1. Special Cases Brian Schwartz, CCP March 20, 2003 Perfusion Technology II

2. Special Cases No case is the same No case is the same A good perfusionist is always prepared for the unexpected A good perfusionist is always prepared for the unexpected The perfusionist needs to be aware of the equipment and special needs for these type of cases The perfusionist needs to be aware of the equipment and special needs for these type of cases

3. Special Cases to be aware of…. Repair of Ascending Aorta Repair of Ascending Aorta Repair of Descending Aorta Repair of Descending Aorta Aortic Dissections Aortic Dissections Circulatory Arrest Circulatory Arrest Operating on the Pregnant Women Operating on the Pregnant Women Cold Agglutinins Cold Agglutinins Jehovah’s Witness Patient Jehovah’s Witness Patient

4. Operating on the Pregnant Patient Changes a women undergoes during pregnancy Changes a women undergoes during pregnancy –Increased heart rate (80-90 beats/min) –Increased cardiac output by 30-50% –Increased respiratory rate

5. Operating on the Pregnant Patient Statistically, the operation is relatively safe for the mother The death rate for the fetus is 50% Surgery is done only if the mother’s life is at risk

6. Time period when it is safest to operate on the pregnant woman First trimester First trimester –Extremely dangerous time period because the fetus is susceptible to hypoxia and drugs Third trimester Third trimester –Also extremely dangerous time period. Surgery during this trimester may cause premature labor

7. Time period for operating(cont) Second Trimester Second Trimester –Considered to be the safest time for both the mother and the fetus –Even though this is the safest time period to operate on the pregnant patient…surgery is only performed when the patient’s condition is life-threatening

8. Anti-coagulation Considerations Heparin Heparin –We may use heparin because it does not cross the placental barrier Coumadin Coumadin –Crosses the placental barrier –If patient is on previous to getting pregnant, it needs to be stopped

9. Peri-operative Considerations Need to prep patient on her left side, elevating the right flank Need to prep patient on her left side, elevating the right flank Need a fetal heart monitor Need a fetal heart monitor Patient’s blood volume will be 90-100 ml/kg Patient’s blood volume will be 90-100 ml/kg Need adequate venous reservoir for the excess volume Need adequate venous reservoir for the excess volume Hct kept around 22-25% Hct kept around 22-25%

10. Considerations (continued) NEVER COOL THE PATIENT NEVER COOL THE PATIENT CI of 3-3.2 L/min/m2 CI of 3-3.2 L/min/m2 MAP for the mother is kept above 65 MAP for the mother is kept above 65 Fetal heart rate above 60 beats per minute Fetal heart rate above 60 beats per minute

11. Controlling Hypertension Never use Nipride because of the risk of cyanide toxicity Never use Nipride because of the risk of cyanide toxicity To help control this type of situation…use hydralazine To help control this type of situation…use hydralazine

12. Controlling Hypotension Drug of choice is epinephrine Drug of choice is epinephrine Epinephrine in these doses acts as a beta stimulant Epinephrine in these doses acts as a beta stimulant

13. Cold Agglutinins An autoimmune reaction An autoimmune reaction They are serum antibodies that work against antigens on RBC’s They are serum antibodies that work against antigens on RBC’s Antibodies mainly involved are the IgA Antibodies mainly involved are the IgA Patients who test positive for cold agglutinins (at certain temps) can not be cooled Patients who test positive for cold agglutinins (at certain temps) can not be cooled

14. Cold Agglutinins (continued) Often found in the cardioplegia Often found in the cardioplegia White percipitate White percipitate Side effects: MI, renal failure, hemolytic anemia and thrombosis Side effects: MI, renal failure, hemolytic anemia and thrombosis

15. Sickle Cell Anemia Caused by hemoglobin S Caused by hemoglobin S An abnormal RBC that is crescent shaped An abnormal RBC that is crescent shaped S/S: blood vessels become occluded, pain, and SOB S/S: blood vessels become occluded, pain, and SOB

16. The Perfusionist’s Plan of Action Patients with the disease need to maintain an oxygen saturation greater than 85% Patients with the disease need to maintain an oxygen saturation greater than 85% Need to avoid acidosis Need to avoid acidosis Hypothermia increases the sickling Hypothermia increases the sickling Hemodilution helps decrease the damage caused by the disease Hemodilution helps decrease the damage caused by the disease A total blood transfusion is necessary at initiation of CPB A total blood transfusion is necessary at initiation of CPB

17. The Jehovah’s Witness Patient JW patients refuse to be transfused any type of blood products…some don’t even allow the use of albumin JW patients refuse to be transfused any type of blood products…some don’t even allow the use of albumin Must follow strict blood conservation techniques Must follow strict blood conservation techniques May use plasma expanders such as hespan or dextran May use plasma expanders such as hespan or dextran We must respect their religious beliefs and not judge them We must respect their religious beliefs and not judge them ALWAYS CHECK YOUR PATIENTS CHART FOR CONSENT FORMS ALWAYS CHECK YOUR PATIENTS CHART FOR CONSENT FORMS