UAB General

Thoraco-Abdominal Aortic Aneurysm (TAAA) or Left-Heart Bypass (LHB) Protocol for Dr. Davies a.k.a. Descending Thoracic Aneurysm LHB O.R. Nurse/Surgeon Cannulation Supplies: 

  • 20Fr thru 24Fr Straight Lighthouse Venous Cannula used in Left Inferior Pulmonary Vein;
  • using 3/8” x 3/8” Straight Connector
  • 20Fr Right-angle Aortic Cannula (Davies) used in Aorta, Distal to Aneurysm;
  • have 20Fr Straight-tip Aortic Cannula available
  • In the event of Femoral Artery cannulation, a 15Fr or 17Fr Arterial Bio-Medicus Cannula and a 3/8” x 3/8” x 3/8” Y Connector should be available for use
  • May also just got femoral and not Y anything…
  • Tourniquets  x2
  • Medusa (have available in room – will use for mesentery perfusion)

  O.R. Anesthesia Supplies: 

  • NIRS Monitoring Strips  x2

  LHB Pump Circuit Build Supplies: 

  • Lung Pack + Pump Pack 
  • Pressure bag – on AngioVac stopcock
  • Used for bumping up venous line
  • Medusa (for mesentery perfusion) – Y into our non-sterile arterial line with 3/8” x 3/8” x 3/8” connector
  • Have table cut sterile medusa’s Y off and then pass back to you to connect to non-sterile Y
  • Prime up with clear and have scrub nurse set medusa off to the feet
  • i.e. same as KWE dissection set up

 -When logging into Viper, use Adult CPB -Under “perfusion strategy” on patient info tab, selected planned AND left heart bypass. -Oxygenator should be used to regulate the patient’s temperature             -Bypass the reservoir as we do in lung transplants Left-Heart Bypass Technique: -Initiate @ 500ml/min -JED will have you come up on flows gradually “1 L/min” -When the cross clamps are placed, JED will want flows near “2 L/min and MAP 60 - 90mmHg” (Flows are very dependent on pressure; Flow and pressure are inversely proportional;   Increase flows to decrease pressure - Decrease flows to increased pressure). -Femoral arterial line is necessary to monitor perfusion pressure distal to the clamped aorta. -Right-radial arterial line is necessary to monitor perfusion pressure proximal to the clamped aorta. -When distal clamp is placed (2nd clamp placed), anticipate your femoral pressure spiking >100 mmHg -- come down on flow preemptively and then adjust accordingly             -If JED sees this high pressure, he will flip his shit…and no one wants that  *Record all clamp times (talk to JED and make notes of it here) Clamp on time Move clamp time? Move clamp time? Clamp off time Then when off LHB, JED will want transfuse patient blood from circuit into patient via; (1) chase circuit with Isolyte, (2) turn RPM’s up to safely pump back, (3) lift up tubing to gravity fill into patient with blood, Both you and Jamey should clamp the line when done! ____________________________________________________________________ Renal Artery O.R. Nurse/Surgeon Cannulation Supplies: 

  • Normal cardioplegia circuit
  • Using a tubing clamp, clamp the CP line off the oxygenator (distal to take off of manifold)
  • Leave red cricket clamp OPEN
  • Load CP like normal in Buckberg configuration
  • 3/16” Male Luer (pass up to table)
  • Double Y adapter (10004D)  x2 (pass up to table)
  • 4mm thru 8mm Vitalcor Straight Ostial Cannulas  x2 available in room
  • 14Fr Retrograde CP Cannula (Davies) (RC2014)  x2 available in room
  • 10Fr - 15Fr Retrograde CP Cannulas (Pereira) (94113T - 94115T)  x4 available in room

 Renal Artery Pump Circuit Build Perfusion Supplies: 

  • Lactated Ringers 1000 ml  x2 (Anesthesia work-room)
  • Solu-Medrol 125 mg  x2 (CRNA or Anesthesiologist)
  • Mannitol 12.5 g  x2

 Renal Artery Pump Circuit Build: -The renal circuit should be primed with Lactated Ringers. Once the circuit is primed and ready to go, add 125mg Solu-Medrol and 12.5G Mannitol per 1 liter of Lactated Ringers (it is in your best interest to have two bags of LR spiked with drugs added to them). Renal Artery Perfusion Technique: 100 - 150mL/min @ 4°C 170 ± 65mmHg Initial dose: 400 - 600mL Subsequent doses 100 - 200mL (remind JED 15 - 20 min) ____________________________________________________________________Distal (Superior Mesenteric Artery) Perfusion Supplies: 

  • 3/8” x 3/8” x 1/4” Y Connector OR 3/8” x 3/8” x 3/8” Y Connector (used to Y the arterial line)
  • Medusa
  • Scrub or JED will cut into arterial line, JED has stated he does not need it Y’d into the circuit every time
  • 14Fr Retrograde CP Cannula (Davies) (RC2014)  x3 available

------------------------------------------------------------

 

Dr. Jamey DaviesManufacturer / Catalog/Ref.Comments
Aortic Cannula

ARTERIAL CANNULA 20FR CURVED TIP W/LL* (Davies)Medtronic / 82020< 2.1 BSA and/or < 100 kg
ARTERIAL CANNULA 22FR CURVED TIP W/LL (Davies)Medtronic / 82022> 2.1 BSA and/or > 100 kg



ARTERIAL CANNULA 20FR STRAIGHT BLUE TIP W/LLMedtronic / 76020Have available when requested
ARTERIAL CANNULA 22FR STRAIGHT BLUE TIP W/LLMedtronic / 76022Have available when requested



3/8" x 1/4" CONNECTOR W/LL CARMEDAMedtronic / CB4620Axillary Artery Cannulation cases (1/4")8mm Dacron graft



CARMEDA FEMORAL ARTERIAL CANNULA 18CM                             15 thru 21FR BIOMEDICUS (Typically 19FR)Medtronic / CB96535-015 thru Medtronic / CB96570-021Have ALL sizes available for Any Re-Op or Ascending - Aortic - Aneurysm/Dissection Circulatory Arrest cases or TAVR and Lead Extraction cases for Aorta or Femoral Cannulation
ARTERIAL INSERTION KIT .038 WIRE x 100CMMedtronic / 96552For Cannulation in Aorta or Femoral Artery









Venous Cannula

VENOUS CANNULA 29/37FR (small 3-STAGE)                   Edward Lifesciences / TF293702< 1.9 BSA and/or < 70 kg
VENOUS CANNULA 36/46FR (LARGE 3-STAGE)                     Edward Lifesciences / TF364602> 1.9 BSA and/or > 70 kg (MVR only cases)



VENOUS CANNULA 29/37FR TRIMFLEX DUAL-STAGE        (small FLAT)Edward Lifesciences / TFR2937O2< 1.9 BSA and/or < 70 kg (Any Ascending - Aortic - Aneurysm/Dissection - Circulatory Arrest cases)
VENOUS CANNULA 36/46FR TRIMFLEX DUAL-STAGE       (LARGE FLAT)Edward Lifesciences / TFR3646O2> 1.9 BSA and/or > 70 kg (Any Ascending - Aortic - Aneurysm/Dissection - Circulatory Arrest cases)



VENOUS CANNULA 24FR RIGHT ANGLE METAL TIP ONLY!Medtronic / 69324SVC cannula for Bi-Caval cases
VENOUS CANNULA 24 thru 34FR                                     STRAIGHT LIGHTHOUSE TIPMedtronic / 66124 thru Edward Lifesciences / TF034LIVC cannula for Bi-Caval cases
1/2" x 3/8" x 3/8" Y CONNECTORMedtronic / 6040Use with ALL Bi-Caval cases



FEMORAL VENOUS CANNULA 60CM                                                       15 thru 25FR MULTI BIOMEDICUSMedtronic / 96600-015 thru Medtronic / 96880-025Have appropriate sizes available for ALL Re-Op or TAVR and Lead Extraction cases for Femoral Cannulation
1/2" x 3/8" STRAIGHT CONNECTORMedtronic / 6013Use on 1/2" Venous Line

 

 



Cardioplegia Needle (Aortic Root Vent)

CARDIOPLEGIA - AORTIC ROOT CANNULA 12GA(9FR) (Davies)Medtronic / 20012ALL cases



CARDIOPLEGIA MULTI-Y (Octopus I) (Davies)Medtronic / 14000ALL cases


RETRO CARDIOPLEGIA CATHETER 14FR (Davies)Edward Lifesciences / RC2014DO NOT PASSUP ON MITRAL ONLY & MYECTOMY CASES!



CORONARY OSTIAL CANNULA 14FR RIGHT ANGLEMedtronic / 30114      ALL AVR or Ascending Aortic Arch or Aneurysm/Dissection cases using direct coronary cardioplegia LCA/RCA 
CORONARY OSTIAL CANNULA 12FR RIGHT ANGLEMedtronic / 30112When requested for smaller direct coronary LCA/RCA
CORONARY OSTIAL CANNULA 10FR (Mushroom tip)Medtronic / 30155When requested b/c the 14 or 12 right angles do not fit or work
CORONARY OSTIAL CANNULA 12FR 45° ANGLEMedtronic / 30212When requested






Cardiac Sump

PERICARDIAL SUMP (Wire)Medtronic / 12010ALL cases / use on #2 - drop (yellow) sucker pump
      Will need a second one on Ascending Aorta Case /                        use on #1 - root-vent (purple/magenta) sucker pump








LV Vent

LEFT-HEART VENT 16FR RIGHT ANGLEMedtronic / 12016Passup only on AVR, Aortic Aneurysm or Combo cases






Ancillary or other Supplies

SENSOR OXIMETER ADULT (NIRS)Covidien / SAFB-SMALL cases - 2 each
PACING CABLE EXTENSION 6FT (Screw-Down)Remington / FL-601-97ALL cases - 2 each
TOURNIQUET KIT (Color Only!)Medtronic / 79004ALL cases
INTRACARDIAC SUMP 12FR (CO2 Diffuser)Medtronic / 12013Use as 'CO2 diffuser' on Left-sided open-heart cases






PLEASE REMEMBER TO CHARGE FOR ANY EXTRA NON-REGULARLY USED ITEMS




Techniques and Notes for Jamey
Initiation of CPB:
He will tell Anesthesia to "give the heparin" and then say "pump off" - clamp venous line
When ACT (heparin) reaches "200 seconds" he will have you to "turn on pump suckers" - approximately #2 @ 400 mL #3 @ 600 mL
He will ask for, “pump on easy” to connect arterial line to cannula
Sometimes: He will also ask you to "check your pressure" of the arterial line to make sure it correlates with the mean arterial pressure of the patient
He puts in the venous cannula(s) or if an AVR case, a retrograde cardioplegia catheter second then LV vent
Then, he will say, “on bypass - stay warm" (37°C) - unclamp venous line
For ALL AVR case, JED will ask for a "little volume in the heart" then place a LV vent via the right superior pulmonary vein
He might say "empty out the heart" or "turn your vacuum up" - confirm occluder set at 'wide open' and vacuum is 'on and up' approximately @ 20-55 mmHg.                     If said again then turn down pump flow as long as the patient can tolerate it.
If this is a valve or aneurysm case then he'll say "pump suckers on high" - turn at a higher flow up to maximum 3 Liters
The next couple of phrases are said at a rapid-fire rate…
"Cardioplegia to me" 
"Plegia off"
"Root vent on"
"Root vent off"
"Flow down"
"Cross-clamp on" (if Left-sided open-heart case "CO2 on" @ 2 Liters)
"Cardioplegia on give 1 liter down the root" (antegrade) or "500 retrograde" followed with "500 antegrade" or some combination thereof
"Flow back up"
If this is a valve or aneurysm case then he'll say "LV vent on low" approximately #2 @ 200 mL
He tells Anesthesia to "stop ventilating"
End of rapid-fire rate of instructions…
Then when your total initial "CP dose in" he'll reply "cardioplegia off"
"Root vent back on low" approximately 100-200 mL
"Let me know 20 minutes"


Cardioplegia (Buckberg only):
Initial Antegrade dose will be 1000 mL at a rate of 200-300 mL and a pressure of 200-250 mmHg, if using handhelds then rate of 100-175 mL depending on if LCA - 400 mL or RCA - 200 mL.
If retrograde is initial dose, he will give 500 mL then 500 mL antegrade. The retrograde dose will be given at a rate of approximately 150 mL. He does not monitor a coronary sinus pressure.
He wants to be reminded every "20 minutes CP" plus every 5 thereafter.
When he wants to run "CP down a vein graft" slowly run CP approximately 30 mL and 100 mmHg for about 20 seconds without recording into Viper.


Temperature Control:
JED stays 37°c (normothermic) on the majority of his cases, he will tell you to “stay warm”. 
If cooling is necessary, he will communicate the temperature.

For Circ. Arrest Cases Prep Heater/Cooler: Have plenty of fresh ice cubes inside H/C tank to facilitate rapid cooling. Then have full tray of ice with two empty buckets, will be needed for longer cooling time and large patients.
Aortic Arch or Aneurysm or Dissections including Circulatory Arrest cases: He will cannulate the Axillary artery using a 8mm Dacron graft to a 1/4" x 3/8" connector with luer to start the case.                                                                                                                                                                                                                                                                                                                                                                              
SPECIAL NOTE; when "heparin is given" or sometime before, have circulator to cool the room all the way down and turn off the patient warming pad.
Go on bypass at 34°C then immediately start cooling patient core to 26-28°C or up to forty-five minutes of cooling.                                                                                                    (LET HIM KNOW IF HEART FIBRILLATES!)
Once circulatory arrest begins Jamey wants to be notified every "10 minutes circulatory arrest". Clamp arterial line and recirculating pump through the recirculation line. Jamey will tell you to leave the venous line open to adequately exsanguinate the patient.
He will perform Antegrade Cerebral Perfusion at a rate of 5-15 mL/kg (500 mL) through the Axillary site (8mm Dacron graft to a 1/4" x 3/8" connector with luer, this is already being used as the arterial line). Keep venous line open during this time!
When he is ready to re-establish full pump-flow, he will move the 1/4" x 3/8" connector with luer and re-cannulate using the side-arm of the Aortic Dacron graft, also start rewarming patient core at this time.                                                                                                                                                                                                              
SPECIAL NOTE; have circulator to warm the room up a little and turn on the patient warming pad.


Termination of CPB:
The next couple of phrases are said at a rapid-fire rate…
"Give the mag" When the cross-clamp comes off he wants 2G of Magnesium-sulfate given into the pump
"Volume (blood) in the heart" fill the heart to just starting to eject
He tells Anesthesia to "start ventilating"
"Flow down"
"Root vent on high 1 Liter" (when de-airing heart via CP needle)
"Cross-clamp off" (repeat him then you reply "CO2 off")
"Flow back up"
He tells Anesthesia to "stop ventilating"
He might say "empty out the heart" or "turn/is your vacuum up?" (confirm the occluder is set at 'wide open')
End of rapid-fire rate of instructions…
"Blood back in - root vent at 1 Liter"
JED will have you "hold volume in, come down to 2 Liters"
Typically, he will have you "come off bypass" while keeping pump-flow up with the aortic root vent which is typically at 1 Liter
Sometimes, he will wean the sicker patients by having you "decrease your pump-flow to 1 Liter" for a couple of minutes (reduce gas sweep rate) and then tell you to "come down on pump-flow to 500 mL" and will have you "come off bypass" you will ask "ok decrease root vent to 500 mL?"
He will have you turn the "root vent off" and take it out, then "drain root vent"
Communicate when Anesthesia starting Protamine to "stop the pump suckers"


CABG (re-op) vs CABG
CABG (re-op) - will set up the operating room normally and will or will not go on bypass.
CABG - will set up the operating room for off pump/standby (pump stays outside of O.R.).
CABG including possible valve - will set up the operating room for off pump/standby (pump stays outside of O.R.).


Conduct of Perfusion for JED:
Pump-flow goals: 2.0 - 2.5 L/min/m2
He would like to maintain a MAP of 50-60 mmHg on relatively healthy patients. For those patients who are of advanced age or who have kidney/carotid disease he would like a MAP of around 70 mmHg
He wants/likes to be notified if hematocrit (21% from the Lab, not I-stat) before adding any packed red cells blood or if you have enough volume to hemoconcentrate to maintain a hematocrit of 24-25
He has no problem with hemoconcentration, but ask that we not pull off too much volume; 1500 to 2000 mL
Consider sending more lab gases plus COAG's, maybe a TEG on the sicker - re-op patients

------------------------------------------------------------

ASD Repair via Mini Sternotomy for JED Central Cannulation

  • 17 Fr Femoral Arterial Cannula (after the case we discussed using a 20Fr EOPA in the future…..he agreed)
  • Bi-Caval Venous Cannulation (SVC-24 Fr Rt Angled Metal Tip; IVC-28 Fr Straight Lighthouse)

Arrested the heart with antegrade CPG  Total CPB Time: 25 min Total X-clamp Time: 5 min Head SATS dropped during the case and JED was made aware. He tried to manipulate the cannulae to improve them, but was unsuccessful. We proceeded with the case and the patient did fine. I went by the unit to check on her the next morning and she was sitting up, extubated, with family members at the bedside

 Clifton Lewis Sternotomy Case Conduct

● Arterial Cannula placed first○ Run it up (to connect)○ Will reposition the arterial line in the holder, this is when you need to test forward flow.○ Let Dr. Lewis know if forward flow is good or not

.● Venous Cannula placed next

● “Let me know” this means if you are RAPing let him know when you are finished. Tell him when you are ready.

● “Go on” or may say “Wait” if he wants to put Retrograde in before going on bypass

● “Volume in” (if retrograde not placed before going on bypass)

● Watch for scrub to grab the Retrograde pressure line. Prepare to flush.

● Lewis will wiggle the line, which means flush retrograde pressure monitoring line (if you are not already doing so.)○ Or Clifton will say “flush your monitoring line”

● Lewis' upper body will shift slightly towards the left, start running cardioplegia . You arenow de-airing octopus○ “Off on Plegia” turn your cardioplegia off. OR “You are open to retrograde, let meknow how it looks”○ Wants you to tell him if you have a good pressure response or not

● Watch for scrub to pass cross clamp Rapid Fire Directions for Cross Clamp

● “Run Retrograde

● “Down on flow”

● “Back up”

● “Change it up”, meaning Clifton is switching the clamps on the octopus to run antegrade. Repeat to him, “running antegrade, clamping the vent”○ TURN ROOT VENT OFF OR CLAMP IT

● Give 1000mL antegrade

● Tell Clifton when antegrade dose is in

------------------------------------------------------------

Dr. Clifton LewisManufacturer / Catalog/Ref.Comments
Aortic Cannula(Will tell what size femoral cannula after cutdown of femoral artery)
ARTERIAL CANNULA 21FR (Lewis)LivaNova / NA-4517ALL Sternotomy cases (Regular)
ARTERIAL CANNULA 24FR (Lewis)LivaNova / NA-4518ALL Sternotomy cases (Larger Patients)                             PLEASE INFORM LEWIS BEFORE PLACING PURSE-STRING SUTURES





ARTERIAL CANNULA OPTISITE 18 thru 22FR W/LLEdward Lifesciences / OPTI18 thru OPTI22Have available for ALL Femoral Cannulation including Robots and Circulatory Arrest cases
PERCUTANEOUS INSERTION KIT ARTERIAL                                       .038 WIRE x 100CMEdwards Lifesciences / PIKAFor OPTISITE Cannulation in Femoral Artery



INTRODUCER SHEATH KIT 19FREdward Lifesciences / IS19A
ENDO-RETURN ARTERIAL CANNULA KIT 21FR (Lewis)Edward Lifesciences / ER21BHave available for all Robot cases
ENDO-RETURN ARTERIAL CANNULA KIT 23FR* (Lewis)Edward Lifesciences / ER23BAll Robot cases (most commonly used)









Venous Cannula(Surgeon or PA to choose femoral cannula once at table)
VENOUS CANNULA 29/37FR (small 3-STAGE)Edward Lifesciences / TF293702ALL Sternotomy cases
VENOUS CANNULA 36/46FR (LARGE 3-STAGE)                     Edward Lifesciences / TF364602PLEASE INFORM LEWIS BEFORE HE PLACES PURSE-STRING  SUTURES





VENOUS CANNULA *HAVE TWO OF EACH*                                                    24FR-28FR STRAIGHT LIGHTHOUSE TIP                                                        (Will use bigger Venous Cannula's if patient is larger)Medtronic / 66124, 66128SVC & IVC cannula for Bi-Caval cases (MVR/TVR) (if patient is <70kg use two 24 Fr Lighthouse)
VENOUS CANNULA 30FR STRAIGHT LIGHTHOUSE TIPMedtronic / 66128IVC cannula for Bi-Caval cases (MVR/TVR)
VENOUS CANNULA 24FR RIGHT ANGLE LIGHTHOUSE TIPTF030LOccasionally use on Bi-Caval cases IVC (for larger patients)
1/2" x 3/8" X 3/8" Y CONNECTORMedtronic / 6040Use with ALL Bi-Caval cases



FEMORAL VENOUS CANNULA 60CM                                                   15 thru 27FR MULTI BIOMEDICUSMedtronic / 96600-015 thru Medtronic / 96880-027Minimally Invasive and Robotic cases
All Femoral Cannulation cases
1/2" x 3/8" STRAIGHT CONNECTORMedtronic / 6013
AVALON VASCULAR ACCESS KITMaquet / 12210Use with any Femoral Cannulation & OptiSite



CARMEDA FEMORAL ARTERIAL CANNULA 18CM                                15FR BIOMEDICUSMedtronic / CB96535-115TAKE TO ROOM FOR ALL MINIMALLY INVASIVE AND ROBOTIC CASES (used as Venous Cannula for Bi-Caval cannulation)


3/8" CARMEDA COATED TUBING (6ft)Medtronic Used for venous line from IJ cannula (attach directly to reservoir)









Cardioplegia Needle (Aortic Root Vent)

CARDIOPLEGIA ANTEGRADE NEEDLE 16GA (Green cap)NovoSci / 201010-000All cases except Robotics



CARDIOPLEGIA MULTI-Y W/ VENT (Octopus II) (Lewis)Medtronic / 14001All cases except Robotics



RETRO CARDIOPLEGIA CATHETER 14FR (Lewis)Edward Lifesciences / RC014All cases using Buckberg Cardioplegia (not used on Robotics)



CORONARY ARTERY CANNULA 4 and 6MM STRAIGHTVitalcor / 315804 and 315806Any AI, AVR or Aortic Dissection cases, have open on field


.
INTRA-CLUDE INTRA-AORTIC OCCLUSION DEVICE 10.5 FREdward Lifesciences / ICF100All Robot cases (Aortic Occlusion and Antegrade Plegia)



PROPLEGE PERIPHERAL RETROGRADE CARDIOPLEGIA DEVICE Edwards Lifesciences / PR9Retrograde Plegia - Robot cases                                                Anesthesia should discuss with surgeon if Retrograde used






Cardiac Sump

INTRACARDIAC SUMP 20FR (Plastic)Medtronic / 12112Use on ALL MVR's and use 2 on Robots and Aortic Dissections






LV Vent

LEFT-HEART VENT 16FR RIGHT ANGLEMedtronic / 12016For AVR or Aortic Aneurysm cases - have available for MVR's






Ancillary or other Supplies

SENSOR OXIMETER ADULT (NIRS)Covidien / SAFB-SMALL cases - 2 each
PACING CABLE EXTENSION 6' (Screw-Down)Remington / FL-601-97ALL cases - 2 each except Minimally Invasive have 1 available
TUBING ORGANIZERSurge / 213-003ALL Sternotomy cases
TOURNIQUET KIT (Clear & Color)Medtronic / 79006Suprasternal TAVR's / not needed for regular cases
SUCTION TUBE - 6FR SHAFT W/FRAZIER TIPMedtronic / 10050CHECK WITH SCRUB-NURSE - SHOULD COME IN CVOR NURSE PACK! / ALL CABG cases (CO2 Blower ONLY!)






PLEASE REMEMBER TO CHARGE FOR ANY EXTRA NON-REGULARLY USED ITEMS

Please make sure there is a (RTP) Rectal Temperature Probe on ALL RENAL COMPROMISED AND CIRCULATORY ARREST CASES!
WARNING: the following dialogue from the surgeon is often softly spoken…if not "YOU WILL HEAR HIM NEXT TIME!"

Techniques and Notes for Clifton
Initiation of CPB:
Sits on stool for IMA harvest, then changes gown
ALL perfusion lines passed off after patient draped, let recirculate for a few minutes, then "clamp at pump and field"
After he says "give the heparin" and ACT is "200 seconds", "turn #3 pump sucker on"
He will ask for, “run it up” to connect arterial line to cannula
As soon as he repositions arterial line in holder, "test forward flow"
If Surgeon and Anesthesia agree that is  safe to "RAP" this patient (optional); Then communicate with anesthesia, and begin arterial RAP. Venous cannula goes in next, as soon as Venous in, he will say “let me know” = RAP venous line. Once RAP complete say “ready to go on” or “waiting on ACT” (ACT >400 sec)
"Go on" bypass.  Leave a "little volume in" for retrograde insertion
Next sequence done quickly:
Watch for scrub to pass pressure line to Lewis.  He will reach and wiggle the line.... THIS IS YOUR SIGN TO FLUSH (Retro.)PRESSURE LINE
"Run your Plegia" (to de-air octopus)
"You are open to Retrograde" let Clifton know if you get a good coronary sinus pressure response. THEN TURN IT OFF!
When ready to clamp: "Run your Retrograde"(make sure Root Vent is on)
"Flow down"
"Clamp is on, Flow back up"
"Change it up" (He will switch you to Antegrade, clamp your Root Vent off)
Give "1000mL Antegrade"(may give a "few hundred retrograde" once Antegrade in)
Tell at "12 or 15 minutes on Plegia" doses, add 5 minutes thereafter
End of sequence…


Cardioplegia (Buckberg only):
Setup pump with a Retrograde Cardioplegia Transducer with a 60 mL syringe to flush monitoring line up to field (set alarm limits HIGH!)
Initial Buckberg Antegrade dose will be 1000 mL.  If using Vitalcor's, will run RCA and LCA at the same time, flow around 250ml. (Only on AVR with AI)
With Vitalcor's, watch line pressures, He will pinch cannula, let him know IMMEDIATELY
Retrograde pressure monitored at pump.  Keep pressure at 40-50 mmHg 
May or may not give Retrograde for Initial dose.  All subsequent doses 200ml Retrograde on CABG
He wants to be reminded every "12 or 15 minutes since Plegia" plus every 5 thereafter. (DO NOT SAY CP!!!)
Will add vein grafts as they are completed to run "GO" with Retrograde 200ml dose
Run Warm (blood only, retrograde) Start when x-clamp comes off, during partial occlusion for proximals. "Warm off" "drain it" (open stopcock on top of CP purge line!)


del Nido Cardioplegia for ROBOTS, DISSECTIONS & VALVE's and w/o CABG:
Setup pump with a Retrograde Cardioplegia Transducer with a 60 mL syringe to flush monitoring line up to field (set alarm limits HIGH!)
Initial del Nido Antegrade dose will be 1000mL at a rate of 200-300 mL's and a pressure of 250-300 mmHg
Remind at "30 minutes since del Nido" (unless different reminder time requested by surgeon) then typically re-dose at 60 minutes
Re-dose of del Nido will be determined by surgeon
Cases with AI ask about del Nido before you spike the bags (tell him EF and RV Function)


Temperature Control:
Drift on temps, but no lower than 35°C (Rewarm when on IMA / Rewarm when seating the valve)
Will usually communicate when to warm, rarely he will forget, so pay attention
If more cooling is necessary, he will communicate the temperature. (FYI: If patient has renal disease; have RNFA use 'rectal temp probe' instead of using foley.)

For Circ. Arrest Cases Prep Heater/Cooler: Have plenty of fresh ice cubes inside H/C tank to facilitate rapid cooling. Then have full tray of ice with two empty buckets, will be needed for longer cooling time and large patients.
Aortic Arch or Aneurysm or Dissections including Circulatory Arrest cases: He will cannulate the Axillary artery using an appropriately sized OptiSite (Femoral or Axillary) Cannula                                                                                                                                                                                                                                                                                                                                                                 
Go on bypass at 34°C then immediately start cooling patient core to 26-28°C or up to forty-five minutes of cooling.                                                                                      (LET HIM KNOW IF HEART FIBRILLATES!)
SPECIAL NOTE; when "heparin is given" or sometime before, have circulator to cool the room all the way down and turn off the patient warming pad.
Will run retrograde Cerebral Perfusion through a 24Fr right angle lighthouse venous cannula at 10 mL/kg
Tell him "every 10 minutes of Circ. Arrest" Time
When time to go back on, open both lines, filled the graft, then clamped the cerebral perfusion line, worked pump flow up to full and began re-warming.
SPECIAL NOTE; have circulator to warm the room up a little and turn on the patient warming pad.


Termination of CPB:
"Lungs up"
"Volume in"
"Beat-through" come down on flow and hold more volume in
"Come down and off"
Communicate with anesthesia while filling in if you need help with pressures
Expects you to fill patient quickly and come down on flows
Let Lewis know when you are at "1 Liter"
"Come off Bypass" if patient is stable and pressures are good
"Run the Medicine" (anesthesia to give protamine)
Communicate when Anesthesia starting Protamine to "stop the pump suckers"


Conduct of Perfusion for CTL:
Pump-flow goals: 1.6 - 2.2 L/min/m2
He would like to maintain a MAP of 50-60 mmHg on relatively healthy patients. For those patients who are of advanced age or who have kidney/carotid disease he would like a MAP of around 70 mmHg
He wants/likes to be notified if hematocrit 21-22 before adding any packed red cells blood or if you have enough volume to hemoconcentrate to maintain a hematocrit of 24-25
He has no problem with hemoconcentration, but asks that we not pull off too much volume; 1500 to 2000 mL
Consider sending more lab gases plus COAG's, maybe a TEG on the sicker - re-op patients
On TVR and Redo's if patient on long term anticoagulation therapy per-op. Please get 2FFP ordered to be put in pump right before termination of bypass.                           Let him know you have them ordered and will put in pump.






Dr. Lewis Robotic Procedure  

  1. Venous Cannula placed first

    1. Make sure venous line is clamped, clamp will be removed from line at the field.
  2. Arterial Cannula placed next

    1. Run it up (to connect)
    2. “Positive” (keep positive pressure (forward flow) on the arterial line.
    3. “Test Forward Flow” (make sure you can get up to full flow, or close, with acceptable line pressures)

      1. Be sure to let Dr. Lewis know if you think there will be any problems with the flows and line pressures.
  3. Endoclamp prepared for insertion

    1. Arterial line is clamped, and balloon is placed
    2. “Test your forward flow” (after balloon in in place you will test forward flow again

      1. Because the endoclamp and your arterial flow share the same lumen of the Endoreturn cannula, line pressures can be high.
      2. Be sure to let Dr. Lewis know if you think there will be any problems with the flows and line pressures. 
    3.  “Antegrade and Vent”

      1. You are not on bypass at this point.  Clamp arterial line proximal to filter.  Open recirculating line on oxygenation, turn on arterial pump. 
      2. Turn on root vent (~200 mL/min) Run cardioplegia (just a bit faster than vent)
    4. “Plegia off”
    5. “Root Vent off”
    6. “Flush from above and below, and zero” (flush the balloon pressure monitoring line at pump, let him know it is zeroed)

      1. Flushing p legia and zeroing the balloon pressure will happen almost simultaneously.  Be prepared.
  4. Docking of the Robot

    1. This is the point in time where I begin to RAP.

      1. Be sure to communicate with anesthesia.
      2. DO NOT let the systolic pressure drop down below upper 90’s

 Chest is CO2 pressurized.  If Systolic pressures drop below the 90’s, with CO2 pressurizing the chest, when the pressure is released, pressures will drop substantially and cause problems. 


    1. “Are you ready”
    2. Dr. Lewis is asking Perfusion if you are ready to go on bypass
    3. Give him an answer
    4. “Go on”
    5. Turn on Root Vent

      1. It is good practice to make this a part of your on bypass procedures.  As it will already be on when the endoballoon is ready to be inflated
  1. Atriclip placement

    1. “Down on Flows”

      1. Because the aorta has to be pushed to the side, flows need to be dropped while Dr. Lewis and Richard are working. 
      2. Dr. Lewis will tell you when to come back up, if he doesn’t, you come back up when he releases the Aorta.
  2. Inflation of Endoclamp balloon and Induction dose of plegia

    1. Keep pressures in the mid 50’s during the duration of the clamp time. 

      1. Any higher than 65 mmHg and you run the risk of pushing the balloon though the Aortic Valve, and damaging it.
      2. Any lower than 50 mmHg and you run the risk of the balloon moving back in the aorta and occluding/cutting off flow to the innominate artery. 
      3. Always keep an eye on the white pressure line, to make sure it doesn’t drop/deviate from the red pressure line
    2. ROOT VENT MUST ALWAYS BE ON ANYTIME THE BALLOON IS MANIPULATED
    3. “Root Vent On”
    4. Watch for Magenta pressure to drop on monitor
    5. Watch for any signs of Right (White) artline dropping out
    6. “Run your antegrade”

      1. Turn on antegrade

 PHYSICALLY CLAMP THE VENT LINE 



      1. Watch for Magenta line to rise to match the art lines.

 Try to keep the pressure on the Ao (Magenta Line) below or the same as systemic pressures Some patients have short, or small aortas.  This will cause the Ao pressure to be higher than the systemic pressures.  Just keep a close eye on the Right (white) art line to make sure it doesn’t drop out. 


    1. “What is your balloon pressure?”

      1. If you do not tell what balloon pressure is after you have said antegrade is running, you will be asked.
      2. Respond with the balloon pressure, monitored on the pump.
    2. Give 1L antegrade
    3. Once dose is in. Turn off plegia and turn on root vent.  Watch for Magenta line to drop.  Will read with a (?) because the monitor can only read to a certain negative pressure
    4. Once negative pressure on aorta is achieved, turn root vent down to a creep.
  1. As the atrium is opened, turn your LV vent and #3 sucker on high.
  2. Watch to make sure you are draining adequately and keep the right heart from distending
  3. Some patients the endoballoon may push into the atrium, and make some stitches difficult to place.

    1. These stitches will be the ones placed first, and the positioned in the upper left corner of the annulus.
    2. As Dr. Lewis begins to take a bite of the annulus with suture, go down on flow a bit
    3. After needle is pulled through the annulus come back up on flow.
    4. No need to drop flows with the second needle of the same stitch.  It only goes through the ring/band
  4. Removal of Cross Clamp (EndoClamp)

    1. “Take the clamp off”

      1. When the atrium is almost fully closed
      2. Pull back on syringe attached to the balloon pressure monitoring line
      3. Toggle back to reading pressure to check numbers
      4. Continue to pull saline out of balloon until you have reached a negative pressure reading on the balloon
  5. Robot has now become a standard pump case
  6. All commands from this point forward are standard to all of Dr. Lewis’s cases

WHAT'S NEEDED FOR PR9


FOR CASES WITH PR9 (Coronary Sinus Catheter placed in neck by Anesthesia) 

  • 3/16” line
  • 3/16” “Y”
  • 3/16” adapter with male luer
  • Cut the connector off the plegia circuit outlet
  • Place on 3/16” Y to outlet of Cardioplegia circuit
  • Connect single leg of 3/16” Y, to the 2” piece of 3/16” tubing on outlet of Cardioplegia circuit
  • Place remainder of 3/16” tubing on 1 leg of 3/16” Y
  • Place dead-ender cap on one leg of 3/16” Y
  • Place 3/16” adapter with male luer on end of 3/16” tubing
  • Attach to reservoir with a stopcock.
  • This will allow you to prime the 3/16” tubing and recirculate through it to remove air
  • After lines have been passed up to the table.  Run the 3/16” line with the male luer adapter up to anesthesia. 
  • Anesthesia will attach it to the appropriate stopcock
  • Have anesthesia attach a syringe to the stopcock, close it to the patient, so you can de-air into the syringe.
  • After all air is gone, open stopcock to patient.  Making sure that PA pressure is reading the retrograde pressure.  And test the retrograde.
  • Make sure you get a pressure response
  • You need to ramp up your retrograde flows fairly quickly.  You don’t want to be giving plegia forever.  Just a quick up and down to make sure you get a pressure response.
  • PRESSURE SHOULD BE VERY SIMILAR TO A NORAML RETROGRADE CATHETER
  • If only small pressure response wait until you are on bypass and you can check it again. 
  • Pressure may be better when the heart empties out, if there is a large coronary sinus
  • If still no pressure response, have anesthesia add more volume to the balloon.

Please keep Dr. Lewis in the loop at all times about if the retrograde is working or not. 

Dr. Eudailey Circulatory Arrest Notes   When handing lines from the sterile field to attach to the pump: 

-- Have Scrub hand off the Medusa with the Y attached. 

-- Hook up ⅜” tubing end to the pigtail off the arterial filter.  (This is where you would normally hook up the arterial line when handed from the field) 

-- CLAMP THE ¼” TUBING OF THE MEDUSA 

-- When the arterial line of the AV loop is handed off attach it to the open leg of the Y connector.  

-- Secure tie band 

-- After attaching Venous line to reservoir, remove clamp from arterial line of AV loop and recirculate like normal 

-- Attach and secure tie bands to all connections made on the ⅜” x ⅜” x ¼” “Y” connector 

-- While pump is recirculating, slightly open clamp on ¼” line of the Medusa, to de-air 

-- Run fluid up

 -- Once fluid is at the level of the table, clamp the ¼” line of the Medusa Going on Circulatory Arrest:

 -- Kyle will say, pump off for Circulatory Arrest 

-- Stop forward flow, turn off vacuum 

-- Clamp Main Arterial line 

-- Leave Venous line open 

-- Open oxygenator recirculation line, and begin recirculating the pump 

-- Start giving retrograde cardioplegia 

-- Do not run any flow through medusa until Kyle asks for it 

-- Remove clamp from ¼” Medusa 

-- You will run up to de-air 

-- Will start flowing 8-10 ml/kg down one head vessel 

-- Kyle will add another head vessel cannula, will let you know when it is opened 

-- Keep head saturations at acceptable levels, increase flow to keep them up.  (Even if you are flowing over the 10ml/kg.  If flows will not keep head saturations up, please let Kyle know.) Notes of Interest: 

-- Tell Kyle when is “Heart Fibrillating”, Kyle will place LV vent (WILL USE 20FR LV VENT, DO NOT PASS UP A 16FR

-- Let Kyle know at 30 minutes of cooling 

-- Will want to know at 60 min on Cardioplegia 

-- After that tell every 30 min 

-- Once circulatory arrested let Kyle know every 10 min of circulatory arrest time Coming off Circulatory Arrest: 

-- Will have you run Antegrade cerebral and open arterial line to de-air the graft and get ready to resume full flow

------------------------------------------------------------

Dr. Kyle EudaileyManufacturer / Catalog/Ref.Comments
Aortic Cannula
(Communicate)
ARTERIAL CANNULA 21FR SOFT-FLOW EXTENDED        (Eudailey)Terumo / 4949SMALL arterial use SMALL venous < 90 kg
ARTERIAL CANNULA 24FR SOFT-FLOW EXTENDED               (Eudailey)Terumo / 4951LARGE arterial use LARGE venous > 90 kg



ARTERIAL CANNULA OPTISITE 18 thru 22FR W/LLEdward Lifesciences / OPTI18 thru OPTI22Have available for ALL Re-Op or any Aortic - Circulatory Arrest with Aorta or Femoral Cannulation cases
PERCUTANEOUS ARTERIAL INSERTION KIT                                      .038 WIRE x 100CMEdwards Lifesciences / PIKAFor OPTISITE Cannulation in Aorta or Femoral Artery



 3/8" x 1/4" CONNECTOR W/ LL CARMEDAMedtronic / CB4620Use on (1/4")8mm side-arm Aortic Dacron graft - cannulation



QUAD ANTEGRADE CEREBRAL PERFUSION - MEDUSSALivaNova / 627391101ALL Circulatory Arrest using Antegrade Cerebral Perfusion
For Total Arch cases, wait to open Arterial Cannula until Kyle decides












Venous Cannula
(Communicate)
VENOUS CANNULA 29/37FR (small 3-STAGE)Edward Lifesciences / TF293702SMALL arterial use SMALL venous < 90 kg
VENOUS CANNULA 36/46FR (LARGE 3-STAGE)Edward Lifesciences / TF364602LARGE arterial use LARGE venous > 90 kg



VENOUS CANNULA 24 thru 28FR RIGHT ANGLE METAL TIPMedtronic / 69320 thru 69328SVC or IVC cannula for Bi-Caval cases
1/2" x 3/8" x 3/8" Y CONNECTORMedtronic / 6040Use with ALL Bi-Caval cases

 
FEMORAL VENOUS CANNULA 60CM                                                 15 thru 25FR MULTI BIOMEDICUSMedtronic / 96600-015 thru Medtronic / 96880-025Have appropriate sizes available for ALL Re-Op or TAVR or Lead Extraction cases for Femoral Cannulation
1/2" x 3/8" STRAIGHT CONNECTORMedtronic / 6013Use with Biomedicus Femoral Cannula if needed
AVALON VASCULAR ACCESS KITMaquet / 12210Use with any Femoral Cannulation & OptiSite









Cardioplegia Needle (Aortic Root Vent)

CP AORTIC ROOT CANNULA 12GA(9FR)                                   W/ FLOW-GUARD (Eudailey)Medtronic / 11012ALL cases



CARDIOPLEGIA MULTI-Y W/ VENT (Octopus II) (Lewis)Medtronic / 14001ALL cases



RETRO CARDIOPLEGIA CATHETER 14FR (Lewis)Edward Lifesciences / RC014ALL cases using Buckberg (Blood) Cardioplegia



CORONARY ARTERY CANNULA 4 and 6MM STRAIGHTVitalcor / 315804 and 315806Any AI, AVR or Aortic Dissection cases, have open on field



RETRO CARDIOPLEGIA CANNULA MANUAL INFLATE 15FRMedtronic / 94915ALL Valve cases + Any Cerebral Perfusion (have 2 available)
RETRO CARDIOPLEGIA CANNULA MANUAL INFLATE 13FRMedtronic / 94113TCerebral Perfusion Smaller patients when requested
RETRO CARDIOPLEGIA CANNULA MANUAL INFLATE 10FRMedtronic / 94110Smaller patients when requested



CORONARY ARTERY CANNULA 10FR - 14FR
Aortic Root Replacement, Any case involving reimplantation of


the Coronary Buttons
Cardiac Sump

INTRACARDIAC SUMP 20FR (Plastic)Medtronic / 12112VALVE cases / use on #2 - yellow sucker pump









LV Vent

LEFT-HEART VENT 20FR RIGHT ANGLEMedtronic / 12002Pass up on all cases that need a vent
LEFT-HEART VENT 16FR RIGHT ANGLEMedtronic / 12016When requested - smaller vent









Ancillary or other Supplies

SENSOR OXIMETER ADULT (NIRS)Covidien / SAFB-SMALL cases - 2 each
PACING CABLE EXTENSION 6' (Screw-Down)FL-601-97ALL cases - 2 each
TUBING ORGANIZERSurge / 213-003ALL cases
TOURNIQUET KIT (Clear & Color)Medtronic / 79006When requested
INTRACARDIAC SUMP 12FR (CO2 Diffuser)Medtronic / 12013Use as 'CO2 diffuser' on Left-sided open-heart cases
SUCTION TUBE - 6FR SHAFT W/FRAZIER TIPMedtronic / 10050Lewis/Eudailey Cart / ALL CABG cases (CO2 Blower ONLY!)






PLEASE REMEMBER TO CHARGE FOR ANY EXTRA NON-REGULARLY USED ITEMS




Techniques and Notes for Kyle
Initiation of CPB:
"Give the Heparin"
When heparin is given and ACT is "200 seconds", turn "#3 pump sucker on"
To connect arterial line, "Pump up" will look for air bubbles. Will de-air leur lock. Will say "keep running" (don't stop running slow forward flow until he says "OFF")
Test forward flow when he asks.
If Surgeon and Anesthesia agree that is  safe to "RAP" this patient (optional); Then communicate with anesthesia, and begin arterial RAP. Venous cannula goes in next, as soon as Venous in, he will say “let me know” = V-RAP venous line. Once V-RAP complete say “ready to go on” or “waiting on ACT” (ACT >400 sec)
Once venous cannula is hooked up, will tell you to "go on bypass"
Once on bypass: he will tell you to "run your plegia", turn on the plegia and the root vent to de-air the octopus
He says "pressure down" you turn "pump flow down" and then when "pressure down" as he places cross-clamp on


Buckberg(Blood) Cardioplegia for involving CABG cases:
Setup pump with a Retrograde Cardioplegia Transducer with a 60 mL syringe to flush monitoring line up to field (set alarm limits HIGH!)
Cardioplegia (Buckberg only): (WILL CALL IT "BLOOD CARDIOPLEGIA")
Initial Buckberg dose: 500-600mL antegrade, 500-600mL retrograde. (Retrograde pressure measured on CVP - keep ~40-50mmHg)
Remind on Buckberg at "12 minutes" maybe every 5 thereafter; he will typically re-dose at 15 minutes
Maintenance Dose: 200-300mL of Low K, most likely given retrograde
Ask if doing proximals under one clamp or using a partial
He says "pressure down" you turn "pump flow down" when taking cross-clamp off
Run Warm (blood only, retrograde) Start when x-clamp comes off, during partial occlusion for proximals. "Warm off" "drain it"


del Nido Cardioplegia for VALVE's (without AI) and w/o CABG:
Initial del Nido Antegrade dose will be 1000mL at a rate of 200-300 mL's and a pressure of 250-300 mmHg
Remind at "45 minutes since del Nido" (then 60), unless different reminder time requested by surgeon, (60 - 90 - 120 minutes)
Re-dose of del Nido will be determined by surgeon, (30 - 60 - 90 minutes)


Temperature Control:
Drift on temperatures, do not go below  34°C on the bladder  (Rewarm when on IMA / Rewarm when seating the valve)
If more cooling is necessary, he will communicate the temperature, 32*C down to 22*C.                                                                                                                                                                 (FYI: If patient has renal disease; have RNFA use 'rectal temp probe' instead of using foley.)


For Circ. Arrest Cases Prep Heater/Cooler: Have plenty of fresh ice cubes inside H/C tank to facilitate rapid cooling. Then have full tray of ice with two empty buckets, will be needed for longer cooling time and large patients.
Aortic Aneurysm or Dissections including Circulatory arrest cases: If cannulating the 8mm side-arm of Aortic Dacron graft to a 1/4" x 3/8" connector with a leur to start the case. If using a 10mm Dacron graft, a 3/8" x 3/8" connector with a leur will be used.
OR Kyle will use an OPTI femoral arterial with PIK-A insertion kit to cannulate the aorta
OR Kyle will use normal aortic cannula. (will discuss with you when he enters room for case)
As soon as you go on bypass start cooling patient core down to temperature specified by Kyle. (LET HIM KNOW IF HEART FIBRILLATES!)
SPECIAL NOTE; when "Give the Heparin" or sooner, have circulator to cool the room all the way down and turn off the patient warming pad
He will perform Selective Antegrade Cerebral Perfusion at a rate of 5-15 mL/kg (500 mL) through the Quad Antegrade Cerebral Perfusion - Smart Perfusion Pack "Medusa" (LivaNova / 627391101) and he will let you know how many he will be needing.(start with only 2 for the Carotids)                                                                                                                  15FR retrograde (Plegia) Cannulas "Kyle's" (Medtronic / 94915)
When he is ready to re-establish full pump-flow, he will move the 1/4" x 3/8" connector with luer and re-cannulate using the side-arm of the Aortic Dacron graft, also start rewarming patient core at this time                                                                                                                                       
SPECIAL NOTE; have circulator to warm the room up a little and turn on the patient warming pad
Mini AVR:                                                                                                                                                                                                                                                                                                                           If doing Hemi-Sternotomy use Central cannulation (21 - 24Fr Soft-Flow Extended Arterial and small or LARGE Dual-Stage Venous Cannulas)                                                                  If doing Anterior-Thoracotomy use Femoral cannulation (18 - 22Fr OptiSite Arterial and QD-25Fr Venous Cannulas - like Dr. Lewis)


Termination of CPB:
"Volume in"
"What are you flowing"
Come down to "whatever flow he tells you"
"Come off"


Conduct of Perfusion for Kyle:
Pump-Flow goals: 1.8 - 2.2
May need to drop flow to 1.8 index when heart is lifted on CABG's, due to less than optimal drainage, and Kyle getting flooded.
Maintain MAP of 65-70 mmHg on relatively healthy patients.  
For those patients who are of advanced age or who have kidney/carotid disease he would like a MAP of around 80 mmHg.
Aortic valve cases wean off CPB with MAP of 90-100 mmHg.
Has no problems with hemoconcentration.  
Notify if you think the HCT is low (21% from the Lab, not I-stat). Not opposed to giving blood on bypass.  
If giving FFP, will want this given on bypass, or he may ask anesthesia to order AT3