Crisis Management -JL

What should be done before bypass for safety?

A pre-bypass checklist MUST be utilized & signed by the primary perfusionist

Arterial Pump/Remote Drive Failure Causes

• Partial or full decoupling

• Heat generation/fusing

• Entire remote drive failure

Arterial Pump/Remote Drive Failure Mitigation

• Diligently perform pre-bypass checklist

• Do not use a centrifugal head adapter plate

• Verify centrifugal head is properly seated

HLM Circuit Mitigation

• Diligently perform pre-bypass checklist

• Inspect the primed HLM for water drips

ON CPB - is the leak significant enough to affect pt safety?

• Could air be drawn into the system?

• Replace the affected component

• Use of zip ties

Clotted Circuit causes

• Insufficient heparinization (Low ACT)

• Static circuit vol

• Protamine administration

  • accidentally given or pump suckers are still on

Visible signs of HLM System Clots (Venous Res)

• Clotting present near res outlet

• Retarded flow thru res/INC’d hold up

• Visible clots at res sucker inlet

Visible signs of HLM System Clots (Tubing)

Visible fibrin deposits or clots in sucker tubing

Visible signs of HLM System Clots (Pericardial Cavity)

• Surgical staff note clots in static blood pools

• Pump sucker tip clogged

Clotted circuit mitigation for Insufficient heparinization

• Was the initial dose infused correctly by anesthesia

• HITT?

• Repeat ACT/ give additional dose of heparin

• Need to give AT III for heparin resistance?

Clotted circuit mitigation for Static circuit vol

• Consider additional heparin

• Recirculate HLM vol

Other Heparin Resistance causes

• Previous use of heparin

• Pregnancy

• Shock

• Infective endocarditis

What is the #1 cause of clotted circuits?

Protamine administration

Clotted Circuit remediation

• Discuss w/ surgeon & anesthesia that the circuit is unusable

• Solution: Safely & rapidly change out the circuit

  • (replace entire circuit bc assume there are clots elsewhere that are not visible)

Electrical failure causes

• Short circuit

• Facility outage

• Breaker overload

Electrical failure mitigation for short circuit

• Plug replacement

• Possible HLM replacement

Electrical failure mitigation for facility outage

• HLM batter conditioning & regular charging

• Prepare spare HLM & setup

Electrical failure mitigation for Breaker overload

• Know where & how to reset breakers on devices & the OR itself

• Do not place too many high load devices into 1 circuit

H/C Failure Causes

• Breaker overload

• System malfunction

• Water leak

Effects of H/C system malfunction

• Overheat

• No cooling or heating

• Pump failure

Effects of H/C water leak

• Water to Blood vs Blood to water

• Insufficient bath contents

H/C failure mitigation for Breaker overload

• Reset breaker

• Isolate device into dedicated circuit

H/C failure mitigation for System malfunction

Replace H/C

H/C failure mitigation for water leak

Insufficient fluid level in the device bath (fill it up)

H/C failure mitigation for water leak (Water to Blood)

• Activate H/C before priming, check for fluid contamination in dry circuit

• Diligently perform pre-bypass checklist

• Diagnose leak - hemolysis, Hemodilution, contamination

• Notify surgeon, stop H/C flow, initiate oxy changeout protocol

H/C failure mitigation for water leak (Blood to Water)

• Diagnose leak - note blood in H/C fluid at oxy Hansen connector

• Depending on stage of operation, stop H/C flow & initiate oxy changeout protocol

High Aortic/Arterial line pressure (post oxy measurement) Causes

• Cannulation not optimal

• HLM clots

• Kinked aortic line

• Aortic dissection

High Aortic/Arterial line pressure mitigation for cannulation not optimal

Reposition cannula

High Aortic/Arterial line pressure mitigation for HLM clots

Must replace HLM disposables & re-prime or replace entire HLM w/ new primed circuit

High Aortic/Arterial line pressure mitigation for Kinked aortic line

• Trace lines & fix kink

• Ask person leaning on tubing to get up

High Aortic/Arterial line pressure mitigation for Aortic dissection

• Recannulate at alternate site

• Call for backup

HPE definition

A sporadic, unpredictable event involving INC’d transmembrane pressure in oxys that can potentially lead to periods of inadequate perfusion & morbidity for the pt

HPE causes

• Protein, Lipid, Platelet aggregation around oxy fibers

• Associated w/ Diprivan (lipid based drug)

• Associated w/ absence of albumin in priming drugs

What will you see in HPE?

• w/in several minutes of CPB onset, pre-membrane pressures INC

• Flow drops/ inflow pressure INC’s regardless of RPM or flow manipulation

HPE Treatment

• Warm pt

• 12.5 g Albumin

HLM Gas loss causes

• Anesthetic vaporizer malfunction

• Facility supply failure

• Blender malfunction

• “Green filter” leak/crack

• Tubing disconnect

E cylinder duration calculation (in min)

= ( PSI x 0.28) / sweep

HLM Gas loss mitigation

Circumvent gas supply system w/ E cylinder O2 tank & tubing

HLM Gas loss mitigation for Anesthetic vaporizer malfunction

• Caused by O ring seating misplacement, deterioration, PM error

• Bypass vaporizer w/ ¼ x ¼ connector (anesthesia must compensate for sedation)

HLM Gas loss mitigation for Facility supply failure

Use E cylinder O2 tank and tubing

HLM Gas loss mitigation for Gas blender malfunction

Use E cylinder O2 tank and tubing

HLM Gas loss mitigation for “Green Filter” leak/crack

• Check gas flow on back of hand

• Replace filter

HLM Gas loss mitigation for Tubing disconnect

• Diligently perform pre-bypass checklist

• Reconnect tubing, consider zip ties

What is the most frequent cause of gas supply leak?

Anesthetic vaporizer