1. Straight forward Case got Complicated –
Managed quickly with Available Resources
- A Case Report
Sr. Clinical Perfusionist
Mobile: +91 8959907711
2. About the Case
It was a case of CABG + Aortic Valve
A 70 year Male Patient
Single Graft + Valve Replacement
Height – 165cm
Weight – 50kg
BSA – 1.51m2
BFR – 3.63 LPM
3. PUMP Set up
Oxygenator – Affinity NT
Custom Tubing Pack – Medtronic
BCD – Myotherm XP
Cardioplegia – Cold Blood Cardioplegia
Arterial Cannula – Select Series Straight
Plastic Tip (72220Fr)
Venous Cannula – DSSVC (32 x 40Fr)
Cardioplegia Antegrade : Direct Ostial Coronary
Cardioplegia (Dlp 30010,
4. CPB Circuit
Routine pump was set up.
AV Loop : Arterial 3/8 x 3/32
Venous ½ x 3/32
Cardioplegia : ¼ x 1/16 line.
5. Cardioplegia Line Set up
Eventhough we use Myotherm we don’t use High Potassium
and Low Potassium separately
In routine, we give blood through BCD (only for cooling) and
Cardioplegia Solution by syringe pump which is connected to
the CP line at the tip with the help of Straight Adapter (DLP -
Method : To Make an universal pump pack for all cases we
adopted this modifications
In other cases where the Isothermic cardioplegia the same
pump head is used.
At any time We can incorporate BCD - to plan Cold Blood
6. About the Case
Patient was put on CPB as routine and cooled to
Aortic Cross clamp applied.
Direct Coronary Cardioplegia delivered
After some time, Suddenly the Surgical Field
was full of blood………..
7. Incident – So called Accident
WITH CROSS CLAMP
DISPLACED CROSS CLAMP
FLOODED WITH BLOOD
Note: These images or not real images of the patient
8. Incident – So called Accident
First Surgeon Shouted, What’s wrong, field is
full of blood, be on low flows and gradually
stop the pump..
Meanwhile cardiotomy and venting was
increased to maximum
Checked for the cause
It was the Cross Clamp displaced, by the
time it was checked, as per the Instructions
of the surgeon I had stopped the Pump.
Here started the Main Problem …………
9. Incident – So called Accident
As soon as pump was stopped there was a column of air
in Arterial cannula.
If there is column of air in arterial line after reposition x
clamp while the pump in standby position there has to be
air in aorta, aortic arch and its branches.
At Table everyone is panic.
At my side I have no assistance.
Then I asked what was the problem… why
Enquired from Anaesthetist what was the cause.
I Told Anaesthetist to place Patient in Steep
10. CPB Management
First I started Rapid Cooling to initiate
Secondly, Asked surgeon to Put CP needle
in SVC and connect one limb of Y-adapter of
cp line to cannula and applied clamp distally
towards RA. Initiated Retrograde Cerebral
Luckily, We planned for Cold Blood CP in this
patient, so the Myotherm is readily cool (8oC)
11. CPB Management
Slow Retrograde perfusion started at 150ml/min to
Meanwhile necessary medications were given
Head is packed with ice packs
As the flow was given for some time, the deairing
achieved with proper venting of aortic root, again
cross clamp re applied, arterial cannula was
disconnected, deaired and connected. Now the
system is now deaired completely and it is ready
to go on pump.
12. CPB Management
Slowly Arterial pump was started, patient
was completely put on pump the SVC
clamp was removed and the Retrograde
Cerebral perfusion was stopped.
Now, Surgeon proceeded with the actual
surgery and Valve Replacement done with
21mm St. Jude Biocor Tissue valve and
One Saphenous Vein Graft to LAD.
13. CPB Management
Aorta closed with layers.
Slowly patient was rewarmed to 32oC.
Regained the Electrical acitivity
Cross Clamp Removed
Heart Came back with VT/VF, reverted
with Cardioversion and Cordarone
Slowly rewarmed fully and Weaned off the
14. Post Operative Scenario
Patient was shifted to Surgical ICU.
Patient was put on Prolonged Ventilation
After 24Hrs slowly weaning of ventilation
Patient was Awake with all limb movements
Responding to verbal commands
15. Patient as on Today
Today, we are glad and very happy to
have this patient 4 ½ year followup.
Patient is doing well with no complications.
16. Take Home Message
At the time of Crisis, one should not be
panic, As a team we should consider ones
suggestions and follow.
Despite of least assistance, the resources
present at the instance should be utilized
for the benefit of patient.