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

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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

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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