table to obtain maximal venous gravity drainage, the
bracket shall not be elevated (requiring vacuum assist venous drainage).

The perfusionist shall begin setting up the circuit once the patient has been sent for by OT
reception (approx 0730).

Addition of blood products and drugs shall be completed prior to the patient being draped.
A banked blood sample and final blood prime gas shall be taken and documented on the
perfusion chart.

500mls PBUF shall be completed with Plasmalyte to ensure the lactate and potassium of the
banked blood is safe for bypass. The lactate shall be less than or equal to 2 and the
potassium less than or equal to 5. Any deviation from these values must be communicated
to the consultant surgeon prior to bypass.

Safety Devices

The perfusionist must use appropriate safety devices during CPB. The following are
considered minimum safety standards for monitoring and safety during CPB (ACTACC, 2016):

 Power failure alarm with a battery powered back-up unit for the cardiopulmonary
bypass machine.

 Battery powered flash-light / torch situated near to the bypass machine.

 Bubble detector on the arterial line of a roller and centrifugal pump with an alarmed
automatic pump cut out facility.

 Level sensor on a hard-shell venous reservoir system with an alarmed automatic

pump cut out facility.

 Retrograde flow alarm and an occlusion device are essential when using a
centrifugal pump as a means to prevent retrograde arterial blood flow.

 Out of range temperature alarm on the arterial limb of the CPB circuit.

 Overpressure alarm on the arterial limb of the CPB circuit with automatic pump cut
out/ flow reduction facility.

 Overpressure alarm on the post pump aspect of the cardioplegia circuit with
automatic pump cut out/ flow reduction facility.

 The cardioplegia circuit should be slaved to the main CPB circuit to ensure that the
cardioplegia flow does not exceed the blood flow to the patient in the event of an
alarm condition in the main CPB circuit.

 Handcranks must be instantly available in the event of power supply issues or pump
malfunction.

19
Additional Safety Guidance:

 Suckers and vents (red, blue and yellow) must be checked by the Perfusionist (and
scrub nurse) to confirm correct function and position to aspirate blood and air away
from the heart or surgical site. One-way pressure relief valve connectors and the
method above must be used.

 Occlusions of main boot pump, suckers, vents and cardioplegia roller heads tested
prior to every case.

o Main boot pump occlusion defined as 1mmHg per 2 seconds (Hensley, 2003)
o Suckers – clamp inlet, turn on sucker high until tubing sucks flat, release
occlusion until tubing releases, increase occlusion by 5 “clicks”.

 All pumps rotate anti-clockwise.

 Prebypass checklist completed.

 8 clamps available per CPB machine.

Alarm Settings on the S5

Ensure the following alarms settings are present on the S5:

 Level 1
o Controlled pump: Pump 1(1) or SCP System 6
o Level control: On
o Function: On

 Bubbles
o Controlled pump: Pump (1) or SCP System 6
o Threshold bubble alarm: Small ¼” or medium (3/8)
o Warning tone micro-bubble(s): On

 ART Pressure
o Controlled pump: Pump (1) or SCP System 6
o Threshold for alarm/stop: 350
o Threshold for warning/control: 325

 CPG Pressure
o Controlled pump: Pump (2)
o Threshold for warning /control: 200
o Threshold for alarm/Stop: 220
o Type of Cardioplegia: Automatic/Manual

 Cardioplegia (Menu 3/6)

o Pump for stop link (1)

20
Monitoring Devices

The following patient monitors should be made available throughout the case:

 ECG, systemic arterial pressure, central venous pressure, nasopharyngeal and skin
temperature, urine output, pulse oximetry (pulsatile circulation) and NIRS, (near
infrared spectroscopy) as required.

The following CPB monitors should be made available throughout the case:

 Spectrum monitor - blood flow indicator mls/kg (plus integrated emboli count) and
total flow (positioned post cardioplegia take off point), SVO2, SaO2, Hb, HCT

 Arterial line pressure (mmHg)

 Cardioplegia line pressure (mmHg)

Charting

 Pre-bypass patient ABG and ACT to be recorded on perfusion chart

 Blood prime gas to be recorded on perfusion chart

o Including age of blood product

 On CPB charting to be completed every 10 minutes

 ABG and ACT every 30 minutes, report to anesthesia

 Post MUF ABG and ACT to be reported (where possible for QA)

 Post protamine ABG and ACT to be reported

 Pump charts are to be stored in the perfusion office, highlighted binder, once the
patient has left the operating theatre

Al-Shifa Data

 Blood products to be recorded post CPB

21
Communication

Effective communication is a requirement for safe patient care, it must be clear, audible and
accurately delivered. All communication is closed loop to avoid misunderstandings and to
ensure the request has been heard and understood

e.g. surgeon requests “yellow sucker up”, the perfusionist then repeats this back “yellow
sucker up” and completes task.

If you do not understand the request you must inform the individual to repeat the statement

e.g. “Dr “X”, I didn’t hear you, please repeat”

Use names to avoid the request being make into an empty space.

The operating room is highly complex and dynamic, involving multiple disciplines’ and
unique challenges. The operating room needs to be quiet, conversations should be limited to
patient related tasks while on CPB and during MUF.

All cell phones should be on silent.

Beep conversations should be taken outside the theatre.

Cell phone use on CPB is a distraction and is not supported.

Movement in and out the OT should be limited as much as possible (reduce infection),
including anesthetic room doors.

Anticoagulation

Hemochron signature device is used to monitor activated clotting time (ACT)

The consultant surgeon will request heparin which shall be administered to the patient by
the anesthesiologist (300-400U/kg). The anesthesiologist will verbally announce total dosage
and time heparin given to the patient. The perfusionist shall document dose and time on
chart. The anesthesiologist will sample an ACT and ABG (if required) 3-5 minutes post
heparin administration.

 Cannulation/Suckers available at ACT 300 seconds

 CPB initiation ACT 400 seconds and greater

Low ACT additional heparin shall be given by anesthesiologist and verbally announced to
perfusionist/ surgeon (closed loop communication required) and repeat ACT (discretion of
anesthesiologist, surgeon and perfusionist). Repeat ACT if it remains lower, consider ATIII
deficiency and FFP requirement.

The ACT shall be checked every 30 minutes while on CPB by the perfusionist and re-bolus as
required.

22
The perfusionist shall take into consideration length of case, temperature,
hemoconcentration, urine output and circuit integrity when interrupting the ACT result.

The perfusionist shall inform the anesthesiologist of heparin requirements during the case.

Post CPB the perfusionist must recirculate volume in CPB circuit continuously (via manifold,
arterial line recirculation line and hemoconcentrator) and consider adding additional heparin
into circuit, dependent on last ACT and time since termination of bypass.

Arterial Line Test

The arterial line shall be tested every case prior to CPB initiation.

 Close manifold, arterial line filter and hemoconcentrator line.

 Stop circulating and clamp arterial (perfusionist discretion) and venous lines (do not
over pressurize line)

 Aorta cannulated (+/- luer lock de-aired), back bleeding out of cannula (de-air and
confirm intraluminal placement)

 CPB circuit connected to arterial cannula via an air free connection (+/- luer lock de-
air)

 Await surgeon’s direction to check arterial line, acknowledge request “Checking

arterial line”

 Compare arterial line pressure with patient pressure and rapidly transfuse half turn
of main boot pump to observe arterial line pressure response.

 Confirm “Arterial line pressure is good”

Initiation of CPB

Under the direction of consultant surgeon

Consultant Surgeon: “Go on bypass”

Perfusionist: “Going on bypass……arterial ON……venous OPEN”

(Perfusionists’ must perform each task prior to verbally
communicating it to the surgeon)

During early stages of bypass initiation normovoleimia should be maintained, to ensure slow
mixing with CPB prime

Feedback to the surgeon and anesthetist should be given on progression through initiation
(e.g. 25, 50, 75 mls/kg) and ultimate achievable flow. Full flow may not be established until
second venous cannula has been inserted.

23
Do not initiate VAVD until both cannulas are inserted (see page 27)

Announce “full flow” so the surgeon is aware and anesthetist can stop ventilation.

- Suitable off-loading of heart

- CVP zero and non-pulsatile wave form
- Good arterial line pressure (see below)
- Color difference in lines with spectrum monitor SaO2 displayed

During asanguineous (crystalloid) prime a slow initiation is required, maintaining ejection to

permit mixing of native venous return to the heart and the circuit prime. When adequate
mixing achieved continue to ½ flow, communicating with the surgeon at all times.

Cyanotic Patients

High oxygen levels, sudden and abrupt, to cyanotic patients on CPB leads to myocardial
damage prior to ischemic cardioplegia arrest, suggesting that the injury seen may in part be
due to reoxygenation injury (Mokhtari, 2014). Injury is mediated by oxygen-free radicals and
results in significant myocardial depression and pulmonary dysfunction (Gravlee, 2003)

Controlled re-oxygenation to these patients is initiated on CPB with FiO2 set at 25% to
maintain normoxia (PaO2 80mmHg). The pO2 should be increased to match the pre-bypass
level of the patient and slowly increased to 135-165mmHg over the next 15-20 minutes.

24
Arterial Line Pressure

The selection of arterial cannula (page 8) is based on patient flow requirements and the
subsequent hemodynamic evaluation of the cannula. The performance gradients are kept
below 100mmHg within the cannula to avoid excessive hemolysis and protein denaturation
as a result of turbulence and cavitation.

The correct placement of the arterial cannula is directed towards the middle of transverse
arch. Pediatric, particularly neonatal patients have extremely small aortas and as a result
cannulas may obstruct the entire vessel, with the tip against the back wall or into an arch
vessel. Careful manipulation may result in the cannula being placed just 1-2mm inside the
lumen only.

Acceptable arterial line pressure on full flow CPB are 250-280mmHg (perfusionist must take
into consideration the patients MAP when evaluating this number, plus the flow range of the
cannula). For example a 10Fr cannula at 700mls flow with a line pressure of 260mmHg with
MAP 40 would warrant investigation of position.

Line pressures greater than 280mmHg are undesirable and the surgeon must be informed
upon initiation, the cannula position should be manipulation and a consideration to upsize
the cannula may be required. Of note in neonates, hypoplastic and coarctation of the aorta
the challenge may be that of anatomy rather than cannula size/placement.

The surgeon must be informed at full flow the exact line pressure number.

e.g.” Line pressure good at 2.5.8” (258mmHg)

Patient Blood Pressure Maintenance

Desired blood pressures are as highlighted below unless otherwise discussed by the
multidisciplinary team (perfusionist, anesthetist and surgeon).

Table 22. Mean Arterial Pressure on CPB

Patient Age mmHg

Neonate 35-40

1 month – 1 year 40-50

1 year + 50-55

25
Low MAP intervention

 Verify closure of all recirculation lines

 Compensate for blood steal whenever an arterial purge line is open e.g. during
cardioplegia delivery, hemofiltration and aortic vent usage

 Ascertain presence of A-V shunts. Consult surgeon

 Ensure arterial line flushed and zeroed confirm location e.g. right or left, radial or
femoral, consult anesthesia

 Ensure absence of vasodilator infusion

 Administer Phenylphrine in 0.5ml bolus' (0.5mg/ml)

 Increase blood flow rate until adequate MAP or the upper limit of blood flow rate
ranged is reached, or as surgical conditions permit (do not flood the surgical field)

High MAP Intervention

 Consult with anesthetist as to whether opioid or muscle relaxer agents should be

administered

 Lower blood flow rate if SVO2 greater than 70%

 Ensure arterial line flushed and zeroed confirm location e.g. right or left, radial or
femoral, consult anesthesia

 In consultation with anesthetist consider vasodilator (e.g. Rogitine/Phentolamine,

Sodium nitroprusside (SNP)/Nipride)

26
Vacuum Assisted Venous Drainage (VAVD)

VAVD is used to augment the venous drainage, while recognized to have other clinical
applications (e.g. reduced priming volumes / tubing length, smaller cannulas) at this time all
pediatric patients undergoing cardiac heart surgery on the heart lung machine within the
NHC shall utilize gravity siphon venous drainage and the oxygenator shall not be raised.

VAVD shall be ready at all times (yellow wall vacuum connected, maquet device tested with
sterile tubing available, not attached) during the case to ensure rapid initiation if required.

- Two venous cannulas inserted (bicaval cannulation)

- Communication with surgeon current flow (mls/kg) and unable to obtain full
flow

- Request confirmation of appropriate location of both cannulas

- Recommend VAVD

- Communicate starting VAVD at -10mmHg and observe venous return

- Increase by -5 mmHg, informing surgeon

- Observation of venous chatter lower vacuum and / or switch OFF

Caution is required while using VAVD always ensure:

1. The use of a vacuum regulator specifically designed for VAVD (Maquet)

2. A one-way over pressurization valve on venous reservoir

3. Connection of a specimen (fluid/condensation) trap to the vent port of the venous

reservoir and connected to the vacuum regulator

4. A vent line connected to the tubing joining the specimen trap to the vacuum
regulator

5. Do not exceed – 40mmHg on vacuum regulator

27
Cardioplegia

Cardioplegia’s most effective component is it a high potassium content. Cardioplegic

solutions with 15-20mEq/L lowers the resting membrane potential, inducing diastolic arrest
causing significant reduction in myocardial oxygen consumption with hypothermia further
reducing oxygen consumption to 0.3ml/100g/min.

NHC Cardioplegia

Ringers Injection USP 500mls

(Kuwait Saudi Pharmaceutical)

Na+ (mEq/L) 147, K+ (mEq/L) 4, Ca++ (mEq/L) 4.5, Cl- (mEq/L) 155

Osmolarity 311mOsm/L

Potassium Chloride 15%

10mls
(2mEq/ml)

Cardioplegia Infusion
(Martindale Pharmaceuticals)
Magnesium Chloride Hexahydrate 3.253g 20mls
Potassium Chloride 1.193g (16mmol)
Procaine Hydrochloride 272.8mg

Sodium Bicarbonate 8.4% (1mEq/ml) 20mls

Aortic Root Cardioplegia

Antegrade aortic root cardioplegia is used on most procedures for induction and
maintenance doses where the surgical procedure does not physically interfere with the
technique.

 Induction dose 40mls/kg

 Maintenance doses 20mls/kg

 Delivery rate at approx. 10mls/kg/ml

 Administered at

o Neonates (less than 30 days)

 Cardioplegia line pressure 80-120mmHg

o Pediatrics

 Cardioplegia line pressure 150mmHg

28
 o Adult congenital: Cardioplegia line pressure 180-200mmHg (200-220mmHg
Vancouver)

 Concentration of blood: crystalloid shall be 4:1

 Water temperature set to 4oC

Neonatal myocardium is vulnerable to coronary endothelial injury from excessive shear

stress due to high cardioplegia delivery pressure (Lake, 2005). Controlled delivery at a root
diastolic pressure of 30-50 mmHg (not cardioplegia line pressure) improves recovery of
systolic function, limits diastolic stiffness and myocardial tissue edema and decreases
coronary vascular resistance.

Cardioplegia line pressures required to close the aortic valve may be elevated than those
stated above, it is important the perfusionist monitors for diastolic arrest and increases flow
rate / line pressure if a delayed onset. Other factors to consider include in adequate x-clamp
occlusion, aortic regurgitation, collateral blood flow and low coronary perfusion pressure
(flow/pressure of cardioplegia)

Coronary Ostium Cardioplegia

A coronary ostium cardioplegia cannula is selected to deliver antegrade cardioplegia directly

into the coronary ostia. Higher cardioplegia line pressures should be expected during
administration of cardioplegia using this method.

Neonates and pediatrics: 150mmHg

Retrograde Cardioplegia

Retrograde via the coronary sinus which must be transuded and maintained below 40mmHg.

Cardioplegia line pressure: less than 150mmHg

Systemic Arrest

When the aortic x-clamp is unable to be applied potassium can be added to the circuit in
order to achieve systemic arrest.

See the example below for approximate calculation:

29
Example

15kg patient
Prime volume (PVcpb): 650mls
Estimated patient blood volume (EBVpt): 1200mls
Last know K+: 4.8mmol/L
Total CPB circulating blood volume (L)= EBVpt + PVcpb
= 1.850L

K + 16mmol/L required for arrest

16mmol x 1.850L = 28.8mmol required
4.8mmol x 1.850L = 8.8mmol existing
28.8mmol – 8.8mmol = 20mmol K+
(Give in 5mmol bolus')

30
Deep hypothermic Circulatory arrest (DHCA)

Ensure ice on patient's head.

At the surgeons’ request begin cooling to 18 degrees, maintaining 8-10 degree temperature
gradient between the arterial blood and patient temperature (nasopharyngeal).

Consult the anesthetist for methods of therapeutic vasodilatation (e.g. SNP/Nitroprusside

sodium or Phentolamine/Rogitine) and more homogeneous cooling.

Blood gas management: Utilizes pH stat during cooling.

Reduce blood flow as the metabolic demand is reduced (see table 24)

HCT less than 30% (Hb less than 10g/dL) is preferred. At lower temperatures red blood cells
are significantly less deformable (especially with banked blood) and may result in
compromised to microcirculatory flow which would exacerbate further with increased
viscosity.

If possible, remain at 18 degrees for five minutes prior to circulatory arrest. The arterial
temperature shall remain above 15 degrees.

Two to three minutes prior to DHCA, reduce the pCO2 level to 35-45mmHg as per alpha stat
management. This supports a more normal cellular transmembrane pH gradient and
enzymatic function.

Increase FIO2 100%, hyperoxygenation just before DHCA takes advantage of increased
oxygen solubility and reduced oxygen consumption by loading the tissues with excess
oxygen.

Consult with anesthetist regarding Thiopentone administration for cerebral protection prior
to circulatory arrest.

Terminate bypass at surgeons’ request, clamp arterial line, clamp venous line once venous
drainage has ceased.

Commence recirculation through recirculation lines at 18 degrees PaCO2 should be kept

between 35-40mmHg. The PaO2 should be kept at the lower end of the range guideline 90-
140mmHg.

Table 23. Hypothermia levels with approximate safe periods of circulatory arrest

Hypothermia Level Temperature Safe Circulatory Arrest Time

o
C (mins)
Mild 37-32 3-9
Moderate 31-28 9-15
Deep 28-18 15-45
Profound 18 and below 45

31
Table 24. Predicted Minimal Pump Flow Rates (MPFRs)

Temperature CMRO2 Predicted MPFR

(ml/100g/min) (ml x kg-1 x min-1)
37 1.48 100
32 0.823 56
30 0.654 44
28 0.513 34
25 0.362 24
20 0.201 14
18 0.159 11
15 0.112 8

Antegrade Cerebral perfusion

Note right radial arterial line AND arterial femoral line on monitor (have both traced
simultaneously if possible)

Ensure placement of bilateral NIRs, this is to monitor differential cerebral perfusion which
may be representative of anatomical variance to the circle of Willis.

SAT probe on left (due to innominate cannulation)

This procedure involves perfusion of the cerebral structures usually via a gortex graft onto
the innominate artery. Once patient has been cooled to required temperature the remaining
head vessels shall be snared/clamped (usually left common carotid and left subclavian).

Low flow antegrade cerebral perfusion is to start at 20ml/kg/min, discussion with both
surgeon and anesthesia to determine adequacy (radial pressure and NIRs). This flow will
usually result in a right radial pressure of 30-40mmHg. Any consideration to changes in flow
must be communicated to all team members prior.

Lower Body Perfusion

Occasionally during low flow antegrade cerebral perfusion the surgeon may attempt to
intermittently perfuse the lower body.

A Y shall be placed in the arterial line by the surgeon in the sterile field

The same size cannula should be used to reduce the chance of preferential flow to one of
the separately perfused vascular beds

Right radial and lower body arterial line monitoring required

32
Blood Gas Management

All blood gas calculations are performed using alpha stat unless the patient is to be cooled to
18 degrees during which pH stat cross over technique is used.

pH – Maintain 7.35 – 7.45

pO2 – Maintain between 150-200mmHg *lower for cyanotic patients*

pCO2 – Maintain between 35-45mmHg *utilize pH stat when cold*

SaO2 – Maintain between 95-100%

SvO2 – maintain greater than 65%

Calcium (Ca++)

Generally an ionized Ca++ level of approximately 0.8-1.0mmol/L is maintained during CPB

until 10-15 minutes after myocardial reperfusion and prior to separation of CPB. Correct the
ionized Ca++ to approximately 1.5mmol/L – confirm dose with anesthetist.

Calculation: (130 -ptCa++) x weight (kg)

example
130 - 90 = 40
40 x 5kg = 200mg

Potassium (K+)

During CPB a normal range of 3.5-5.5mmol/L is aimed for, confirm with anesthetist prior to
administration. Example

4.5 - 3.5 = 1mmol/L

1 x 5kg = 5 ÷ 5
= 1mEq

If after multiple doses of cardioplegia, a patient becomes hyperkalemic this can be corrected
by conducting ZBUF with 0.9% saline.

Glucose

A normal pediatric glucose range is considered 4.0-6.0mmol/L. Glucose levels during CPB
should be kept below 15mmol/L. Causes of progressive hyperglycemia during CPB include;
surgical stress, hypothermia, IV solutions containing glucose, preoperative steroid
administration. Communicate with the anesthesiologist and insulin administration could be
considered under their direction.

HCO3 – Maintain between 22-26mmol/L

BE – Maintain between +2.5 /- 2.5mmol/L

Calculation: (0.3 x kg x ptBE) ÷ 2

33
Rewarming

Slow core rewarming from DHCA allows target temperature to be reached without inducing
cerebral hyperthermia.

Arterial blood temperature should be no greater than 36 degrees and a temperature

gradient of 6-8 degrees shall be maintained (arterial blood temperature and
nasopharyngeal)

Brain temperature continues to increase for at least six hours in children following CPB.

Discuss with anesthesia vasodilatation therapies to assist homogeneous rewarming if

required.

X-Clamp Removal

Administration of Mannitol 20% pre-x-clamp removal (acts as a free radical scavenger), OFR
are a primary source of myocardial injury following reoxygenation and reperfusion.

Controlled re-oxygenation with pO2 maintain at lower level for x-clamp remover (150mmHg)

Neonatal myocardium is venerable to coronary endothelial injury from excessive shear

stress due to elevated reperfusion pressure immediately following cross clamp removal,
therefore slowly come up on flow.

Calcium correction is administered by the perfusionist under the guidance of anesthesia.

Reperfusion injury is marked by excess Ca2++ influx. Calcium administration should be 10-15
minutes post x-clamp removal and the patient temperature must be above 34 degrees.

Termination of CPB

Prior to termination ensure :

- Warm, post x-clamp ABG completed and read aloud to team by the perfusionist
(pH, pCO2, pO2, K, Ca, BE, lactate)

- Correction of electrolytes including base deficit and calcium level

- Patient warm nasopharyngeal (36 degrees) and skin temperature adequate

- Good ECG, pacing etc.

- Confirm anesthesia are ‘Happy with ventilation’’

34
Modified Ultra Filtration (MUF)

MUF is performed following the termination of CPB, it is a technique used to remove the
fluid overload and inflammatory mediators associated with use of bypass (see table25). It
has been shown to reduce morbidity after cardiac operations in children.

Table 25. Summary of effects of Modified Ultrafiltration (Hensley, 2008)

Feature Effect
Total body water ↓
HCT ↑
Blood loss ↓
Blood transfusion requirement ↓
Colloid osmotic pressure ↑
Cardiac output ↑
HR ↓
Arterial Blood pressure ↑
Pulmonary vascular resistance ↓
Diastolic compliance ↑
Inotropic drug use ↓
Cerebral recovery from DHCA ↑
Plasma endothelin-1 ↓
Lung compliance ↑
Cytokine levels ↓
Activation complement levels ↓
Heparin concentration ↑

A-V MUF shall be conducted on all pediatric cases unless deemed to be unnecessary by the
surgeon, anesthesiologist and/or perfusionist.

Patients must remain heparinized during MUF.

CPB is terminated in the usual manner ensuring the manifold, arterial line filter purge line
and oxygenator recirculation lines are closed. Both the venous and arterial lines (arterial line
at perfusionists' discretion) are clamped.

Communicate vent rate to surgeon, where possible vents shall be discontinued prior to
termination of CPB however this is at the surgeons discretion and the perfusionist must
match vent rate once off CPB.

Perfusionist informs team they are "OFF bypass and setting up for MUF" and once ready
informs the surgeon "Ready to MUF".

MUF should be commenced upon surgeons' request and the perfusionist asks "is your
arterial line and venous line clear" (ensuring no air).

A MUF flow rate is initiated at 10-15ml/kg/min to a maximum of 20ml/kg/min (do not

exceed flow rate of hemoconcentrator –100mls).

35
Once MUF established for 30 seconds the clamp from the hemofilter effluent line is
removed, a 60ml syringe used to create suction on the effluent line and accelerate fluid
removal.

The volume of filtrate to be removed during MUF is calculated using the following formula:

Volume of filtrate = ((a - b) x c) ÷ b

a = final HCT desired

b = final HCT on bypass
c = Total circulating volume (patient blood volume + prime)

Aim for a final HCT of 35

For example 3kg patient:

1. HCT 35 - HCT 25 = 10%

2. 10 x 645mls (TCPBCBV page 10 minus plegia prime volume) =6450

3. 6550 ÷ 25 = 258mls filtrate volume

During MUF volaemia is maintained via the main boot pump, the patient's blood pressure
and filling pressure (CVP) is to be maintained and unchanged at all times. The perfusionist
must consult with surgeon and anesthesiologist to determine the target filling pressure
necessary to achieve hemodynamic stability.

MUF should be continued for 15 minutes.

During MUF the noise volume in the OT should be that of clinical communication only.

Manipulation of the arterial cannula must be avoided as it can result in cavitation and air
entrainment if occluded (AV MUF).

Once MUF completed the CPB circuit configuration and alarms are reactivated in
preparation for emergency initiation of CPB of an unstable patient.

36
Arterial-Veno (AV) MUF

RA Aorta RA
Termination of CPB
1. Close manifold and ALF purge line
2. Clamp venous (1) and arterial line – OFF CPB

Set-Up MUF
1
1. Ensure cardioplegia temp 37 degrees
2. Clamp cardioplegia crystalloid line (3)
b 3. Unclamp cardioplegia bypass line (4)
4. Remove stop link from main pump
5. Apply clamp to cardioplegia line (3) in-between
the 3-way stopcocks
6. Aseptically remove hemocon. line from 3-way
stopcock (a) and attach to 3-way stopcock (c)
a 7. Aseptically remove hemocon. line form 3-way
stopcock (b) and attach to 3-way stopcock (d)
8. Recirculate cardioplegia volume (removal of
high potassium)
9. Confirm cardioplegia line attached to Y
connector of venous line
4
10. Request to sump venous line (ensure both SVC
3 and IVC clamped)

Initiate MUF (under surgeons’ direction)

1. Remove arterial clamp (2), if applied, initiate at
10-15mls/kg/min
3
2. Maintain boot pump at 1RPM (avoid negative
d pressures and cavitation)
c
Transfuse volume
1. Increase the main boot pump RPMs when
necessary to maintain filling pressures

Benefits

- Large volume to ultrafiltrate approx. 300mls (higher Hb)

Challenges

- Extreme caution required ensuring no negative pressures in arterial line, causing

cavitation and subsequent air (at location of oxygenator and cannula/aorta) -
manipulation of arterial cannula is not recommended during this time.

- Non physiological

- Coronary steal

37
Circuit Volume Post CPB

Using AV MUF the volume remaining in the CPB circuit is of a low HCT/Hb due to the MUF
process therefore no sequestration should be required. On completion of AV MUF (filtrate
removal stopped) the blood volume remaining in the MUF circuit (approx 100mls) shall be
circuited for 2 minutes ensuring the high Hb/HCT concentrated blood left in the
hemoconcentrator is given to the patient.

At no point is the MUF circuit to be opened to air and transfused into patient. This process
requires dropping the patients MAP and subsequent filling of the patient (with the MUF
circuit blood), fluctuating hemodynamics has been deemed undesirable and unstable for
patients at this stage in the surgery.

Protamine

Administration by anesthesia

Anesthesia verbally announces to the team “Protamine Starting” and ensures closed loop
communication from the perfusionist.

Anesthesia verbally announces to the team “50 % of Protamine In” and ensures closed loop
communication from the perfusionist.

Perfusionist to repeat “50% Protamine in – SUCKERS OFF” ensuring closed loop

communication from the surgeon.

Disposal of CPB Circuit

Lines handed back once chest is closed.

Disposal of circuit in yellow biohazard trash bag (double lined).

Water lines to be removed once dressing applied to sternum.

38
Roles and Responsibilities

The primary perfusionist is directly responsible and accountable for the conduct of perfusion
and the bypass machine. All communication regarding the case shall be with the primary
perfusionist.

 Independent check of perfusion drugs prepared by the secondary perfusionist

 Check blood (if required) with secondary perfusionist

 Obtain cannulas and axillary equipment

 Complete perfusion charting q10 minutes while on bypass

 Post CPB wash hands and restock perfusion OR cart. Ensuring emergency equipment
available.

The secondary perfusionist assists the primary perfusionist in record keeping and delegated
tasks as defined below:

 Conduct daily electronic ACT QC, ensuring equipment functioning correctly

 Input details into spectrum monitor (Patient ID number, height, weight), to ensure
flow calculations are accurate on initiation of CPB

 Aseptically prepare perfusion drugs (listed below), apply medication label to syringes
and complete an independent drug check (reduce drug error). Aseptic technique is
employed to maximize and maintain asepsis, the absence of pathogenic organisms,
in the clinical setting.

o Albumin 20%, Mannitol 20%, Heparin, Calcium chloride 10%, and Sodium
bicarbonate 8.4%

 Aseptically prepare cardioplegia solution and label

 Remove blood from OT fridge, complete blood check with the primary perfusionist

 Attach patient identifiers to Perfusion bypass document

 Calibrate spectrum with first venous and arterial sample

 Complete perfusion charting q10 minutes while on bypass

 Post CPB wash hands and restock perfusion OR cart. Ensuring emergency equipment
available.

39
On-Call Perfusionist

Two perfusionists shall be on-call and available within 45 minutes of the NHC (response
time).

Emergency Overnight Set Up

The pediatric emergency operating room is OT 2

The heart lung bypass machine shall be plugged into a red wall outlet, medical air, oxygen
and vacuum lines connected, the heater-cooler plugged into a red wall outlet and the
spectrum monitor plugged in at all times.

The emergency overnight set-up consists of:

Red, blue, yellow suckers/vents and cardioplegia devices in raceways but not occluded,
hemoconcentrator device assembled, cardioplegia and arterial pressure transducers
attached.

Water lines shall be attached, not primed to cardioplegia device and oxygenator water lines
draped over oxygenator bracket.

An RX5 bracket shall be set up on the emergency pump, and pump number 1 set to 1/4"
tubing diameter with appropriate red struts.

The pump is draped, with overnight checklist completed and signed.

The perfusion cart is stocked

The emergency set-up and cart is completed by the perfusionist in OT 2 during the day.

40
Perfusion/CPB Standby

To avoid confusion a CPB standby consists of:

 S5 and 3T heater-cooler plugged in to red wall outlet

 Medial air, oxygen and vacuum connected
 CPB circuit set-up and crystalloid primed (including cardioplegia set)
 Level and bubble alarms attached and activated
 Spectrum medical SVO2, SaO2 and flow probe attached
 Pre-bypass checklist completed
 One unit blood in OT fridge
 Cannulas inside OT
 All drugs available

41
Pediatric Cardiopulmonary Bypass Practice Guidelines have been reviewed and accepted by
the perfusion department.

Name Signature Date

Thuwayba Ahmad Al Raisi

Saleh Khalifa Ali Al Kiyumi

Maria Al Bulushi

Habiba Saud Al Marjibi

Gopikrishnan Thalapathy

Fatma Ibrahim Al Ajmi

Denny Jose

Adil Mubarak Al Nofli

Abdul Raheem Al Rawhi

Saleh Badwi Al Harthy

Victoria Harris

42
Pediatric Cardiopulmonary Bypass Practice Guidelines have been reviewed by the Division
of Pediatric Cardiac Surgery.

Name Signature Date

Dr Ala Al-lawati

Dr Andrew Campbell

Dr Abdulluh Mohsen

Dr Sunny Zacharias

Dr Hamood

Dr Pranav Subbaraya Kandachar

Dr Raj Gopal Meno

43
Pediatric Cardiopulmonary Bypass Practice Guidelines have been reviewed by the Division of
Pediatric Cardiac Anesthesia.

Name Signature Date

Dr Ranga Ananthasubramanian

Dr Mohan Mathews

Dr Madan Maddali

Dr Charanjit

Dr Suman Subbaraya Kandachar

Dr Anil Punnoose

Dr Niranjan

Dr Soundr

Dr Prasant

Dr Sai

44
 References

Great Ormond Street Hospital for Sick Children, London, UK. Perfusion Protocols, January
2018

The Children's Hospital at Westmead. Sydney, Australia. Paediatric Cardiopulmonary

Bypass Protocol – Heart Centre for Children – CHW Perfusion Services .July 2018

Children's Hospital of Philadelphia, USA. CHOP CPB Protocol. Feb 2015

The Royal Children's Hospital. Melbourne, Australia. Perfusion Unit: CPB Protocol. October
2014

BC Children's Hospital, Vancouver Canada. Perfusion Protocols. May 2010

National Heart Centre, Royal Hospital Oman. Retrospective review of 100 cases June 2018-
August 2018. Perfusion department CPB documentation.

Hensley, FA., Martin DE., Gravlee, GP. Cardiac Anesthesia, fourth edition. Lippincott
Williams and Wilkins, Philadelphia 2008.

Gravlee, GP., Davis, RF, Kurusz, M and Utley, JR. Cardiopulmonary Bypass. Principles and
Practice, second edition. Lippincott Williams and Wilkins, Philadelphia 2008.

Lake, CL., Booker, PD. Pediatric Cardiac Anesthesia, fourth edition. Lippincott Williams and
Wilkins, Philadelphia 2005.

Vetter, VL. Pediatric Cardiology. Elsevier 2006

Medtronic. CardioVascular Cannula Products. 2009

Edwards Lifesciences. Protection Cannulae Product Guide. 2010

Wang, S. and Undar, A. 2008. Vacuum-assisted venous drainage and gaseous microemboli in
cardiopulmonary bypass. The Journal of ExtraCorporeal Technology (40) 249-256.

Ghorbel, MT. 2012. Controlled reoxygenation cardiopulmonary bypass is associated with

reduced

Mokhtari, A and Lewis, M. 2014. Normothermic and hyperoxic cardiopulmonary bypass in

congenital heart disease. BioMed Research International

45
 Appendix 1

Veno-arterial (VA) MUF

RA Aorta Termination of CPB

1. Close manifold, ALF purge and
2 hemoconcentrator 3-way stopcock (a)
2. Clamp venous (1) and arterial line (2) – OFF CPB
4
Set-Up MUF
1 1. Clamp post venous reservoir outlet (3)
2. Clamp arterial line post oxygenator pre ALF (4)
3. Open hemocon. 3-way stopcock (a) to circuit
4. Open hemocon. 3-way stopcock (b) to circuit (off
b to reservoir)
5. Open MUF line (4)

4 Initiate MUF (under surgeons’ direction)

1. Remove arterial clamp (2) if applied, initiate at
10-15mls/kg/min
3
a Transfuse volume
1. Stop MUF
2. Clamp MUF line (4)
3. Remove venous reservoir outlet
4. Transfuse volume from the main boot pump to
maintain filling pressures
5. Stop pump
6. Clamp venous reservoir outlet
7. Open MUF line
8. Re-initiate MUF

Benefits

- More physiological process in comparison to AV MUF

- Provides support post bypass (slow wean), beneficial in neonates and complex
cases with long bypass / x-clamp times

Challenges

- Ultrafiltrate only the volume in reservoir approx. 100mls (lower Hb)

o Hemoconcentrate circuit post MUF to elevate Hb

- Unstable hemodynamics as unable to transfuse and MUF simultaneously

See Appendix 2 for circuit configuration with additional roller pumps – Future

46
Appendix 2

47
 Appendix 3

NHC inventory cannulas

Venous Cannulas

Medtronic DLP Single Stage, Straight

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection -20mmHg
(mm) (mls)

66112 12 (4.0) 2.7 30.5 1/4 350

66114 14 (4.7) 3.4 30.5 1/4 600

66116 16 (5.3) 4.1 30.5 1/4 950

66118 18 (6.0) 4.7 35 1/4 – 3/8 1300

66120 20 (6.7) 5.1 35 1/4 – 3/8 1650

66122 22 (7.3) 5.8 35 1/4 – 3/8 2100

66124 24 (8.0) 6.4 1/4 – 3/8 2400

66126 26 (8.7) 6.9 3/8 3000

66128 28 (9.3) 7.5 3/8 3600

Medtronic DLP Single Stage, Right Angle Metal Tip (Standard tip)

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection -20mmHg
(mm) (mls)

67312 12 (4.0) 3.4 35.6 1/4 450

67314 14 (4.7) 4.1 35.6 1/4 750

67316 16 (5.3) 4.7 35.6 1/4 900

67318 18 (6.0) 5.4 35.6 1/4 1250

67320 20 (6.7) 6.1 35.6 1/4 1500

69322 22 (7.3) 6.7 35.6 3/8 2100

48
 69324 24 (8.0) 7.4 35.6 3/8 2600

69328 28 (9.3) 8.7 35.6 3/8 3500

69331 31 (10.3) 9.7 35.6 3/8 4000

Edwards Thin-Flex Single Stage, Straight

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection
(mm) (mls)

TF012L 12 (4.0) 28 1/4 120

TF014L 14 (4.7) 28 1/4 350

TF016L 16 (5.3) 28 1/4 560

TF018L 18 (6.0) 35 1/4 – 3/8 650

TF020L 20 (6.7) 35 1/4 – 3/8 700

TF022L 22 (7.3) 35 1/4 – 3/8 1070

TF024L 24 (8.0) 35 1/4 – 3/8 1210

TF026L 26 (8.7) 35 3/8 1560

TF028L 28 (9.3) 35 3/8 1900

TF030L 30 (10.0) 40 3/8 2280

TF032L 32 (10.7) 40 3/8 2770

TF034L 34 (11.3) 40 3/8 3350

Edwards Thin-Flex Single Stage, Right Angle plastic tip with side holes

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection
(mm) (mls)

TF010O90 10 (3.3) 28 1/4 200

TF012O90 12 (4.0) 33 1/4 – 3/8 550

TF014O90 14 (4.7) 33 1/4 – 3/8 850

49
TF016O90 16 (5.3) 33 1/4 – 3/8 1000

TF018O90 18 (6.0) 35 3/8 1200

TF020O90 20 (6.7) 35 3/8 1400

TF022O90 22 (7.3) 38 3/8 2000

TF024O90 24 (8.0) 38 3/8 2600

TF028O90 28 (9.3) 38 3/8 3500

50
Sorin two-stage

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at -10mmHg
(mm) (mls/kg)

32/40

Anocor Flexline Straight

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at -10mmHg
(mm) (mls/kg)

01V201L8 20 39 3/8

01V221L8 22 39 3/8

01V241L8 24 39 3/8

01V261L8 26 39 3/8

01V281L8 28 39 3/8

01V301L8 30 39 3/8

01V321L8 32 39 3/8

01V341L8 34 39 3/8

Anocor Flexline Right Angle

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at -10mmHg
(mm) (mls/kg)

01V221L9 22

01V241L9 24

01V261L9 26

01V281L9 28

51
Arterial Cannulas

DLP Pediatric One Piece (vented)

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

77006 6 (2.0) 1.52 22.9 1/4 400

77008 8 (2.7) 2.05 22.9 1/4 700

77010 10 (3.3) 2.5 22.9 1/4 1250

77012 12 (4.0) 3.04 22.9 1/4 2100

77014 14 (4.7) 3.64 22.9 1/4 2800

77016 16 (5.3) 4.02 22.9 1/4 3750

Bio-Medicus (non-vented)

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

96820-008 8 (2.7) 2.05 19 1/4 750

96820-010 10 (3.3) 2.5 19 1/4 1250

96820-012 12 (4.0) 3.04 19 1/4 2100

96820-014 14 (4.7) 3.64 19 1/4 2800

Medtronic Select Series

Angled Tip with side holes 45o

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

73420 20 (6.7) 30.5 3/8 5.5L at 80

73422 22 (7.3) 30.5 3/8 5.5L at 50

73424 24 (8.0) 30.5 3/8 6L at 40

52
Sorin Flexible Aortic Arch Cannulae

Curve tip with suture Ring, non reinforced tubing (connector with luer vent)

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

NA-5537 21 25 3/8 4.75

Medtronic EOPA

Blunt tip introducer without guidewire

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

77418 18 (6.0) 30.5 3/8 4.75 at 100

77420 20 (6.7) 30.5 3/8 5L at 80

77422 22 (7.3) 30.5 3/8 5.7L at 50

77424 24 (8.0) 30.5 3/8 6L at 40

Percutaneous (Femoral) Cannula

Medtronic

Internal Rated Flow

Lot Fr (mm) Diameter Length (cms) Connection at 100mmHg
(mm) (mls/kg)

96530-015 15 (5.0) 4.8 43.2 3/8 2600

96530-017 17 (5.7) 5.47 43.2 3/8 3800

96530-019 19 (6.3) 6.04 43.2 3/8 5000

96530-021 21 (7.0) 6.72 43.2 3/8 6500

53
Venous (Femoral) Medtronic Biomedicus (connector 3/8")

15, 17, 19, 21

Maquet (connector 3/8")

19, 21, 23, 25

54