Cardiopulmonary Bypass:

Equipment

By:-
Dr. Armaanjeet Singh
Moderator:-
Dr. Bikram Gupta 1
 Components of CPB Machine
• CBP console
• Venous Reservoir
• Arterial Pump
• Oxygenator
• Heat Exchanger
• Cardioplegia Circuit
• Vent Circuit
• Monitoring and Safety systems
• Filters

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 Circuit Selection
• Body Surface Area:- √(Height(in cm) x Weight(in kg)/ 3600)
• Flow :- 2.4 – 3.0 L/min/m2 or 60-70 ml/kg/min
• Choice of Circuit
Blood Flow Venous Arterial Pump Oxygenator Arterial Prime
(ml/min) Line Line Boot filter volume (ml)
< 1500 __” __” __” Terumo RX05 Terumo ~ 350 ml
CXAF02
1500 – 2000 3/8” 1/4” 3/8” Terumo SX10 Terumo ~ 750 ml
CXAF02
2000 – 3000 3/8” 3/8” 3/8” Terumo SX10 Terumo ~ 1000 ml
CXAF125X
> 3000 1/2” 3/8” 1/2” Terumo SX18 Terumo ~ 1250 ml
CXAF125X
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 Priming
• The prime for cardiopulmonary bypass (CPB) is calculated
such that the combined hemoglobin (i.e.. patient and bypass
pump blood) is approximately 80-90 g/L as a minimum.
• HCTr = Patient’s preoperative red blood cell volume /Total
volume of distribution at the start of CPB
• HCTr = (BVp × HCT)/ (BVp + PVc)
• Total prime dilution should not exceed 40 ml/kg.
• Balanced salt solution + Osmotic (to discourage edema) +
Diuretics (e.g. mannitol)
• Other compounds that can be used are heparin, albumin,
bicarbonate etc.

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 Central Venous Cannulation
• Single simple cannula in RA: Inserted through a purse-string
suture in the RA free wall or atrial appendage
• Cavoatrial or “two-stage” single cannula: A single-lumen
cannula with a wide proximal portion with drainage slits
situated in the RA, and a narrower distal end placed into the
IVC. This is the most common type of cannulation for coronary
artery and aortic valve surgery.
• Bicaval cannulation: Separate cannulae are placed into the
SVC and IVC either directly or indirectly through the RA
through purse-string sutures. Bicaval cannulation is most
effective at totally diverting blood away from the heart.

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 Venous Cannula
• Plastic, wire reinforced
• Straight/Right angled metal or hard plastic tipped
• Favorable internal diameter to external diameter
(ID:OD) ratio

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 VENOUS CANNULA SIZES

FLOW SVC IVC

ml/min. mm/FR mm/FR
0 - 400 3.9/12 3.9/12
400 - 600 3.9/12 5.3/16
600 - 800 4.7/14 5.3/16
800 - 1000 4.7/14 6.0/18
1000 - 1400 5.3/16 6.0/18
1400 - 1800 6.0/18 6.0/18
1800 - 2000 6.0/18 6.5/20
2000 - 2250 6.5/20 6.5/20
2250 - 2500 6.5/20 7.3/22
2500 - 2750 6.5/20 7.3/22
2750 - 3000 7.3/22 8.7/24
3000 - 3600 8.7/24 8.7/24
3600 - 3900 8.7/24 9.5/28
3900 -> 9.5/28 9.5/28

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 Peripheral Venous Cannulation
• Used for minimally invasive/“port-access” approaches,
surgery via left thoracotomy, or for cannulation before
entering the chest
• Most commonly, venous cannulae are placed via the femoral
vein (and rarely the IJ vein)
• As peripheral venous cannulae are smaller and longer than
directly placed cannulae, resistance to drainage is greater and
may require use of augmented venous drainage

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 Arterial Cannula

A: Tapered, bevel-tipped cannula with molded flange near tip.

B: Angled, thin-walled, metal-tipped cannula with molded flange.
C: Angled, diffusion-tipped cannula designed to direct systemic flow in four
directions (right) to avoid “jetting effect”
D: Integral cannula/tubing connector and luer port (for deairing)
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 Site Advantages Limitations
Ascending Aorta Convenient Atheroembolism
Lower risk of dissection(~0.1%) Ascending aortic pathology

Femoral/Iliac Ease Retrograde dissection

For minimal access surgery Peripheral Vascular Disease
During re-entry, especially if Ischemia of cannulated
developed bleeding extremity
Pre-incision if low EF Post release emboli
Axillary/Subclavian Best for patients with aortic dissection More difficult and time
Permits selective cerebral perfusion consuming
Decreased risk of atheroemboli

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 Venous Reservoir
• A large-capacity (3000–4000 ml) reservoir is kept proximal to
the blood pump to buffer fluctuations in venous return.
• Hard-shell (open) reservoirs are preferred as they have a large
capacity filter to manage cardiotomy suction and filter venous
blood.
• Soft-shell, collapsible plastic bag, “closed” venous reservoirs
eliminate the gas–blood interface and reduce the risk of
massive air embolism as they collapse when emptied and do
not permit air to enter the systemic pump
• When soft-shell reservoirs are used, a separate cardiotomy
reservoir is required

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 Centrifugal Roller

Output inversely proportional to afterload Output independent of afterload

Output not directly related to rpm Output = rpm x volume per revolution
Requires flowmeter to determine output
Will allow retrograde flow of aorta if turned
off

Will not blow out arterial line Will blow out arterial line if clamped

Cannot pump massive air Can pump massive air to the patient

No risk of spallation Risk if wear and spallation

Cause lesser damage to blood components Cause more damage to blood components

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 Membrane Oxygenators
• Function similarly to natural lungs
• Membrane between the ventilating gas and the flowing blood
• Microporous polypropylene (PPL) serves as the “membrane”
through which gas exchange occurs. With excessive pressure
in the blood path or over prolonged time, plasma may leak
through the membrane
• Pressure in the gas space should never exceed the pressure in
the blood space, or gaseous emboli will form
• Poly-methyl pentene (PMP) diffusion membrane has the
advantage of minimizing the risk of plasma leak and microair
aspiration and permits prolonged oxygenation

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 Heat Exchanger
• Heat exchangers consist of heat-exchanging tubes
(often metal) through which the blood flows.
• These tubes are surrounded by water of varying
temperatures.
• Heat exchangers are often incorporated in the
oxygenator.
• Heater–cooler device adjusts the water
temperature and pumps it through the heat
exchanger (counter-current with the blood flow).
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 Arterial Line Filter
• Screen filters (pore size 20–40 μm) provide a
final stage of protection against systemic gas
and particulate embolization.
• Blood flow creates a centrifugal effect,
trapping the less dense air bubbles in the
center and top of the filter.
• Arterial line filters must be continuously
“purged” by allowing a small amount of blood
to recirculate back into the venous reservoir.

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 Cardioplegia Delivery Circuit
• Aortic root cannula has a“Y” connector: Cardioplegia delivery
system and suction (vent the left ventricle [LV] or aspirate air).
• Special hand-held cannulae can be placed directly into right
and left main coronary arteries.
• Balloon-tipped cannulae are inserted into coronary sinus
through purse- string suture in low lateral wall of the RA.
• These cannulae have pressure port to monitor pressure in
coronary sinus (30 -50 mmHg).
• Free wall of the right ventricle and posterior 1/3 of septum
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are poorly perfused by retrograde delivery

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 Cardioplegia Solution
• Potassium is always used as the arrest agent
• The ratio of blood to crystalloid is generally 4:1 or 8:1.
• Chemicals added to the cardioplegia solutions are
designed to make the solution slightly hypertonic to
reduce edema, buffer the heart’s production of acidic
metabolites and a substrate for energy
• Sterile concentrate for Cardioplegia infusion contains
Magnesium Chloride Hexahydrate 163mg/ml
Potassium Chloride 60mg/ml
Procaine Hydrochloride 14mg/ml

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 Safety Features
Monitors provide early warning of impending problems and automatically
alter pump controls:
• Venous oxygenator saturation monitor providing a global estimate of CPB
adequacy;
• Venous reservoir level detector/alarm alerting to fall in venous return and
venous air entrainment;
• Arterial line pressure monitor/alarm alerting to circuit/patient
barotrauma; it indicates clot formation or arterial cannula malposition;
• Arterial line bubble detector/alarm – alerting to the presence of air-
embolism, gross venous air entrainment, arterial line filter failure or loss
of membrane
• integrity;
• Oxygen analyzer in the oxygenator gas supply line;
• venous and arterial line temperature monitors;
• In-line arterial blood-gas monitoring.
• Battery backup or manual hand-crank to maintain the output of the
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