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