Simple Steps to Reduce Perfusion-Related Risk in the Cardiac Operating Room

The suggestions provided below are intended only to serve as a general, informal safety and risk management guideline for clinical perfusionists.  

Pre-Bypass

1. Checklists shall be utilized on every case.  This would include
   assembly, priming and initiation of CPB.
2. All medications shall be clearly labeled with name, concentration and
   expiration date.
3. Backup hardware and disposable components shall be immediately
   available.
4. Hand cranks for the arterial pump head and cardioplegia pump should be
   readily available (mounted on the pump)
5. The Perfusionist shall participate in an OR “time-out” procedure.
6. The perfusionist should communicate a patient-specific management plan
   to the OR team prior to CPB including: Cannulation strategy, target
   temperature, hemostasis and blood management and unusual steps.
7. Target blood flow rates shall be calculated prior to CPB.
8. When employing vacuum assisted venous drainage, the perfusionist should
   ensure that all necessary components and safety mechanisms are utilized. 
   Please refer to the VAVD protocol.
9. Cardiotomy suction and vent lines shall be tested with fluid immediately
   after the lines are handed up to the sterile surgical field.
10. A post heparin ACT and/or heparin concentration should be documented and
    announced to the surgical team prior to arterial cannulation. 
11. The arterial line and cannula should be visually inspected for air on
    every procedure.  Inspection should be verbally confirmed by the
    Perfusionist and surgical care team.
12. All CPB-related safety devices available must be used on EVERY CASE
    according to manufacturer recommendations.
13. Protamine should never be drawn up until after CPB has been terminated.
14. The battery backup on the pump should be tested during the assembly and
    priming phase of setup.

 On Bypass

1. The perfusionist should minimize distractions while on CPB (the sterile
   cockpit), and remain in the immediate vicinity of the CPB machine during the
   entire duration of support.
2. The perfusionist should participate in closed-loop communication with
   the surgical team during patient support.  
3. The perfusionist should follow company protocol  with regard to
   cell phone use and texting. All cellular communication, including the
   content of the text messages, is easily discoverable in a lawsuit.
4. The perfusionist should document periods of low blood flow considered
   outside of the prescribed threshold for routine patient care.
5. The perfusionist shall notify the surgeon of any adverse events or
   conduct of care considered below the acceptable standard of care.  Back-up
   clinical and support and Perfusion.com management shall also be notified.  
6. When using centrifugal pump technology, the perfusionist must ALWAYS
   ensure forward flow. Forward flow can be tested after the arterial line is
   connected to the arterial catheter.  It is highly recommend perfusionists
   clamp distal to (after) the arterial line filter.  The low RPM rate shall be
   set no lower than 1200 RPM. The low flow rate alarm shall also be engaged.
7. If the arterial pump fails, the perfusionist shall immediately notify
   the surgeon and call for backup support. The next priority is to restore
   pump flow to the patient.   If the problem cannot be solved quickly, hand
   cranking should be initiated.   If the root cause of the flow problem cannot
   be ascertained, replace the entire CPB pump and circuit if possible.
8. The perfusionist should maintain the venous cardiotomy reservoir level
   according to manufacturer instructions for use (normally 300ml at minimum).
9. The perfusionist must confirm with anesthesia that the patient is being
   adequately ventilated prior to weaning from CPB.

 Post Bypass

1. The cell saver blood collection bag must NEVER be pressurized. Extreme
   caution is required when transfusing washed red blood cells directly to the
   patient from the cell salvage device collection bag.  This is the single
   most common cause of air embolism.
2. The CPB circuit should be kept intact and ready for use until the
   surgeon confirms disposal. 
3. All adverse or unexpected events shall be recorded in the patient
   record.  Consult with management before disclosing information to anyone
   else. When applicable, institution-specific incident reporting forms should
   be completed and submitted.