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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4000_Библиотеки_им_академика_М_И_Перельмана
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Contents ix
Nicks procedure, 176
Nikaidoh procedure, 176
Noonan syndrome, 176
Norwood operation, 176
Pannus, 176
Pentalogy of Cantrell, 176
Potts shunt, 177
Rashkind procedure, 177
Rastelli operation, 177
Ross procedure, 177
Sano shunt, 177
Scimitar syndrome, 177
Senning operation, 177
Shone’s complex, 178
Takeuchi procedure, 178
Taussig–Bing anomaly, 178
Trusler repair, 178
Van Praagh classification, 178
Warden procedure, 178
Waterston shunt, 178
Williams syndrome, 178
Yasui procedure, 179
10
Abbreviations for congenital heart
surgery,180
11 Recommended reference books, 186
12 Comprehensive experience-based
equipment selection chart
Select medications administered during
bypass,187
Index, 190
x
The art and science of providing perfusion for patients
undergoing surgical correction of congenital heart lesions
has advanced rapidly in the past decade. The complex equip-
ment; the unique acid–base management strategies; the spe-
cialized perfusion and ultrafiltration techniques; the wide
variation in patient’s age, size, and vulnerability to physio-
logic trespass; and the wide variety of surgical procedures
performed set perfusion for congenital heart surgery apart
from that provided for correction of acquired heart disease
in adults. Consequently, provision of cardiopulmonary
support for repair of congenital heart lesions has become a
specialty unto itself.
There is no doubt that perfusionists caring for patients
with congenital heart disease will find this manual invalu-
able. More importantly, from the perspective of a pediatric
anesthesiologist and intensivist, this manual will be an
essential resource for cardiac anesthesiologists and inten-
sivists. The practical hands-on information contained
herein is not currently readily available in any other publi-
cation. This manual will and should become part of the
teaching curriculum for anesthesia and intensive care
residents and fellows involved in the care of these complex
patients.
James A. DiNardo, M.D., FAAP
Professor of Anaesthesia
Harvard Medical School
Chief, Division of Cardiac Anesthesia
Francis X. McGowan, Jr., M.D.
Chair in Cardiac Anesthesia
Boston Children’s Hospital
Foreword
xi
Preface
There are numerous excellent textbooks available today on
congenital cardiac disease. Most congenital cardiac perfu-
sion services have at their disposal updated texts regarding
the disciplines of cardiology, cardiac surgery, anesthesia,
nursing, and perfusion. The perfusion texts, of which I am
most interested, can be found to have both vague and con-
tradictory statements regarding how to actually “run the
pump” for congenital cardiac cases. It is my hope that this
book provides some direction. The aim of this book is not
to provide a comprehensive textbook for congenital
cardiac surgery or cardiopulmonary bypass. Nor is it to
simply publish clinical practice protocols. Rather, the aim
is to provide easily referenced information and reminders
to the pediatric perfusionist and non-perfusionist alike,
which can influence a bypass plan and perhaps become
part of one’s practice. The pediatric perfusionist, with at
least a general understanding of the other disciplines
involved with cardiac surgery, should be able to reference
this book with its provided notes, as I prefer to call them,
to confidently devise a plan for a pump run.
The idea of creating this book stems from over 17 years
of practicing perfusion for congenital heart surgery and
nearly 25 years of working with critically ill children. The
academic institutions where I have trained and worked
regularly host visitors from around the country and world.
They include fellows of anesthesia, cardiac surgery, and
the intensive care unit, perfusion and nursing students, as
well as current practitioners in those fields. The most
common visitor question a department receives is, “Can I
get a copy of your protocols?” My standard answer is
always a qualified “yes.” It is quite simple to pass along
perfusion protocols and customized tubing pack specifi-
cations. Those items are essential and useful. Though, in
isolation, they fail to capture much of the thought and
consideration put into every cardiopulmonary bypass
plan for congenital cardiac cases. It is my hope that this
book is a step toward filling this gap in currently available
offerings.
Finally, we are all imperfect clinicians, and it has been
said that no one can harm (or even kill) a patient faster
than a perfusionist (or surgeon). With that being said, may
your clinical errors be minor and preferably off
cardiopulmonary bypass!
Gregory S. Matte, CCP, LP, FPP
Disclaimer
Perfusionists, by law, provide cardiopulmonary bypass
under the supervision of a physician. This book contains
information and recommendations that should be sanc-
tioned by the supervising physician. Errors and omissions
with the information provided are possible. Clinical prac-
tice is constantly evolving. Use of the information within
this book is at your own discretion and risk.
xii
Acknowledgments
A special thanks to Willis Gieser, former Chief of Perfusion
at Boston Children’s Hospital, who accepted my unsolic-
ited phone call, gave me an interview, and hired me many
years ago.
I am also deeply indebted to the following individuals
who provided feedback regarding the content of this book
and/or reviewed chapters: James DiNardo, Frank Pigula,
Kirsten Odegard, Chris Baird, Kevin Connor, Robert
Howe, Mark Wesley, Robert Groom, Robert Wise, and
Gerard Myers.
Perfusion for Congenital Heart Surgery: Notes on Cardiopulmonary Bypass for a Complex Patient Population, First Edition. Gregory S. Matte.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
1
The cardiopulmonary bypass plan starts with basics
of patient height, weight, allergy history, original diag-
nosis, previous surgeries, and current indications for sur-
gery. Theperfusionist must select and assemble an array of
equipment matched to the patient’s size, expected pump flow
rates, and other factors related to diagnosis. The following is
an overview of the major components of a bypass circuit.
Please refer to Chapter6 for equipment considerations in
addition to patient size. Figure1.1 is provided as a reference
to basic equipment arranged for cardiopulmonary bypass.
Oxygenators
The contemporary “oxygenator” is actually several integrated
items that in addition to the oxygenating membrane may
include the arterial line filter (ALF), venous reservoir and
filter, cardiotomy filter, and heat exchanger. Figure 1.2
depicts the components of the Terumo CAPIOX FX series
of “oxygenators.” Figure1.3 depicts typical components of
an oxygenator system.
The oxygenator membrane
• Membrane oxygenators allow for diffusion of gas,
oxygen and carbon dioxide most importantly, across a
material separating the blood path from the gas flow
path (also called the blood and gas phases).
• True membrane oxygenators allow for diffusion of gases
through a membrane separating the blood and gas
phases (see Figure1.4). The type and thickness of the
membrane, as well as blood and gas flow characteristics
on opposing sides, determines overall diffusion rates.
• Microporous membrane oxygenators allow for diffusion
of gases through microscopic holes in the membrane
material (see Figure1.4). The gas transfers directly through
these micropores and is therefore less impacted by the
membrane material. However, blood and gas flow charac-
teristics on opposing sides still impact diffusion capacity.
• The vast majority of oxygenators for cardiopulmonary
bypass are microporous membrane oxygenators. True
membrane oxygenators have limited applications today
including the use for ECMO at some institutions.
• The membrane oxygenator size chosen for a particular
patient should be the smallest which will allow for safe per-
fusion with some degree of functional reserve in case of
decreasing efficiency during extended bypass runs or to
account for markedly increased pump flows due to aorto-
pulmonary connections (MAPCAs, surgical or other
central shunts) or significant aortic regurgitation. Increased
pump flow rates in these situations may be required to
maintain adequate effective systemic perfusion.
• Using an oxygenator above its manufacturer recom-
mended maximum flow rate may increase arterial line
GME transmission and is not recommended.
• It is recommended to define the patient BSA and select
an oxygenator based on the maximum expected pump
flows. It is important to note that for neonates and
infants in particular, their relatively higher metabolic
requirement may require markedly increased pump
flows during normothermic bypass (i.e., rewarming).
Flows of 3.0–3.5 L/min/m
2
are not uncommon and
should be considered for equipment selection.
• Primary consideration is given to the manufacturer-
recommended maximum flow rate that is based on gas
Equipment for bypass
CHAPTER1
Arterial limb
Venous limb
Gas source and
ow meter
Arterial line lter
with bypass loop
clamped
Oxygenator with
integrated heat
exchanger. Angled
ports are for water
lines
LV vent pump head
Arterial pump head
Integrated cardiotomy venous reservoir (CVR)
Cardiotomy lter
Suction pump head
Field suction
LV vent
Suction pump head
Venous reservoir and lter
Figure 1.1 Simplified schematic for basic cardiopulmonary bypass equipment (excludes cardioplegia system).
AA
A
B
B
B
Figure 1.2 Terumo CAPIOX FX series of oxygenators. Left to right: Terumo CAPIOX FX05, Terumo CAPIOX FX15-30, Terumo CAPIOX FX25.
A—cardiotomy venous reservoir and B—oxygenator membrane with integrated arterial line filter and heat exchanger. (See insert for color representation of the figure.)
TOP VIEW
SIDE VIEW
Nonltered
luer lock
Auxiliary port
1/4”–3/8”
Sampling line
Venous blood
sampling line connection
Two luer locks
on venous inlet
Thermistor probe
Venous blood inlet port
Three ltered luer locks
to cardiotomy lter
Five suction ports
Quick prime port
Purge line from
the oxygenator
Vent port
Venous blood inlet port
Cardiotomy lter
Purge line
Guide hole for holder
Clamp
Connecting ring
One way valve
Heat exchanger
Gas inlet port
Arterial lter
Water inlet port
Gas exchange
module
Water outlet
port
Luer port (for recirculation or
blood cardioplegia)
Thermistor probe
Blood outlet port
Gas outlet port
Detachable connector
One-way valve
Blood inlet
port
Sampling line-
arterial side
Reservoir
outlet port
Sampling
system
Hardshell
reservoir
Oxygenator
with integrated
arterial lter
Sampling line-
venous side
Venous lter
Detachable
connector
Figure 1.3 Typical components of an oxygenator system. Reproduced with permission from Terumo Cardiovascular Group, Ann Arbor, MI. All rights reserved.
Gas ow
Blood ow
Gas ow
Blood ow
Gas transfer only
True membrane oxygenators
Gas diffuses through a solid membrane (shown
in gray). There are no direct
communications between the gas and blood
compartments.
Microporous membrane oxygenators
Gases diffuse through tiny holes in the
membrane material (shown in gray). There are
direct communications between the gas and
blood compartments. Microair in the blood
compartment may pass into the gas
compartment to facilitate removal of gaseous
microemboli in the blood. Blood cannot pass.
Figure 1.4 Primary types of oxygenators currently in use.
4 Chapter1
exchange and other aspects of oxygenator, heat exchanger,
and reservoir performance. The American Association
of Medical Instrumentation (AAMI) standard reference
values are usually not relied solely upon since they may
not take into account additional factors that the manu-
facturer evaluates for overall performance.
• Increased oxygenator bundle size does not linearly relate
to performance since characteristics of the blood and
gas flow paths vary among devices.
• Oxygenators have either radial or axial blood flow paths
that affect performance in competing ways in regards to
oxygenating efficiency, pressure drop, microemboli removal,
and heat exchanger performance (see Figure1.5).
• Microporous oxygenator bundles are important in the
removal of air from the blood path. Some centers, par-
ticularly outside of the United States, deem the micro-
porous oxygenator effective enough at air removal that
they do not utilize a standalone ALF.
• One oxygenator on the market, the Medtronic Affinity
Fusion, has taken advantage of the air handling capabil-
ities of microporous oxygenators, and unique bundle
wrapping technology, to be FDA approved for use as an
ALF as well as an oxygenator.
• The perfusionist must be familiar with the manufacturer
recommendations for treating an oxygenator sus-
pected of “wetting out.” These values are listed in
Tables1.1 to1.4.
• Oxygenators are usually qualified for use by the manu-
facturer for up to 6 h. Use beyond this limit does occur
and most often there is not a significant decrease in
performance. However, safe use beyond this limit is not
guaranteed. Consideration should be given to changing
out an oxygenator after a long case in which an addi-
tional bypass run is a serious possibility. Elective change
out while off bypass can be accomplished in a controlled
manner and can eliminate several concerns of emer-
gently resuming bypass with a product at the end of its
rated performance limit.
• Blood proteins coat a membrane oxygenator’s surface
area, including the micropores through which gas
exchange occurs.
• Microporous membranes may experience increased
protein coating and subsequent decrease in oxygen
transfer during extended bypass runs. It is important to
note that this protein coating may also decrease the air
handling capabilities of the membrane.
• The pressure drop across an oxygenator membrane is
frequently listed as a specification. It may be measured
in real time during bypass. A change in this value over
time is important to consider during bypass as it can be
an indicator of change in function.
• Pressure drop is frequently equated with shear stress
where a lower pressure drop is considered beneficial
with lower shear stress. That is not always the case since
Oxygenator bundle
Oxygenator bundle
Heat exchanger
Heat exchanger
Heat exchanger
Heat exchanger
Oxygenator inlet
Oxygenator inlet
Oxygenator outlet
Oxygenator outlet
Axial blood ow path
Blood travels along the axis of the
heat exchanger rst and then along
the axis of the oxygenator bundle
before exiting a low point in the
device.
Radial blood ow path
Blood enters and radiates through the
heat exchanger and oxygenator
bundle before exiting a low point in
the device. Some oxygenators
preferentially have blood exit the heat
exchanger top before owing through
the oxygenator bundle.
Oxygenator
Oxygenator bundle
Figure 1.5 Simplified schematic of blood flow paths through an oxygenator.
Table 1.1 Oxygenators rated up to ~2 LPM.
Manufacturer Oxygenator
(microporous
polypropylene
except as
noted)
Oxygenator
bundle (m
2
)
Oxygenator
prime
volume
Manufacturer
recommended
blood flow
range (LPM)
Heat
exchanger
size (cm
2
)
Heat exchanger
performance
factor at
manufacturer
maximum
recommended
blood flow rate
Reservoir
capacity
(mL)
Compatible
with
vacuum
assisted
drainage
Integrated
arterial filter/pore
size/surface area
Minimum
operating
volume
Gas flow range
(LPM)
Maximum
temporary gas
flow for suspected
wetting out of
oxygenator
Sorin D100 0.22 31 Up to 0.7 300 0.65 500 Yes No 10 Up to 1.4 LPM
with a max
V/Q of 2:1
Up to 2.8 LPM
witha max
V/Q of 4:1
Sorin Liiliput D901 0.34 60 0.8 200 0.72 675 Yes No 15 Up to 1.6 LPM
with a max
V/Q of 2:1
None specified
Maquet Quadrox-i
Neonatal
0.38 38 0.2–1.5 700 0.62 800 Yes No 15 0.1–3.0 None specified
Maquet Quadrox-i
Neonatal with
integrated ALF
0.38 40 0.2–1.5 700 0.62 800 Yes Yes/33 µm/20 cm
2
15 0.1–3.0 None specified
Terumo Capiox RX05 0.5 43 0.1–1.5 350 0.65 1000 Yes No 15 0.05–5,
minimum 0.2
V/Q
5 LPM for 10s,
do not repeat
Terumo Capiox FX05 0.5 43 0.1–1.5 350 0.65 1000 Yes Yes/32 µm/130 cm
2
15 0.05–5,
minimum0.2
V/Q
5 LPM for 10s,
do not repeat
Sorin D101 0.61 87 Up to 2.5 600 0.6 1500 Yes No 30 Up to 5 LPM
with a max
V/Q of 2:1
Up to 10 LPM
with a max
V/Q of 4:1
Medtronic Pixie 0.67 48 0.1–2.0 Not
specified
0.65 1200 Yes No 20 Up to 4.0 LPM
with a max
V/Q of 2:1
None specified
Table 1.2 Oxygenators rated ~2 to ~5 LPM.
Manufacturer Oxygenator
(microporous
polypropylene
except as noted)
Oxygenator
bundle (m
2
)
Oxygenator
prime
volume
Manufacturer
recommended
blood flow
range (LPM)
Heat
exchanger
size (cm
2
)
Heat exchanger
performance factor
at manufacturer
maximum
recommended blood
flow rate
Reservoir
capacity
(mL)
Compatible
with
vacuum
assisted
drainage
Integrated arterial
filter/pore size/
surface area
Minimum
operating
volume
Gas flow
range
Maximum
temporary
gasflow for
suspected
wetting out
ofoxygenator
Sorin Lilliput D902 0.64 105 Up to 2.3 200 0.48 1800 Yes No 200 Up to 4.6
LPM with
a max
V/Q of 2:1
None specified
Maquet Quadrox-i Pediatric 0.8 81 0.2–2.8 1500 0.62 1700 Yes No 30 0.1–5.6 None specified
Maquet Quadrox-i Pediatric
with integrated ALF
0.8 99 0.2–2.8 1500 0.62 1700 Yes Yes/33 µm/55 cm
2
30 0.1–5.6 None specified
Maquet Quadrox-iD Pediatric
(polymethylpentene)
0.8 81 0.2–2.8 1500 0.62 1700 Yes No 30 0.1–5.6 None specified
Medtronic Minimax 0.8 149 0.5–2.3 Not
specified
0.45 2000 No No 150 None
specified
None specified
Maquet Quadrox-i Small
Adult
1.3 175 0.5–5.0 3000 0.62 4200 Yes, with
VHK 2001
reservoir
No 300 Up to 15 None specified
Maquet Quadrox-i Small
Adult with integrated
ALF
1.3 295 0.5–5.0 3000 0.62 4200 Yes, with
VHK 2001
reservoir
Yes/40 µm/430 cm
2
300 Up to 15 None specified
Sorin Inspire 6 (optional
integrated arterial
filter)
1.4 184/284
with ALF
Up to 6.0 4300 0.6 4500 Yes Optional/38 µm/68 cm
2
150 Up to 12
LPM, not
to exceed
2:1 V:Q
Up to 12 LPM,
not to exceed
2:1 V:Q
Terumo Capiox RX15, 30 1.5 135 0.5–4, 5 LPM
with assisted
venous
drainage
1400 0.6 3000 Yes No 70 0.5–15 15 LPM for 10s,
do not repeat
Terumo Capiox RX15, 40 1.5 135 0.5–5.0 1400 0.6 4000 Yes No 200 0.5–15 15 LPM for 10s,
do not repeat
Terumo Capiox FX15, 30 1.5 144 0.5–4, 5 LPM
with assisted
venous
drainage
1400 0.6 3000 Yes Yes/32 µm/360 cm
2
70 0.5–15 15 LPM for 10s,
do not repeat
Terumo Capiox FX15, 40 1.5 144 0.5–5.0 1400 0.53 4000 Yes Yes/32 µm/360 cm
2
200 0.5–15 15 LPM for 10s,
do not repeat
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