Ebook Principles of miniaturized extracorporeal circulation: Part 2
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Ebook Principles of miniaturized extracorporeal circulation: Part 2
Surgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2patients being operated on minimized extracorporeal circulation (MECC) are impressive, and the net outcome from their use is a stable intraoperative and postoperative course for the patient and a significantly reduced morbidity as well as lower perioperative mortality 11|. However, use of MECC deman Ebook Principles of miniaturized extracorporeal circulation: Part 2ds a close multidisciplinary effort from the surgical team (surgeon, anaesthesiologist. perfusionist) comprising delicate and focused manoeuvres intraEbook Principles of miniaturized extracorporeal circulation: Part 2
operatively as well as a high level of cooperation from the team. Hence, a learning curve for obtaining the best performance is necessary' [2]. RemadiSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2erable learning curve 13J. As a result the report of a reduction in intraoperative blood loss after 50 cases with MECC was explained by this learning curve. Overall, teaching MECC has to be focused in the proper intraoperative setting, the consideration of tips and tricks, pitfalls, and drawbacks of Ebook Principles of miniaturized extracorporeal circulation: Part 2 the technique as well as the manoeuvres which are necessary from each one of the surgical team so as to perform a safe and stable procedure.RegardingEbook Principles of miniaturized extracorporeal circulation: Part 2
surgical strategy, in the set-up the MECC system has to be placed always as close as possible to the right side of the patient’s head and not paralleSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2 cannulation technique for connecting the system to the patient with heparinized cannulae is used. Special care must be taken in managing any active drainage perfusion system, such as MECC. during cannulation procedure. Hence, ’airtight’ cannulation site is secured with two silk ties around the tour Ebook Principles of miniaturized extracorporeal circulation: Part 2niquets and cannula in order to ensure fixation after placement of the cannula. Ascending aorta is cannulated usually with an arterial 24 Fr cannula (Ebook Principles of miniaturized extracorporeal circulation: Part 2
Fig. 5.2). For the venous part a doublestage cannula is commonly used (32/40 Fr is usually adequate): two purse-string sutures and two snares for secuSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2d on the quality of the right atrial appendage tissue. The venous cannula is then also doubly enforced with two silk ties (Fig. 5.3). Lines are connected with due diligence to avoid gaseous bubbles.Fig. 5.1 Position of MECC system as close as possible to patient's headK. Anastasiadis Ct al.. Princip Ebook Principles of miniaturized extracorporeal circulation: Part 2les of Miniaturized ExtraCorporeal Circulation, DOI lO.lOO7/978-3-M2-32756-8_5. © Springer-Verlag Berlin Heidelberg 201351525 Surgical ConsiderationsFEbook Principles of miniaturized extracorporeal circulation: Part 2
ig. 5.2 Arterial aortic cannulation using two pledget-reinforced purse-string sutures (a): the cannula is secured with two silk ties (b).Fig. 5.3 VenoSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2rate positioning of the venous cannula so as to achieve the optimum drainage from the vena cavae hence allowing minimum heart tilling throughout theprocedure. A useful trick is to use a swab externally into the pericardial cavity adjacent IO the IVC compressing the right atrium after positioning the Ebook Principles of miniaturized extracorporeal circulation: Part 2 tip of the cannula accurately into5 Surgical Considerations53Fig. 5.4 Longitudinal positioning of the venous cannula and use of a swab externally intEbook Principles of miniaturized extracorporeal circulation: Part 2
o the pericardial cavity adjacent to the IVC for maintaining adequate venous returnFig. 5.5 Thive-stage cannula for venous return (MAQUET GmbH & Co KGSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2nula has to be maintained continuously since bending or twisting it during heart displacement may result in poor venous drainage (Fig. 5.4). A three-stage cannula was introduced by some surgeons to overcome the issue of poor venous drainage (Fig. 5.5) (4J. This is an interesting modification of the Ebook Principles of miniaturized extracorporeal circulation: Part 2standard cannulation set-up for CPB. However, we advocate alternatively the use of standard cannula along with pulmonary artery (PA) venting which isEbook Principles of miniaturized extracorporeal circulation: Part 2
equally efficient for maximising venous drainage and does not need special consumables. We believe that venting through the PA trunk is the best site Surgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2 measures, it is frequent in MECC for the heart not to be completely unloaded during the procedure and for a persistent coronary flow to be observed in the arrested heart to the majority of patients. This may lead to difficulty in the construction of distal anastomoses in some patients. This minimal Ebook Principles of miniaturized extracorporeal circulation: Part 2, residual perfusion of the arrested heart needs to be elucidated. but it is used as the explanation for improved myocardial protection observed durinEbook Principles of miniaturized extracorporeal circulation: Part 2
g MECC use since it eliminates air embolisation of the coronary system [5|. For this reason, we advocate additional venting through the ascending aortSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2dard venting catheter (c)cardioplegia route, and a line for root pressure monitoring. This vent may be used intermittently so as to alleviate a blood-filled left ventricle, limit coronary' blood flow, and hence make surgery545 Surgical ConsiderationsFig. 5.7 Positioning of aortic root vent using two Ebook Principles of miniaturized extracorporeal circulation: Part 2 pledget-reinforced purse-string sutures (a.b)comfortable. Special concern for not sucking air from the coronary arteries through the vent (which willEbook Principles of miniaturized extracorporeal circulation: Part 2
be entrapped in the circuit) has to Ik undertaken. Continuous monitoring of the aortic root pressure is usually the threshold for venting. FurthermorSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2um. Use of aortic root vent in valve cases is mandatory since the venting line is used for de-airing during reperfusion when the cross-clamp is removed (Fig. 5.7). Redirection of aspirating blood to a cell-saving device has been suggested [6). However, we do not prefer this policy. Venting the heart Ebook Principles of miniaturized extracorporeal circulation: Part 2 and redirecting the blood into the circuit do not modify the system's qualities since there is no blood-air interaction. Thus, integration of an aortEbook Principles of miniaturized extracorporeal circulation: Part 2
ic root vent and using it discontinuously do not renderthe system as semi-closed. Alternatively, intraluminal shunts to the coronary arteries are freqSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2tter myocardial protection. In cases when volume-loaded circulation is present, a soft-bag closed reservoir connected to the circuit is beneficial for facilitating construction of distal anastomoses in a bloodless field.After connecting the patient to the system, special care has to be taken for the Ebook Principles of miniaturized extracorporeal circulation: Part 2 prime volume of the circuit. The short tubing and hence small prime volume of the system is ideal for retrograde autologous priming (RAP). HaemodilutEbook Principles of miniaturized extracorporeal circulation: Part 2
ion can lx? eliminated by using the RAP technique, as we always employ in our patients. It has been demonstrated that RAP in combination with autologoSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2d transfusion [7Ị: it may also improve the postoperative result since low haematocrit during CPB has been associated with adverse outcomes (mortality, morbidity, and long-term survival) after CABG surgery |8|. Generally. RAP contributes to preservation of the haematocrit intraoperatively. However, t Ebook Principles of miniaturized extracorporeal circulation: Part 2his technique prerequisites a relevant strategy and proper manoeuvres from the anaes-thesiologist: limitation of the intravenous fluids during the indEbook Principles of miniaturized extracorporeal circulation: Part 2
uction of anaesthesia and most of times some vasoconstriction using a small dose of phenylephrine. The aim is to withdraw 300-400 ml of blood from theSurgical Considerations5Minimized cardiopulmonary bypass (CPB) systems represent a promising technology in heart surgery. The results from series of p Ebook Principles of miniaturized extracorporeal circulation: Part 2 optimal scenario of full RAP is not always feasible, utilising half RAP which is withdrawing only the prime from the arterial tubing (which comprises the 2/3 of the total priming volume of the circuit) and repriming it w ith autologous blood from the aorta is most of the time enough for avoiding ha Ebook Principles of miniaturized extracorporeal circulation: Part 2emodilution (Fig. 5.8).After going on-CPB, the aorta is crossclamped in the usual fashion, and preservation of the heart is achieved by infusion of CaEbook Principles of miniaturized extracorporeal circulation: Part 2
latiore blood cardioplegia (Fig. 5.9). The initial dose of potassium is usually 5.7 mmol/min. the second dose is 3.4 mmol/min after 20 min. and subseqGọi ngay
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