Major Extracorporeal Perfusion

Circulation of blood through an artificial circuit containing a:

Organisation of Service

A hospital providing major extracorporeal perfusion should have:

  • A Head of service
    • Responsible for administration and delivery
    • Usually a cardiac anaesthetist or cardiac surgeon
  • Appropriate staffing
  • Appropriate equipment
  • Dedicated space
    • Easy access to operating theatres and intensive care unit
    • Storage of hardware and disposables
  • Appropriate training
    • Managing patient on bypass
    • Administration of medication
    • Assembly and operation of bypass equipment
    • For anaesthetic trainees training as medical perfusionists, requirements include:
      • At least 12 months
      • 75 perfusions
        The first 50 cases should be closely supervised.
    • Critical scenarios including:
      • Pump head failure
      • Gas in the circuit
      • Oxygenator changeout
    • Maintenance
      • At least 40 cases per year

Equipment

Heart-lung machine should:

  • Meet electrical standards
  • Undergo routine inspection and maintenance
  • Include:
    • Pump heads
      • 3 or more available
      • Alarms
      • Servo-controlled mechanisms
      • Manual override capability
        In the setting of:
        • Low blood resevoir
        • Arterial over-pressure
        • Bubble detection
      • Runaway control protection
      • Display of flow
        In L/min or RPM.
      • Easily calibrated
      • Cranking system
      • Transparent removable covers
    • Gas supply
      • Connect to an indexed piped medical gas system
      • Alarms
      • Emergency oxygen supply
      • Gas flow meters and gas blenders
      • Oxygen analyser
        Either on:
        • Oxygenator gas supply line
        • Oxygenator effluent gas
      • Scavenger
        If volatile agents in use.
    • Heat exchanger
      • May be external or self-contained water supply
      • Water between:
        • 4 and 42°C
        • 10 and 25 L/min
      • Not at pressures ≥600mmHg
    • Monitoring and alarms
      Appropriately positioned, maintained, and calibrated.
      • Low-level detection monitor
        Detects when the blood resevoir runs low.
      • Arterial line pressure monitor
      • Pre- and post-membrane pressure monitor
      • Gas-emboli detector
      • Venous saturation

Clinical Management

Involves:

  • Assembly, checking, and priming of the ECP circuit
  • Completion of pre-bypass checklist
  • Exclusive availability of the perfusionist for that patient
  • Assessment and documentation of coagulation status
  • Continuous assessment of physiology and coagulation during ECP
  • Appropriate flows, perfusion pressures, gas exchange, and acid-base homeostasis
  • Consideration of co-morbid disease
  • Appropriate contemporaneous documentation

References

  1. ANZCA. PS27: Guidelines for Major Extracorporeal Perfusion.