“Most clinicians, when challenged as to what the basis is that they referenced a clinical decision on, will obviously defer to their residency or training program and cite a clinical policy- whether institutionally based, or part of the public domain.”
Welcome to PERFUSION POLICIES 101. This will be a continuing series provided to assist your programs with that one puzzle piece we all run into now and then- that one time that an unexpected patient condition may give you pause…
The intention here is to disseminate some basic recipes that have probably been implemented at countless institutions, for God knows how long. The usual disclaimers obviously apply:
Due Diligence is the Responsibility of the Reader!
Use the information as you feel fit, recognizing that this is information gleaned from multiple sources, it is recruited from the public domain of the internet, with no implied assurance of accuracy- but is cogent, and based on logical and reasonable clinical rationale.
Frank Aprile 🙂
AXILLARY ARTERIAL CANNULATION, ANTEGRADE CEREBRAL PERFUSION (ACP)
Antegrade cerebral perfusion through the axillary artery, in combination with hypothermic circulatory arrest, provides protection to the brain during operations that involve the aortic arch. Axillary artery cannulation may be used as an alternative aortic cannulation site in the presence of a highly calcified aorta or in procedures that the surgeon deem necessary for repair of the aorta and its branches.
- Dacron graft is attached to the axillary artery. (These are now a commonly available preassembled cannulae by Vaskutec)
- Appropriate size arterial cannula is inserted into the graft and tied so tip of cannula is within wound to prevent kinking.
- Dual-stage cannula is used for venous drainage.
- Arterial pressure should be monitored in the left radial artery and/or groin while on cardiopulmonary bypass (CPB), and in the right radial artery during selective cerebral perfusion.
- Cool per surgeon’s request (18-28*C).
- Aortic cross clamp and deliver cardioplegia solution.
- Hypothermic circulatory arrest. Deliver 100% Oxygen at an appropriate rate to lower the CO2 to safe level. Clamp arterial line and allow the pt to drain via venous line, and leave open.
- Initiation of ACP. Surgeon should tell you to flow 10-20cc/kg/min. Right radical pressure should be monitored at this time. Values should be in the 55-80 mm Hg range.
- Open the venous line to allow continous drainage of the cerebral vasculature and monitor cvp.
- Set appropriate FIO2 and sweep gas and sevoflorane if used.
- Arch replacement with graft and increase in flow to all head vessels (20cc/kg).
- If applicable, Surgeon replaces distal graft into descending thoracic aorta, and then cannulates the distal graft for perfusion with second arterial line and cannula.
- Proximal graft is sewn to aortic root.
- The proximal and distal grafts are sewn together.
- Surgeon will tell you to come off ACP.
- Head vessels are clamped, and the graft is deaired by surgeon.
- Full flow will begin, and rewarming through aortic line(s) commences.
- The preferred pressure to monitor during full CPB is left radial or groin pressure. Right radial pressure will often be elevated because of proximity of the cannulation site.