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Aliases:
Pediatric heart lung machine
Ped cbp
Paed CPB
Paediatric cpb
Pediatric cpb
Paediatric cardiopulmonary bypass

Topic aliases are alternate phrasings for a particular topic.


Mechanical circulatory support provided during open-heart surgery, bypassing the heart to facilitate surgery on the heart or major vessels.
The body's venous supply of blood is oxygenated and then pumped back into the arterial system.
The bypass machine also provides intracardiac suction, filtration, and temperature control.
Some of the more important components of these machines include pumps, oxygenators, temperature regulators, and filters. (UMDNS, 1999) www.nlm.nih.gov/cgi/mesh/...

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If heart performance is unexpectedly poor coming off bypass check that the snare over venous cannulae has been removed.

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If systemic perfusion pressures are low after commencing CPB despite adequate flow and little response to vasopressors, consider the potential for a patent ductus arteriosus before too much vasopressor is administered.
Once the surgeon closes the PDA the pressures are likely to improve, and if large doses of vasopressor have been given the pressures after closing the PDA may be a little too generous.

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If there is continuing ventricular ejection whilst on full bypass, this may mean that blood is returning to the left ventricle via a PDA (more common in neonates), or the venous cannulae may be too small or non-occlusive, resulting in venous blood reaching the right heart.

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If, when preparing to introduce a femoral arterial cannula for cardiopulmonary bypass, you discover clots within the femoral artery, consider that retrograde arterial flow from the femoral arterial cannula introduces the risk of intracerebral embolic events.

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Discuss the likelihood of requiring blood to prime the bypass circuit in children less than 10kg.
In larger children this can generally be avoided as the dilution of their haemaglobin by the priming fluid is less significant.

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Tell the parents that it is not unusual for procedures to take much longer than expected, and if this happens it does not mean there has been a complication. #dup

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Bypass circuit

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The pump prime (and hence increase in volume of-distribution for a small child circuit is approximately 400ml, for a large child/small adult approximately 1000ml.

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When planning the case think:
1. What are the haemodynamic goals for this cardiac condition?
2. What blood products will I need to organise ( Blood, FFP, Platelets)?
3. Will a blood in-motion-bag be needed in theatre at induction ( eg redo sternotomy)?
4. Is the patient too high risk to undergo induction in the induction room?
5. Nasal (infant) vs oral (older child) ETT?
6. Is this a redo sternotomy with all its necessary precautions?
7. Will you need tranexamic acid or aprotinin (low vs high pressure sutures) or should you avoid tranexamic acid (eg insertion of small shunt)?
8. Can the arterial line be placed in either arm (is there a BTS)?
9. Do we need to avoid putting lines the femoral artery in case they are required for emergent suction bypass (eg Redo sternotomy)

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Consider performing hourly blood gases on younger children if there is a prolonged period from induction to going onto bypass (eg prolonged redo sternotomy), looking in particular for hypoglycaemia and rising lactate.
#IS

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If the child already has a femoral arterial-line in situ, consider placing a radial arterial-line in addition to this to achieve a pressure trace that better reflects cerebral perfusion-pressure.
Aortic cross clamping will result in loss of the femoral pressure trace.
#DM

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In an emergency where you find yourself with inadequate intravenous access, heparin may be administered by the surgeon through an intracardiac injection.

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Tranexamic acid or occasionally aprotinin may be administered as an antifibrinolytic to minimise perioperative bleeding.

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Although the younger paediatric patients do not exhibit the same haemodynamic side effects seen with the rapid administration of protamine in adults, the older paediatric patients may.
Consider a slow administration in this older age group.
#safety #ref

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Consider running an inotrope (eg dobutamine) coming off the table even if none is immediately required. Patients following bypass will frequently develop a low cardiac output state (LCOS) 6-12hrs afterwards in ICU, and having drug primed in the line will make managing this easier. #DM

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If a gortex shunt is present, consider withholding the tranexamic acid until the patient is heparinised to minimise the risk of shunt thrombosis. #DM

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If the chance of needing ECLS support coming off bypass is high consider using aprotinin instead of tranexamic acid as an antifibrinolytic as it may help reduce fibrin deposition in the ECMO circuit.

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Prime the bypass circuit with 0.2mg/kg pancuronium, 0.5mg/kg morphine. #DM #RCH

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Steroid ( Methylprednisolone) at induction in children <25kg #ref

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When heparin is being administered for full anticoagulation, the central line is more reliable than a peripheral line as the peripheral line is out of view.

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If running a clear prime, consider running an FiO2 of 100% when going on bypass (where appropriate) to increase oxygen content in the context of the expected fall in HCT from the clear prime.
Below is a NIRS reading in a clear prime for an ASD repair related to HCT. #anzcaasm2012 #JS

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When inflating the lungs in preparation for coming off bypass, watch them deflate in the surgical field. If they deflate slowly this may be an indicator of endotracheal tube obstruction requiring suctioning. #IM

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When reinflating the lungs for deairing of the heart maintain a constant inspiratory pressure until deairing is complete.

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For patients that are at high risk of arresting at induction/intubation (eg ALCAPA repair, pulmonary hypertension ), have the patient positioned and prepared up to the stage you are usually about to sterilise the chest.
This means that in the event they require emergent bypass, the patient is already positioned, and lines and pressure areas are taken care of.
Once the drapes are on it is very difficult to do this after the fact.

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For the child > 1yr old -
1. ketamine 10mg/kg plus
2. 0.25mg/kg midazolam in 50ml Syringe.

Running this at 10ml/hr gives an infusion of 2mg/kg/hr ketamine and
50mcg/kg/hr of midazolam

For the child < 1yr old -

Run midazolam 1mcg/kg/min.

#DM

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If needing volume before going on pump and have reached the ceiling of crystalloid or colloid, consider taking some blood from the primed pump circuit.

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Cell salvaged blood taken before bypass has minimal heparin. Therefore, unlike "pump blood", it does not require the ongoing administration of protamine to neutralise it.

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Aim to give as much of the donor blood back as possible within volume limits. The patient will continue to ooze from the chest drain postoperatively, and topping up their haemoglobin preemptively may reduce the risk of being exposed to an additional unit of transfused blood in PICU.

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Children more than 10kg in size having short bypass times (secundum ASD or uncomplicated VSD, and some LVOT repairs), with a good haematocrit, may not require blood to prime the bypass circuit.

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Consider administering 1mg of protamine for every 20ml of pump blood returned to the patient to counter the heparin in the pump blood. #IM

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In the patients coming off bypass in a cyanotic state, aim to maintain a high normal haemoglobin to optimise oxygen carrying capacity.
#AS

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Perform a baseline ACT prior to heparinisation and commencement of bypass

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When suctioning pleural blood, consider filtering this through the cell salvage to remove some of the activated platelets.
#ref

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Handing over to ICU:
Ensure patient has been transferred to ICU monitoring and ventilator, and is stable before performing handover then :
1. 10,000 ft one sentence overview eg "This is a 4yr old with HLHS who has undergone a fairly uncomplicated fontan completion and LP plasty"
2. Overview of patient's history
3. Description of surgical procedure
4. Intraoperative complications
5. Outline cardiac function and support
6. Outline respiratory function and support
7. Haematology, blood products
8. Urine output
9. Lines
10. Other

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SVT may revert to sinus rhythm on injection of cold volume through the central line. (eg 25ml in 10kg child)

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Items to consider during bypass time:
1. Is the heating blanket switched off?
2. What inotropes or vasodilators do you need to prepare for coming off bypass.
3. When are antibiotics next due?
4. What blood products are likely to be required coming off bypass that need to be ordered?
5. Will the lines with inotropes or vasodilators you're likely to need coming off bypass be sufficiently primed by the time they're needed?

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