Perfusion Conference/Transplant

Hey Everyone! I hope everyone is having a great time at their clinical rotations! So Brett and I had the opportunity to speak at a perfusion conference at Lake Tahoe that was organized by Stanford. I gave a case presentation on an adult male who we successfully weaned from ECMO after about 48 hours. He had congenital issues as a kid and had 2 surgeries as a child, then came into Stanford in July for a PVR that went relatively well with few complications. After he was discharged, he was home for about 7 days before coming back into Stanford complaining of SOB. Once admitted, they realized he was hyponatremic (Na+ was 120!) due to aggressive diuresis (he has CHF). So he was in the hospital for another 6 days when they decided to do a pleural effusion, he then arrested. They believe he arrested due to Pulseless Electrical Activity, which I had not heard of before and if you haven't either, google it! It's pretty interesting...the simple way of saying it is that the patient has electrical activity (including an active ECG) but the heart is not contracting (therefore there is no pulse). Anyways, we put him on V-V ECMO that same day, kept him on it for about 48 hours, then weaned him from it. He kept failing his swallowing test, so the biggest issue with him is that he couldn't put on weight, making him extremely weak. Eventually, he was discharged from the hospital about 20 days after he was weaned. He is now back in Hawaii where he is from and really enjoying life! It was such a cool experience following him during his entire stay at the hospital! So that's what I presented at the conference. Brett gave a really interesting presentation on coated tubings, which had a ton of information on it. I'm sure he would love to explain his findings to anyone who wants to hear more about them :)

The other cool thing I did yesterday (which some of you might have saw on my facebook status) was I got to go with the surgeons to harvest the donor organs for a heart-double lung transplant. So we took a private jet to the hospital, and I got to watch the entire surgery of removing the donor organs. It was so cool to see all of the other organs besides the heart and lungs (since we have seen those now multiple times haha)! All of the organs had such vibrant colors, I couldn't believe it. The donor was only 13 (sad story) so the organs were all very healthy. We then flew back and I watched them implant the new heart-double lungs into the recipient. It was so interesting to see the entire process of how organs are harvested, transported, and implanted, so if you guys are given the opportunity to do this, I would definitely recommend it!! It was a LONG day since I had already been in the hospital for a scheduled surgery then went back at 12:20 am that night and finally went home around 3 pm so I was a little sleepy but definitely worth it!!

Anyways, I hope everyone is having a great experience!! I heard the new class is even more talkative than we are haha Hopefully we will be seeing each other again in New Orleans for the AmSECT conference!! Talk to you guys soon :)

New Toys at MCCG

Hey I just wanted to show everyone our fun new toys at MCCG. We finally got the new Sorin S5 heart-lung machines, and new heater-coolers (that self clean)!!! We are very excited about them, and I can't wait to pump a case with them. At a later date we will have the new Gem Premier 4000 ABG machines. For the new students that come next year will probably have electronic charting! I will let you know how our first case goes with the new machines.

Sonya Mollohan

Minimally Invasive Robot

Here at Spectrum we have 2 surgeons who perform many of their valves and myxomas via the DaVinci Robot system. The system is very cool, they typically start by grafting the arterial line to the femoral artery (which is great for the line pressure!), they Y the venous and place a venous cannula in the femoral vein up to the inferior vena cava and then into the jugular vein. They also typically try to place the retrograde catheter in via this route as well, but sometimes this can be difficult to accomplish. There are 2 to 3 incisions made, typically one large incision between the costals to reach the right side of the heart. Once all of the arms of the robots are in place the RNFA or the PA will usually place the arms and readjust, replace, readjust the arms as the surgeon needs it. Bypass is typically run as normal, go on early and stay on with vacuum assist as needed. There is really no large differences in our job which is nice, plegia is typically given both antegrade and retro (if they can place it). The system is a nice set up, the surgeon is right next to you working the robot which makes it nice for communication, the actual preparation for surgery takes a bit longer but the outcomes are phenominal being that there is no sternotomy. If you come across this type of pump case, it is interesting and a great learning experience! Don't be afraid of the DaVinci!

Spectrum Health, Grand Rapids Michigan

Spectrum is really a great clinical observation site if you want to stay busy and work with some great teachers. There are 8 male perfusionists at Spectrum and all have been working here for no less than 10 years. They have 6 surgeons and are very busy. There has not been a day during the week since I have been here that I haven't had a case (or two) to pump. There are some specialties that the perfusionists do, like ECMO, VADs, Minimally invasive robotic cases, pediatrics, etc. In two weeks there will be a new surgeon adding to the mix that will be here solely for Heart and Lung Transplants (world renowned surgeon, I hear). Soon they also will be opening up the children's hospital where they will (most likely) be adding new pediatric surgeons. The hospital itself if beautiful, and the cardiac team has been extremely welcoming. The learning experience is great, you sit in front of the pump early (week 1), and they give you a lot of responsibility early on, let you decide which cases you want to do, and work with you on your schedule if there are any conflicts. You do take call, depending on how many students are here with you, I for instance switch with another student who's here, so every other week and weekend. The perfusion department here is extremely respected here by the surgeons and the cardiac team, if you have questions about the site, please email me! malia.goozen@azwebamil.midwestern.edu

Frustration!

Since this blog was made to inform and to educate I have been dealing with some frustration. Nothing at Washington Hospital Center. It has to do with anesthesia. There was a case that I pumped a few days ago that caused the frustration and today enforced this. The patient was small which means small blood volume and low Hgb. The case was a CABG and we were doing many grafts. We went on and the case was going exceptionally well. We maintained a steady volume and were approaching the end of the case. At WHC we use the CDI 500 (absolutely love it!!), as we are approaching the end of our case we had a resident anesthesiologist walked over and looked at our CDI and notice the Hgb was close to 7.5. He immediately walked over and began to check a unit of blood. WHAT!? We had been doing all that we could to increase the Hgb, (Hemoconcentrating, mannitol, etc.) He had already planned on giving this patient a unit of blood based only on 1 number. We also use the Sominetics Cerebral Monitoring (love it too!) the only thing that was a little off was the Hgb, all the other blood gases and monitors were good. It was really upsetting that someone on our cardiac team can destroy all of the efforts that were made for blood conservation, and give blood.

The educational part of this is there needs to be involvement of every member of the team, education is the foremost. This resident didn't look at "the big" picture but focused on only one thing. The perfusionist that I was with was livid. She couldn't believe what she was seeing. She truly was a "patient advocate". I learned that it is my job to stick up to anyone no matter who it is or what the issue is, the patient has a right to the best service. All of this so the anesthesia resident didn't have to work too hard.

Thus the issue today, another small patient, another small Hgb. Prebypass anesthesia gave over 2 liters. The estimated post dilutional hematocrit was 6.3, we ended up priming with one unit of blood. Turns out we had plenty of volume (it was a valve) and could have hemoconcentrated while on bypass to help with the Hgb. Patient did great ended with a Hgb of 9.8 and anesthesia gave over 3.5 liters is a bypass run of just over an hour.

My learning points. 1. Don't jump the gun when deciding to give blood, wait and see what the first gas comes back with before adding. 2. Be more aggressive when RAPing, and VAPing, even if I need anesthesia's help in getting pressure up so I can accomplish this task. 3. Use all of the tools to put together an action for each patient not just a single number. 4. Don't treat a number! Treat a patient.


Greg

About MCCG

Well I guess I will give some of the new students some info about the Medical Center of Central Georgia. We are busy all the time, we currently have 2 students here and we each average about 2 cases a day. Although some days and with certain surgeons maybe 3 cases a day. Perfusion is in charge of all of the cell savers used in all ORs, so if you aren't pumping a case you are probably running a cell saver. So know how to calculated estimated blood loss because they will be asking!!!! We use ACD as an anticoagulant for cell savers, so its setup is quick and easy. Our cell saver is the Medtronic Autolog which we use because of its small footprint. Right now we have the Medtronic Bio console centrifugal pump, with COBE century roller pumps for the vent and suckers, and the MPS Quest for cardioplegia. By the way you will love the quest it truly is one of the best perfusion devices ever created...I have seen a spontaneous conversion to normal sinus rhythm within about of minute after cross clamp removal on 99.5% of all of my cases. I literally believe we have only had to shock 3 of my hearts since I have been here. Truly love this device! We will however, this month be switching to the Sorin S5 heart-lung machines, new blood gas machines, new heater coolers, and possibly electronic charting (don't worry the quest will be here for you to love and enjoy). The staff in the OR is very friendly, but like all ORs politics play a major role, so smile nod and keep quiet for those fun things. Oh...and when a surgeon stops turns around and yells at you just smile and nod, in the end surgeons don't like issues or deviations from normal. Learn to be quick, and always, always anticipate the next step because sometimes the surgeon may not give you a command you understand, and if you know where they are then you know what they want. We have 4 Cardiac ORs and a large CVICU. We control IABP while in the OR and help with insertion in the OR, but the nurses manage the IABP while in the CVICU. Right now we do not used PRP but they did used to do it here, and the supplies are available for you to learn how if you choose. Get used to low volume in your reservoir because almost all of your cases will be 300cc's or less in your reservoir. Last but not least learn a little about the Abiomed Impella LVAD and Tandem Heart LVAD because they both here at this hospital. My final bit of advice...if you don't know something be honest because they love to teach and explain things..some of them like to quiz you and some of them like to give you homework assignments!

Sonya Mollohan

Changing out a reservoir

So to many this may seem interesting...why would you need to change out your reservoir???? Well you will need some background info to understand this one. We had a patient that was in for surgery on a descending thoracic/abdominal aneurysm and CABG. This was the patients 3rd CABG procedure and first aneurysm repair. The approach was a gigantic left thoracotomy extending almost to the groin incision for vein harvest and femoral cannulation cut down. We have a surgeon that has an interesting but effective method for these type of aneurysm repairs, which may also be common at other centers that I am not aware of. We cannulated both arterial and venous femorally, using a Terumo cannula with an 8mm graft already attached for the arterial cannula, and a femoral cadiovasions cannula for the venous side. Here is the interesting setup, a Wye is placed on both the venous line and arterial line from the pump. The second arm of the Wye's are connected with 3/8 tubing, i.e, a bypass line. Normally during the bypass run this bypass line is clamped. However, when the heart becomes too empty because these procedures are done beating heart, the surgeon will clamp the arterial line and open the bypass line to fill the heart by pumping blood up the venous side. Since the aorta is clamped out we have to monitor for both lower and upper body pressures which are completely dependent upon the pump flow. If you flow too high you unload the heart too much and the pressures fall in the upper body. This is really a true balancing act. I had 3 clamps on my venous line when we finally went on bypass so I didn't drain the patient too much. So enough about the setup. After the surgeon did the CABG off pump, they dissected out the aneurysm and determined that we would not be able to clamp the distal portion of the aorta. So we essentially went on sucker bypass. The surgeon clamped our arterial line and opened the bypass line, and all volume was transfused to the patient via the venous side. The lower body of the patient was not being perfused during this period. While on sucker bypass we had 3 suckers on the pump with an additional reservoir setup for the cell saver draining back into our pump (since we use ACD for anticoag in cell savers it was shut off since its a calcium chelator). We had to give 4 units of PRBCs while on sucker bypass, added a hemoconcentrator into the circuit because we did not get the opportunity to RAP the patient. After being on sucker bypass for about an hour we were running our blood through the oxygenator recirculation line trying to keep the blood warm as the patient was cooling down because of the large incision. When we opened the recirculation we noticed our reservoir volume was decreasing significantly even though we were not transfusing to the patient. After adding more volume to the circuit and attempting to open the recirc line again blood began to over flow the reservoir filter and we decided that if we had to go on full bypass that this reservoir was not going to make it. So we had to change out the reservoir. Since this was a beating heart we pumped as much blood as we could into the patient before diverting blood elsewhere to give us a cushion for change out time. We shut off all pump suckers, reconnected those lines to the new reservoir immediately, along with the hemoconcentrator lines, second cell saver line, and all VAVD lines as well. Pumped all remaining volume in the reservoir (just below the outlet of the reservoir) into prime bags. Clamped the outlet, (since there was already clamps on the inlet we just used those) and swapped lines to the new reservoir. We dropped about 500 cc of normosol and 10000 U heparin to wet the filter and prime some of the reservoir, we then recirculated the volume again through the recirc line to remove any air. Finally, we dropped our blood back in the circuit, turned on the suckers, and re-hemoconcentrated some more. We actually would not have ever gone on full bypass if this patient's temperature did not drop so low, but we made a full conversion to bypass to rewarm for about 30 minutes. Surprisingly this patient is doing well. They were extubated in less than 12 hours, sitting up and talking, had good kidney function despite being in chronic renal failure (and no renal perfusion for over an hour), has not received any products since being in surgery, tomorrow will be removing their spinal drain, and hopefully going home soon after that. These are the type of cases that truely amaze me how much patients can handle and how quickly they can bounce back!

Sonya Mollohan

Tandem Heart turned ECMO turned Oxygenator Change Out!

Well here in Macon we generally don't do ECMO cases, so this was a first for a lot of people. So, I thought I would let everyone know how our first case of ECMO is going at MCCG, since it is a very interesting case. We had a patient scheduled for surgery yesterday for a Redo AVReplacement and CABG. The patient was also scheduled to have the Tandem Heart put in (this is also the hospitals first experience with the Tandem Heart as well). The patient had their first AVR in March as a Mini AVR with a tissue valve, in end stage renal failure, and was readmitted several time for pulmonary HTN after the surgery. Due to continued CAD, valvular dysfuction, and CHF the patient was admitted for surgery. Yesterday, the bypass run was relatively uneventful except we had to give several units of PRBCs. The patient was put on the Tandem Heart cannulating the femoral vein using a transeptal cannula into the left atrium and the femoral artery. After the surgery the patient was stable until a few hours after their lungs began to fail, so we added in an oxygenator to our circuit. We also had to pull the transeptal cannula out of the left atrium to sit in the right atrium, so the lungs could rest while on ECMO. The patient became relatively stable on ECMO, and with attempts to wean this morning the patients lungs seem to be recovering. There was some miscommunication issues in that the respiratory therapist thought they were also supposed to wean from the ventilator. As we weaned to 21% fio2 the patient did well until the ventilator a little while later was also at 21% fio2, and before we could establish the ventilator was being weaned we had a fun surprise from the oxygenator (pics attached). We had plasma strike-through after 17 hours on ecmo with the Medtronic Affinity NT oxygenator, thus warranting an oxygenator change out. We did a change out which went relatively smoothly, and we are currently awaiting a Quadrox oxygenator from Emory in ATL if we need to do a second change out. We did at one point attempt to wean the patient from the Tandem Heart altogether to see if they still needed it, and now we believe the patient is in right heart failure. As it stands now we will start weaning the patient again tomorrow and determine if a biVAD is needed, otherwise we will need to re-advance the arterial cannula back into the left atrium to assist the left heart after oxygenation is no longer needed.

Here is how we did the change out, which will be easier to understand from the photo of the circuit setup. We used an standard pump pack, using the arterial filter and bypass lines. We removed the arterial filter, and shorted the bypass line reconnecting it to the 3/8 wye. We have a small pump setup for left heart bypass cases, and we setup the reservoir and connected the bypass tubing to the inlet and out of the new oxygenator for priming. We used normal saline to prime without heparin because the patient was still bleeding quite a bit from the chest tubes. A dead-ender was attached to the oxygenator recirculation port since this port would not be needed. Finally, we clamped the tubing just outside the bypass line on the inlet and outlet of the oxygenator and transferred it to the patient. Since the Tandem heart was off the lines to the patient were clamped, and for the reconnection of the lines we used what is called a wet technique. A person using a syringe of normal saline fills the tubes with fluid as the connections are made as to make sure there is no air in the lines after connection. We could have considered bleeding the lines from the patient but that would have been a bloody mess, and when the patient is sitting at a hematocrit of 18 this is not a wise choice. Once connected and air free the Tandem Heart pump was turned back on and all clamps removed expect the clamp for the bypass line. Let me know if you have any further questions!

Sonya Mollohan