Bypass question

charles-thor · Jan 13, 2005

I think it totally depends on the institution in which you work. For example, today I had a patient on bypass for removal of a left atrial myxoma. Once she was on bypass, we dripped in some propofol and kept the patient still while the perfusionist pretty much took over i.e. gas exchange, pump flow, ect. I've heard of other places where the perfusionist controls flow, while anesthesia manages SVR, although I'm not sure what benefit this achieves. Also, it seems to vary by intuition with respect to who manages hemodynamics when weaning from bypass (surgery, anesthesia, or perfusion). I'm curious to see what everyone else has to say.

mwbeah · Jan 13, 2005

In my experience, once the perfusionist takes over any agent you give (ie narcs, benzos, etc) is given via a port on the bypass machine. You have to make sure you are administering certain agents because the patient is still metabolizing agents and the pump itself may filter some of the agents as it circulates. The perfusionist does have a vaporizer on the machine and he/she can control MAP with the flow rate through the machine. Granted it has been two years since I have performed anesthesia for open-heart and it was only at one institution. The perfusionist will also control temp. We didn't administer anything via our central lines/IVs until we resumed control, everything went through the bypass port while on pump.

Mike

WntrMute2 · Jan 14, 2005

In my experience, once the perfusionist takes over any agent you give (ie narcs, benzos, etc) is given via a port on the bypass machine. You have to make sure you are administering certain agents because the patient is still metabolizing agents and the pump itself may filter some of the agents as it circulates. The perfusionist does have a vaporizer on the machine and he/she can control MAP with the flow rate through the machine. Granted it has been two years since I have performed anesthesia for open-heart and it was only at one institution. The perfusionist will also control temp. We didn't administer anything via our central lines/IVs until we resumed control, everything went through the bypass port while on pump.
Well I do a lot of hearts these days and while on pump, we monitor Bp and perfusion, we give BZDs and sufenta to adjust Bp and insure amnesia/hypnosis. We occasionally give neo is the perfusionist's attention is elsewhere and the pressure sags. Drips for post pump need to be made, lines changed over, bed heights get adgusted. work area gets cleaned up, drugs for the next case get pulled. Monitoring continues. Not really busy but we continue to work. (Remember to give any drugs proximal to the SVC snare so the pump picks it up, otherwise you may get an unexpected bolus at some point later.) Interestingly, Tenesma pointed out at one time there is/was a trend for MDs (maybe CRNAs too) to leave the room during pump and not have any anesthesia provider in the room during a pump run. YIKES

Tenesma · Jan 14, 2005

I don't really remember saying there was a trend about MDs leaving the room while on pump....

The pump issue depends on the institution, the complexity of the case and the experience of the perfusionist. In a good solid team, the perfusionist knows what to do when and also knows when to ask for assistance. The perfusionist has control over the temperature, the SVR, the flow rate, gas exchange, as well as the occasional volatile (however, they tend to use it more for vasodilation then for amnesia :).... However, at any given moment, if i (or the surgeon) want to make a change we just let the perfusionist know (ie: pick up the flow, change this temperature to that temperature).. It is all about good communication. Will I walk into the hallway or into another OR while on a pump run??? only if the patient is stable on pump and i have a resident (we don't have any CRNAs doing cardiac at our institution) watching the situation....

however, as far as what most people do while the patient is on the pump: catch up with charting, prepare your drugs/blood products for when you come off pump, watch the surgery, do a TEE to evaluate proper placement of a valve (i usually do that as we are coming off pump) and twiddle my thumbs :)

WntrMute2 · Jan 14, 2005

I don't really remember saying there was a trend about MDs leaving the room while on pump....
QUOTE]
Tenesma...sorry if it wasn't you. I remember someone including a link to an editorial that concerned the leaving the OR during pump runs. I thought it concerned MDs and I thought it was your link.

gaspassah · Jan 15, 2005

i may have posted something about that a while back, it was an editorial from the asa website where there were mds leaving the pt once they went on pump. where we do our heart rotation the mds leave the srnas in the room when the pat goes on pump and comes back when the pt is ready to come off.

d