1.060 Set-Up and Priming of the Bypass Circuit. Perfusion Technology Department. Perfusionists

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1 TITLE/DESCRIPTION: DEPARTMENT: PERSONNEL: Set-Up and Priming of the Bypass Circuit Perfusion Technology Department Perfusionists EFFECTIVE DATE: 8/97 REVISED: 09/07, 04/09, 9/17 PURPOSE: The function of the cardiopulmonary bypass (CPB) circuit permits blood to bypass the heart and lungs into sterile tubing and components that oxygenate and pump oxygenated blood at arterial pressure back to the patient. CPB sustains systemic flow, oxygenation and ventilation during periods of time when 1) the heart is asystolic or not ejecting a normal cardiac output and 2) the lungs are unable to perform physiologic gas exchange owing to inadequate perfusion. The pump priming solution generally consists of a mixture of electrolytes, buffer, mannitol and heparin. If "clear" prime would result in excessive hemodilution, packed red blood cells may be added to the priming solution. EQUIPMENT LIST: 1. Heart-lung machine 2. Oxygenator, Tubing pack, Cardioplegia unit 3. Oxygenator Holder, A/V manifold holder, cardioplegia bracket, and IV pole. 4. CO 2 Flush system specific) 5. Priming fluids (surgeon 6. Clamps CONTENTS: STEPS: KEY POINTS:

2 NOTE: Be sure Heart Lung Machine has been cleaned as outlined in Equipment-Specific Cleaning and Maintenance EQUIPMENT SET UP 1. Carefully check the packaging as the oxygenator is removed. Check connecting ports on the oxygenator and hardshell reservoir for damage. See IFU for vendor specific details 1. If damaged during transport, return to manufacturer for replacement. 2. Place the oxygenator and reservoir into the holder. 3. Connect the water circuit to the oxygenator and circulate for 5 minutes. Check for water leaks. Discard and use standby oxygenator if water is present in the blood compartment. 4. Before proceeding with sterile tubing set-up: Tighten A/V sampling Manifold connections. 5. Using sterile technique and removing caps one by one as connections are made, the circuit may be set up as follows: a. Pump line from outlet of reservoir to inlet of oxygenator. b. A/V loop - oxygentor outlet to venous inlet on reservoir. c. Recirculation line from the cardioplegia port to a 1/4" cardiotomy inlet port. 6. Accessory parts may be set up including: a. Stopcock and purge line with one way valve from arterial line filter (ALF)

3 to top of reservoir. b. Pressure monitor from leur port of ALF/bypass line. 7. Commercial cardioplegic (CPG) delivery system may be set-up. See specific set-up protocol. 8. Date and Initial bottom of Perfusion Open-Heart Disposables Charge/Order Sheet 8. (Dry) Circuit should be discarded if not used in 7 days. PRIMING THE CIRCUIT 9. Begin C0 2 flush through leur port of ALF/bypass line with: 9. A CO 2 flush of the oxygenator is not required, but recommended prior to priming. a. Oxygenator outlet line clamped before the ALF/bypass leur port and bypass line of ALF clamped until AV loop side flushed. b. Remove clamp from oxygenator outlet line and place distal to ALF and continue to flush so as to flush oxygenator side c. CPG delivery port and roller head to CPG delivery system are open. 10. Place sucker and vent lines into roller heads and connect to the 1/4" cardiotomy inlet ports. 11. End C0 2 flush by: a. Occluding CPG roller head or clamp inlet lines. b. Clamp the CPG outlet line from the

4 oxygenator. c. Turn arterial stopcock to the closed position. d. Remove clamp from ALF bypass loop and place on inlet of ALF d. ALF is now isolated. 12. Before dropping prime:. a.. Be sure pump line is in roller head. b. Clamp the cardioplegia line. c. Double check that the purge port of the gas module is open. 13. Drop < 2000ml priming fluids (surgeon specific). 14. Slowly prime the pump line, oxygenator, and recirculation line. Prime A/V loop (ALF isolated) to a 75cm column of water displacement. Set the pump head occlusion by adjusting the occlusion until a 2.5cm drop per minute is achieved. Check occlusions at 6 points. 15. Allow recirculation between the oxygenator and venous reservoir and slowly increase recirculation from 500 ml/min. up to 5 liters/min. 16. Ensure that oxygenator is bubble free and gradually reduce blood flow. 17. Decrease flow to 2L and proceed to prime ALF.

5 a. Open purge line with one way valve on ALF. b. Move ALF outlet clamp to distal position to retrograde fill the ALF via bypass line. 18. Vigorously tap filter to free it of any gross air. Allow time period for recirculation of circuit 19. Prime accessory lines: a. A/V sampling manifold b. Arterial line pressure display. 20. Remove clamps from ALF inlet and distal to ALF. Clamp the bypass line. 21. Debubble all lines by tapping gently at inlets, outlets and connectors. 22. Recheck ALF closely. 23. Open clamp to CPG delivery line. 24. Proceed to priming the CPG delivery system. See specific CPG system protocol. 25. After CPG delivery system is primed, close all stopcocks. 26. Add required medications per surgeon preference. 27. Stop the main pump and clamp the venous and arterial lines. 28. Insert temp probes.

6 INITIATION OF BYPASS 29. Check for adequate levels of anticoagulation prior to initiation of bypass. 30. Remove arterial and venous clamps and gradually increase blood flow and then initiate gas to blood flow ratio of 1:1 with a minimum FiO 2 of 80% or per manufacturers guidelines. OPERATION OF BYPASS 31. Arterial PO2 is controlled by varying the percent concentration of oxygen present in the ventilating gas. - To DECREASE the PO2, DECREASE the amount of oxygen in the ventilating gas by decreasing the FiO 2 on your oxygen blender. - To INCREASE the PO 2, INCREASE the amount of oxygen in the ventilating gas by increasing the FiO 2 on your oxygen blender. 32. PCO 2 is controlled primarily by varying total gas flow rate. - To DECREASE PCO 2, INCREASE the total gas flow rate to increase the amount of CO 2 removed. - To INCREASE PCO 2, DECREASE the total gas flow rate to decrease the amount of CO 2 removed. 33. Patient temperature is controlled by regulating the temperature of water flow into the heat exchanger. TERMINATION OF BYPASS 34. Terminate bypass as individual

7 case and patient condition indicates 35. Turn gas flow off prior to turning off blood flow. 36. Turn off water flow to heat exchanger. 37. After terminating bypass, continue to slowly recirculate through oxygenator using recirculation line and/or reconnected arterial venous loop. REFERENCES: Manufacturers Insert of Instructions for Use. ATTACHMENTS (To hardcopy kept in Department): Use. Vison (Gish) Integrated CVR Membrane Oxygenator, Insert of Instructions for Capiox (Terumo) - Integrated CVR Membrane Oxygenator, Insert of Instructions for Use Affinity (Medtronic) - Integrated CVR Membrane Oxygenator, Insert of Instructions for Use

8 PT1.060ByPasCir Distribution: Perfusion Services