Special CasesSpecial Cases

Brian Schwartz, CCPBrian Schwartz, CCP

March 20, 2003March 20, 2003

Perfusion Technology IIPerfusion Technology II

Special CasesSpecial Cases

• No case is the sameNo case is the same

• A good perfusionist is always A good perfusionist is always prepared for the unexpected prepared for the unexpected

• The perfusionist needs to be aware The perfusionist needs to be aware of the equipment and special needs of the equipment and special needs for these type of casesfor these type of cases

Special Cases to be aware Special Cases to be aware of….of….

• Repair of Ascending AortaRepair of Ascending Aorta

• Repair of Descending AortaRepair of Descending Aorta

• Aortic DissectionsAortic Dissections

• Circulatory ArrestCirculatory Arrest

• Operating on the Pregnant WomenOperating on the Pregnant Women

• Cold Agglutinins Cold Agglutinins

• Jehovah’s Witness PatientJehovah’s Witness Patient

Operating on the Pregnant Operating on the Pregnant PatientPatient

• Changes a women undergoes during Changes a women undergoes during pregnancy pregnancy – Increased heart rate (80-90 beats/min)Increased heart rate (80-90 beats/min)– Increased cardiac output by 30-50%Increased cardiac output by 30-50%– Increased respiratory rateIncreased respiratory rate

Operating on the Pregnant Operating on the Pregnant PatientPatient

Statistically, the operation is relatively Statistically, the operation is relatively safe for the mothersafe for the mother

The death rate for the fetus is 50%The death rate for the fetus is 50%

Surgery is done only if the mother’s Surgery is done only if the mother’s life is at risklife is at risk

Time period when it is safest to Time period when it is safest to operate on the pregnant operate on the pregnant womanwoman• First trimester First trimester

– Extremely dangerous time period Extremely dangerous time period because the fetus is susceptible to because the fetus is susceptible to hypoxia and drugshypoxia and drugs

• Third trimesterThird trimester– Also extremely dangerous time period. Also extremely dangerous time period.

Surgery during this trimester may cause Surgery during this trimester may cause premature laborpremature labor

Time period for Time period for operating(cont)operating(cont)

• Second TrimesterSecond Trimester– Considered to be the safest time for Considered to be the safest time for

both the mother and the fetusboth the mother and the fetus– Even though this is the safest time Even though this is the safest time

period to operate on the pregnant period to operate on the pregnant patient…surgery is only performed when patient…surgery is only performed when the patient’s condition is life-threatening the patient’s condition is life-threatening

Anti-coagulation Anti-coagulation Considerations Considerations

• HeparinHeparin– We may use heparin because it does not We may use heparin because it does not

cross the placental barrier cross the placental barrier

• CoumadinCoumadin– Crosses the placental barrier Crosses the placental barrier – If patient is on previous to getting If patient is on previous to getting

pregnant, it needs to be stopped pregnant, it needs to be stopped

Peri-operative Peri-operative ConsiderationsConsiderations• Need to prep patient on her left side, Need to prep patient on her left side,

elevating the right flankelevating the right flank• Need a fetal heart monitorNeed a fetal heart monitor• Patient’s blood volume will be 90-100 Patient’s blood volume will be 90-100

ml/kgml/kg• Need adequate venous reservoir for Need adequate venous reservoir for

the excess volumethe excess volume• Hct kept around 22-25%Hct kept around 22-25%

Considerations (continued)Considerations (continued)

• NEVER COOL THE PATIENTNEVER COOL THE PATIENT

• CI of 3-3.2 L/min/m2CI of 3-3.2 L/min/m2

• MAP for the mother is kept above 65MAP for the mother is kept above 65

• Fetal heart rate above 60 beats per Fetal heart rate above 60 beats per minuteminute

Controlling HypertensionControlling Hypertension

• Never use Nipride because of the risk Never use Nipride because of the risk of cyanide toxicityof cyanide toxicity

• To help control this type of To help control this type of situation…use hydralazine situation…use hydralazine

Controlling HypotensionControlling Hypotension

• Drug of choice is epinephrine Drug of choice is epinephrine

• Epinephrine in these doses acts as a Epinephrine in these doses acts as a beta stimulantbeta stimulant

Cold Agglutinins Cold Agglutinins

• An autoimmune reactionAn autoimmune reaction

• They are serum antibodies that work They are serum antibodies that work against antigens on RBC’sagainst antigens on RBC’s

• Antibodies mainly involved are the IgAAntibodies mainly involved are the IgA

• Patients who test positive for cold Patients who test positive for cold agglutinins (at certain temps) can not agglutinins (at certain temps) can not be cooledbe cooled

Cold Agglutinins (continued) Cold Agglutinins (continued)

• Often found in the cardioplegiaOften found in the cardioplegia

• White percipitate White percipitate

• Side effects: MI, renal failure, Side effects: MI, renal failure, hemolytic anemia and thrombosis hemolytic anemia and thrombosis

Sickle Cell AnemiaSickle Cell Anemia

• Caused by hemoglobin SCaused by hemoglobin S

• An abnormal RBC that is crescent An abnormal RBC that is crescent shapedshaped

• S/S: blood vessels become occluded, S/S: blood vessels become occluded, pain, and SOBpain, and SOB

The Perfusionist’s Plan of The Perfusionist’s Plan of ActionAction• Patients with the disease need to Patients with the disease need to

maintain an oxygen saturation greater maintain an oxygen saturation greater than 85%than 85%

• Need to avoid acidosisNeed to avoid acidosis• Hypothermia increases the sicklingHypothermia increases the sickling• Hemodilution helps decrease the Hemodilution helps decrease the

damage caused by the diseasedamage caused by the disease• A total blood transfusion is necessary A total blood transfusion is necessary

at initiation of CPBat initiation of CPB

The Jehovah’s Witness The Jehovah’s Witness PatientPatient• JW patients refuse to be transfused any JW patients refuse to be transfused any

type of blood products…some don’t even type of blood products…some don’t even allow the use of albumin allow the use of albumin

• Must follow strict blood conservation Must follow strict blood conservation techniques techniques

• May use plasma expanders such as May use plasma expanders such as hespan or dextranhespan or dextran

• We must respect their religious beliefs and We must respect their religious beliefs and not judge themnot judge them

• ALWAYS CHECK YOUR PATIENTS CHART ALWAYS CHECK YOUR PATIENTS CHART FOR CONSENT FORMS FOR CONSENT FORMS