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Complications and safety during cpb
This document discusses safety protocols for cardiopulmonary bypass (CPB). It notes that fatal perfusion accidents occurred in 1 in 1800 cases in 1981, with serious incidents in 1 in 130 procedures. Standards have improved with better safety features and techniques. It emphasizes organizational aspects like teamwork, cooperation and effective communication. It recommends establishing equipment records, a faults book, agreed perfusion protocols, and procedures for equipment failures. Patient specific safety protocols include identification, machine checks, priming according to protocol, and ensuring identification on equipment and fluids used. Accidents can be due to human error or equipment failures. Reduced oxygenation and arterial line air embolism are discussed as common perfusion incidents. Guidelines for managing gross air e
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Complications and safety during cpb
- 1. Safety during CPBSafetyduring CPB
- 2. Bypass safetyBypass safety Conceptof safety is subjective.Concept of safety is subjective. Fatal perfusion accidents occurred 1/1800Fatal perfusion accidents occurred 1/1800 cases.(1981)cases.(1981) Serious incident 1/130 procedures (1981)Serious incident 1/130 procedures (1981) With better saftey features and perfusionWith better saftey features and perfusion techniques standards has improvedtechniques standards has improved considerably.considerably.
- 3. Organizational aspectsOrganizational aspects Mostimportant and fundamental aspect ofMost important and fundamental aspect of cardiac surgery.cardiac surgery. Describes the quality required of the unitDescribes the quality required of the unit members and their responsibilities.members and their responsibilities. Describes the components required for anDescribes the components required for an open-heart unit.open-heart unit. Emphasizes team work.Emphasizes team work. Emphasizes co-operation,co-ordinationEmphasizes co-operation,co-ordination and effective communication.and effective communication.
- 4. Perfusion department safetyPerfusiondepartment safety organizationorganization Establishment of equipment records:Establishment of equipment records: 1.1. Identification and location of eachIdentification and location of each individual device.individual device. 2.2. Record of maintenance and repair ofRecord of maintenance and repair of each device.each device. 3.3. Establishment of routine preventiveEstablishment of routine preventive maintenance protocols.maintenance protocols. Faults bookFaults book
- 5. Perfusion protocolPerfusion protocol Establishagreed protocols to be followed by allEstablish agreed protocols to be followed by all perfusionistsperfusionists 1.1. Basis for selction of equipmentsBasis for selction of equipments 2.2. Pre-operative machine checksPre-operative machine checks 3.3. Priming solutions and techniquesPriming solutions and techniques 4.4. Case record which should includeCase record which should include a) patient statisticsa) patient statistics b) equipments usedb) equipments used c) fluids and drugs used.c) fluids and drugs used. d) measured parameters.d) measured parameters. e) frequency of entries.e) frequency of entries.
- 6. Perfusion protocol contd.,Perfusionprotocol contd., Pre-bypass check list.Pre-bypass check list. Basic guideline for perfusionBasic guideline for perfusion managementmanagement 1.1. Blood flowsBlood flows 2.2. Pressure limitsPressure limits 3.3. Fluid replacementsFluid replacements 4.4. Blood gas and electrolyte limitsBlood gas and electrolyte limits 5.5. Anticoagulation and temperature controlAnticoagulation and temperature control
- 7. Perfusion protocol contd.,Perfusionprotocol contd., Procedures to be followed in the event ofProcedures to be followed in the event of equipment failureequipment failure 1.1. Electrical powerElectrical power 2.2. Mechanical pump failureMechanical pump failure 3.3. Reservoir failureReservoir failure 4.4. Gas supply failureGas supply failure 5.5. Temperature controlTemperature control 6.6. Circuit ruptureCircuit rupture
- 8. Perfusion protocol contd.,Perfusionprotocol contd., Team responsibility and communicationTeam responsibility and communication 1.1. Establish agreed areas of responsibilityEstablish agreed areas of responsibility and systems of communicationand systems of communication 2.2. Establish a procedure in the event ofEstablish a procedure in the event of failurefailure Establish protocol for cleaning andEstablish protocol for cleaning and decontamination of all non-disposabledecontamination of all non-disposable equipments.equipments.
- 9. Patient specific safetyprotocolsPatient specific safety protocols Identification of patientIdentification of patient 1.1. Patient statisticsPatient statistics 2.2. DiagnosisDiagnosis 3.3. Pre-operativePre-operative haematology,biochemistry,drug theraphyhaematology,biochemistry,drug theraphy 4.4. Cardiac investigative resultsCardiac investigative results 5.5. Proposed opertationProposed opertation
- 10. Patient specific protocolscontd.,Patient specific protocols contd., Selection of equipment according to protocolSelection of equipment according to protocol Machine checksMachine checks a)a) Availability of alternate systemsAvailability of alternate systems b)b) Calibration checksCalibration checks c)c) Occlusion checksOcclusion checks Circuit componentsCircuit components a)a) Sterility b) visual check for defectsSterility b) visual check for defects c) Availability of alternativesc) Availability of alternatives
- 11. Protocol contd.,Protocol contd., Primeaccording to protocolPrime according to protocol Double check all fluids and drugsDouble check all fluids and drugs Institute case recordInstitute case record Ensure record of identification data onEnsure record of identification data on equipment and fluids usedequipment and fluids used Follow protocols for cleaning andFollow protocols for cleaning and decontamination.decontamination.
- 12. Accidents OR MishapsIn PerfusionAccidents OR Mishaps In Perfusion OccasionalOccasional OftenOften TWO Categories:TWO Categories: Human errorHuman error Equipment failuresEquipment failuresTerumo conf.Dubai June 2002Terumo conf.Dubai June 2002
- 13. Human errorHuman error InadequateknowledgeInadequate knowledge CarelessnessCarelessness OverconfidenceOverconfidence Poor investigationsPoor investigations Poor communicationsPoor communications
- 14. Human errorHuman error CriticalsituationCritical situation Odd timesOdd times Poor medical ethicsPoor medical ethics interdepartmental politics or egointerdepartmental politics or ego Untidiness or disorganized setupsUntidiness or disorganized setups
- 15. Non-human elementsNon-human elements MechanicaldefectsMechanical defects Environmental factorsEnvironmental factors Lighting conditionsLighting conditions
- 16. Human factors ofaccidentsHuman factors of accidents Adventurous spiritAdventurous spirit Inadequate trainingInadequate training Negligence and irresponsibilitiesNegligence and irresponsibilities FatigueFatigue StressStress ImpatienceImpatience CarlessnessCarlessness The ageing processThe ageing process
- 17. Equipment failuresEquipment failures Equipmentfailures:Equipment failures: Attention, resolve at the earliestAttention, resolve at the earliest Failure attracts the attention of manyFailure attracts the attention of many Too many opinionsToo many opinions Confusion - Perfusionist - DiversionConfusion - Perfusionist - Diversion
- 18. Accidents only tomedical field?Accidents only to medical field? Common to any given speciality.Common to any given speciality. More common in teaching institutionsMore common in teaching institutions Interns and StudentsInterns and Students Does not spare even the mostDoes not spare even the most experienced and in the hands ofexperienced and in the hands of observers.observers.
- 19. TO Err ishumanTO Err is human Acceptance gains knowledgeAcceptance gains knowledge Denial fools selfDenial fools self Knowledge gets ignoredKnowledge gets ignored
- 20. Reduced oxygenationReduced oxygenation Mostfrequent incidentMost frequent incident Gas delivery system may develop leak orGas delivery system may develop leak or blockage.blockage. Forgetting to turn on the gas before goingForgetting to turn on the gas before going on cpbon cpb Gas line not connected to oxygenator.Gas line not connected to oxygenator. Defective oxygenatorDefective oxygenator Blood flows more than the rated flowBlood flows more than the rated flow
- 21. Arterial line airembolismArterial line air embolism Most sudden and distressing incidentMost sudden and distressing incident during CPB.during CPB. Mostly occurs due to non usage of safetyMostly occurs due to non usage of safety devicesdevices Level alarm is a usefull aid but not aLevel alarm is a usefull aid but not a substitue for proper vigilance.substitue for proper vigilance. The use of arterial filter and bubble traps.The use of arterial filter and bubble traps.
- 22. Other perfusion relatedcauses ofOther perfusion related causes of gross air embolismgross air embolism Oxygenator related.Oxygenator related. 1.1. Break in the integrity of oxygenatorBreak in the integrity of oxygenator connectionsconnections 2.2. Detachment of oxygenator from holderDetachment of oxygenator from holder 3.3. Non-venting of oxygenatorNon-venting of oxygenator 4.4. Clotted oxygenatorClotted oxygenator
- 23. Pump related causesof gross airPump related causes of gross air embolismembolism runaway arterial pump head.runaway arterial pump head. Reversal of arterial pumpReversal of arterial pump Occluded line proximal to arterial pumpOccluded line proximal to arterial pump head.head. Reversal of vent pumpReversal of vent pump Ruptured pump boot due toRuptured pump boot due to overocclussion.overocclussion. Foreign bodies entering pump head.Foreign bodies entering pump head.
- 24. Cardiotomy reservoir relatedCardiotomyreservoir related Production of positive pressure at theProduction of positive pressure at the input to the reservoir.input to the reservoir. Air forced back up an arterial filter purgeAir forced back up an arterial filter purge lineline Air forced back along vent system throughAir forced back along vent system through a non-occlusive pumpa non-occlusive pump Large amount of air entrained in theLarge amount of air entrained in the cardiotomy reservoircardiotomy reservoir
- 25. Management of grossair embolismManagement of gross air embolism Prevention is the best form management.Prevention is the best form management. Guidelines and procedures should beGuidelines and procedures should be setup and practiced by perfusionist.setup and practiced by perfusionist. Stop arterial pump immediatley.Stop arterial pump immediatley. Clamp venous line.Clamp venous line. Place patient in a steep head downPlace patient in a steep head down position.position. Cannula removed and circuit purged of air.Cannula removed and circuit purged of air.
- 26. Management of airembolismManagement of air embolism contd.,contd., Arterial line is connected to venousArterial line is connected to venous cannula to facilitate retrograde perfusion.cannula to facilitate retrograde perfusion. Start flow at 1 to 2lts/mt with flow directedStart flow at 1 to 2lts/mt with flow directed up the SVC.up the SVC. Try to cool the patient to 20 degrees.Try to cool the patient to 20 degrees. Suction system is to retrieve blood fromSuction system is to retrieve blood from aortotomy.aortotomy. Anesthetist exerts pressure on carotids.Anesthetist exerts pressure on carotids.
- 27. Air embolism contd.,Airembolism contd., Retrograde perfusion is continued until theRetrograde perfusion is continued until the arterial system is cleared of air.arterial system is cleared of air. Standard bypass is resumed withStandard bypass is resumed with hypothermia.hypothermia. Air from the coronary system is alsoAir from the coronary system is also removed by pharmocological elevation ofremoved by pharmocological elevation of perfusion pressure.perfusion pressure. Dexamethasone and thiopentone areDexamethasone and thiopentone are administered.administered.
- 28. Contd.,Contd., Rewarming accomplished slowlyto coreRewarming accomplished slowly to core temp of 35 deg and bypass discontd.temp of 35 deg and bypass discontd. Patient ventilated on 100% oxygenPatient ventilated on 100% oxygen Deep barbiturate anesthesia may beDeep barbiturate anesthesia may be useful.useful. Hyperbaric treatment is useful with goodHyperbaric treatment is useful with good results especially within 48 hrs of injury.results especially within 48 hrs of injury. Mean arterial pressure at 100 to 130Mean arterial pressure at 100 to 130 mmhgmmhg
- 29. How to avoidaccidents?How to avoid accidents? Sound KnowledgeSound Knowledge Regular updatesRegular updates Regular Maintenance of equipments.Regular Maintenance of equipments. Build up of trust and team spiritBuild up of trust and team spirit
- 30. How to avoidaccidents? Contd.,How to avoid accidents? Contd., Follow the standards of perfusionFollow the standards of perfusion Good data managementGood data management Check list and double checkCheck list and double check Reconfirmation of settingsReconfirmation of settings Vigilant alwaysVigilant always Never be overconfidentNever be overconfident
- 31. Contd.,Contd., Good communicationGood communication Sharpnessin sight, hearing andSharpness in sight, hearing and reasoningreasoning Engage all the saftey gadgets on theEngage all the saftey gadgets on the HLMHLM Widens the saftey windowWidens the saftey window Machines have alarm, alertMachines have alarm, alert and auto shut offand auto shut off
- 32. Contd.,Contd., Saftey gadgets givesrelaxation to theSaftey gadgets gives relaxation to the operating perfusionistoperating perfusionist Keep the safe timing limitsKeep the safe timing limits Develop good organising skillsDevelop good organising skills Methodic approachMethodic approach
- 33. Standards to followStandardsto follow Document all the vital parameters,Document all the vital parameters, history of the Patienthistory of the Patient Appropriate the equipment selectionAppropriate the equipment selection and the disposables as per the patientsand the disposables as per the patients needneed Never go with blind approachesNever go with blind approaches
- 34. DrugsDrugs Always read thedrug labelAlways read the drug label Never follow the color or shape of theNever follow the color or shape of the vial or containervial or container May lead to increase in Morbidity andMay lead to increase in Morbidity and mortalitymortality
- 35. Overcoming accidentsOvercoming accidents LearningLearning –An ongoing processAn ongoing process – UniversalUniversal – No age limitNo age limit – Do not deny the opportunityDo not deny the opportunity Dedicate your time and age forDedicate your time and age for achievements.achievements.
- 36. Ultimate goalUltimate goal Savethe life inspite of all the oddSave the life inspite of all the odd situationssituations Prevent the re-occurrencePrevent the re-occurrence Draft protocols and applicationsDraft protocols and applications Be committed to the professionBe committed to the profession
- 37. Contd.,Contd., Do not workfor rewards aloneDo not work for rewards alone Earn the confidence of the teamEarn the confidence of the team Knowledge, hard work and efficiencyKnowledge, hard work and efficiency Earns a better livingEarns a better living
- 38. Sincereity, punctuality, honesty,Sincereity,punctuality, honesty, vigilance, dedication, thoroughvigilance, dedication, thorough knowledge and good communicationknowledge and good communication Earns a good professionalEarns a good professional
- 39. Constant updateConstant update TextbooksText books MediaMedia CMECME Conferences National, InternationalConferences National, International Medical exhibitionsMedical exhibitions Help to develop the management skillsHelp to develop the management skills of the perfusionistof the perfusionist
- 40. Worldwide experience shows:Worldwide experience shows : Human errors > 90%Human errors > 90% Equipmental errors <10%Equipmental errors <10%
- 41. Perfusion management andPerfusionmanagement and perfusion systemsperfusion systems inspite of advanced technologies,inspite of advanced technologies, monitoring the adequacy of perfusion ismonitoring the adequacy of perfusion is not reliable.not reliable. Oxygen delivery to the vital organsOxygen delivery to the vital organs depends on multi-faceted interaction ofdepends on multi-faceted interaction of perfusion conditions.perfusion conditions. There are no easily measured indicatorsThere are no easily measured indicators of adequacy avilable to us in OTof adequacy avilable to us in OT
- 42. Perfusion systemsPerfusion systems theCPB machine,patient and perfusionistthe CPB machine,patient and perfusionist constitute a system.constitute a system. Systems performance is a scienceSystems performance is a science employed by diverse agencies such asemployed by diverse agencies such as atomic energy commission and NASA.atomic energy commission and NASA. From the perfusionist point of view it isFrom the perfusionist point of view it is important that the fundamental priciples ofimportant that the fundamental priciples of system performance are recoganised.system performance are recoganised.
- 43. Perfusion system contd.,Perfusionsystem contd., An FDA sponsored study identified fourAn FDA sponsored study identified four broad areas as the cause ofbroad areas as the cause of unsatisfactory perfusion.unsatisfactory perfusion. 1.1. Inadequacy of current perfusionInadequacy of current perfusion management technique.management technique. 2.2. Pre-bypass pathalogical problems inPre-bypass pathalogical problems in patientpatient 3.3. Bypass device inadequacy or failureBypass device inadequacy or failure 4.4. User error-accounts 80% of all errors.User error-accounts 80% of all errors.
- 44. Safety for theperfusionistSafety for the perfusionist Awareness of safety factors related toAwareness of safety factors related to hepatitis B infection and HIV hashepatitis B infection and HIV has prompted concern among the team.prompted concern among the team. Protection of health care staff is theProtection of health care staff is the responsibility of management to help inresponsibility of management to help in the vaccinationthe vaccination Avoidance of skin, mucus membrane andAvoidance of skin, mucus membrane and skin puncture contact with affected blood.skin puncture contact with affected blood.