1. Perfusion Safety,
cardioplegia delivery management
Ns. Ida Tiur Simanjuntak. S.Kep
National Cardiovascular Centre Harapan Kita Jakarta
TAPS Thailand, 2010

3. Perfusion safety ???

4. Safety is a committed respect
for human lives
in which we have
responsibility
(Reed, 1988)

5. Perfusion safety
• Absence of structural and functional damage after cardiopulmonary
bypass
• Protect life and talent and avoid negative social and economical
consequences
• Avoid feeling of personal guilt and maintain team’s reputation

6. Cardioplegia
paralysis of the heart, as may be done electively in
stopping the heart during cardiac surgery,
cardioplegia may be done using chemicals or
electrical stimulation
(The American Heritage, Medical Dictionary, 2007)

7. The problems had reported in case
management cardioplegia delivery
• Failure to add a sufficient amount of Potassium is the most common error
when preparing cardioplegia solutions
• The heating cooling unit may fail and cardioplegia may not be delivered at the
right temperature.
• A simple test is to feel the cardioplegia line during delivery. It should be at the
temperature during delivery and also a mist must form if giving cold
cardioplegia and if using metallic direct cardioplegia cannulae the handle must
cool.
(Patient Management & Perfusion Technique, The Regents of the University of Michigan, 2009)

8. Safety management of
cardioplegia delivery
1. Cardioplegia solution
2. Cardioplegia delivery circuit
3. Cardioplegia delivery technique

9. Perfusion Safety…
I. Cardioplegia solutions
• Preparing cardioplegia solutions
• Cardioplegia solution label  expired date
Check boxes are provided to indicate which solution has been prepared.
• Two perfusionist  check when add the CPG into the solutions
• Blanks are also provided for the initials of the preparer as well as the time
and date of preparation.

10. Content of Cardioplegia Concentrate
• 20 ml (1 ampoule) of DBL Cardioplegia Concentrate
contains:
Magnesium chloride 16 mmol
Potassium chloride (KCl) 16 mmol
Procaine hydrochloride 1 mmol

11. High potassium cardioplegia solution (H):
DBL Cardioplegia Concentrate 2 ampoules
Sodium Bicarbonate 30 mmol
Asering Solution 500 ml
Low potassium cardioplegia solution (L):
DBL Cardioplegia Concentrate 1 ampoule
Sodium Bicarbonate 30 mmol
Asering Solution 500 ml

12. Perfusion Safety…
II. Cardioplegia circuit
• Cardioplegia Roller Pump Calibration
– The cardioplegia roller pump should be calibrated prior to the initiation of
CPB.
• Refer to 4:1 Cardioplegia roller pump Calibration Chart below and
find the appropriate stroke volume for the prescribed 4:1
cardioplegia pump boot.
Cardioplegia Set 4:1 Cardioplegia Boot Diameters Stroke Volume/Revolution
MUF/4:1 CP Set 3/32” & 3/16” 10 ml
Non MUF 4:1 CP Set 3/32” & 3/16” 10 ml

13. Perfusion Safety…
calibration
PRESSURE PUMP

14. III. Cardioplegia delivery technique
A. Flow
 Antegrade cardioplegia
• aortic root to the coronary ostia
• flow 250-350 ml/min
conditions that influence the flow of cardioplegia delivery :
Low flow (below therapeutics dose) :
– Severe widespread coronary artery disease
– Small patient
– Intimal infusion
High flow (above therapeutics dose) :
– Large patient
– Aortic incompetence
– Crossclamp malposition

15. Cont…..
 Retrogade cardioplegia
• Coronary sinus via a retrograde catheter
• Flow 200 ml/min
conditions that influence the flow of cardioplegia delivery :
Low flow (below therapeutics dose) :
 Overinflated baloon
 Too deep insertion of cannula into coronary sinus
 Rotation of heart
High flow (above therapeutics dose):
 Inadequate cardioplegia distribution (severe stenosis)
 Leakage of blood around inadequately filled balloon
 Ruptured coronary sinus

16. B. Pressure
Antegrade :
• Aortic root pressure : 50-90 mmHg
• High pressures (>100 mm Hg) cause difficulty with visualization and may lead
to myocardial edema.
• Low delivery pressures (<50 mm Hg) will result in inadequate myocardial
perfusion or left ventricular distention due to aortic valve incompetence
(Young JN, Choy IO. Aortic root pressure monitoring during antegrade cardioplegia administration.
Ann Thorac Surg 1996;62:1213–4)

17. Retrograde :
• Coronary sinus pressures : 28 - 50 ml.
• Keep coronary sinus pressures mid 30 mmHg as too low
pressures may compromise cardioplegia distribution, while too
high pressures may rupture the coronary sinus

18. • Additionally, delivery of retrograde cardioplegia takes longer compared
to antegrade delivery because of lower flow rates and pressures
employed to prevent the development of myocardial edema and
coronary sinus injury (antegrade cardioplegia is delivered at systemic
pressures).
• Because of this, many surgeons advocate initiating cardiac arrest with
a single dose of antegrade cardioplegia, followed by interval dosing of
retrograde cardioplegia.

19. C. Volume
• Induction dose : 20ml / kgBW for 4 minutes
• Maintenance dose : 10ml / kgBW for 2 minutes

20. Perfusion Safety…
D. Temperature
• Check the heat exchanger and the ice
• Cardioplegia solution temperature is controlled with a dual
cooler/heater unit.
• The cooler portion of the unit is set at 4oC for cold
cardioplegia delivery.

21. Giving Methods Cardioplegic Solutions
Crystalloid cardioplegia
• More likely to be used in pediatric where cross-clamp time of less than
1 hour
• Simple circuit and low cost
• Less oxygen carrying
• When given in large amounts of risk for hemodelution

22. Blood Cardioplegia
• advantage of blood cardioplegia is the blood oxygen carrying capacity greater
than crystaloid,
• Natural buffers hemoglobin
• Is a metabolic substrate carrier and free radical scavengers of natural
• oncotic also increase, preventing edema myocardia
• In some references mention that the blood kardioplegia more effective on long
cross-clamping conditions (> 1 hour)
• Need Potassium is higher than the cristaloid because it will mix with blood.
Usually the ratio is 4:1 (that is usually used in the protocol harkit)

23. Mechanism of myocardial protection with Cardioplegia
• Mechanical arrest (potassium-induced) will reduce oxygen consumption
• Hypothermia will reduce consumption
• Aerobic metabolism can be maintainted with oxygenated cardioplegia

24. Hot Shot
• Given just prior to the removal of the aortic cross clamp.
• "Hot Shot" is delivered retrograde at 150 - 200 ml/min at a
temperature of 32 - 37oC.
• Total dose of 30 ml/kg is ideally delivered over a 2 - 4
minute

25. Conclusions…
Cardioplegia delivery management :
1. Check the cardioplegia solutions
2. Check the cardioplegia circuit
3. Check when cardioplegia is delivery

26. SO……
IF WE GIVE THE GOOD CARDIOPLEGIA
SOLUTIONS WITH THE GOOD CARDIOPLEGIA
DELIVERY MANAGEMENT,,HOPE THE OUTCOMES
OF PATIENT WILL BE GOOD TOO…..

27. Perfusion safety…
safe for the patient and safe for our team…
THANK YOU……