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