Cardiac surgery is a high-stakes procedure requiring precision and teamwork. Whether you’re a cardiac surgeon, cardiac perfusionist, cardiac anesthesiologist, or intensivist, ensuring the patient’s safety before bypass is a critical component of the surgical process. One way to mitigate risks is by adhering to a pre-bypass safety checklist.
In this post, we’ll explore the essential components of this checklist, ensuring that your team is aligned and prepared. From verifying equipment functionality to ensuring the right blood parameters, each step in this process plays a pivotal role in delivering successful outcomes. Let’s dive into the details.
Why a Pre-Bypass Safety Checklist is Crucial
Every cardiac surgery involves a delicate balance of patient physiology, surgical precision, and advanced technology. By having a standardized pre-bypass safety checklist, you can:
- Minimize risk during cardiopulmonary bypass (CPB).
- Ensure proper preparation for ECMO or IABP if required.
- Maintain control over patient hemodynamics, ensuring stability during critical phases.
- Identify and correct any potential equipment malfunctions before they compromise patient safety.
Key Components of the Pre-Bypass Safety Checklist
- Patient Preparation
- Verify Patient Identification: Double-check the patient’s name, procedure, and surgical site. This ensures that no mix-ups occur, especially in high-pressure settings.
- Review Medical History and Medications: Confirm preoperative medications, allergies, and any previous surgeries that might affect the procedure. It’s essential for avoiding complications.
- Pre-Operative Blood Work: Ensure that ACT (activated clotting time), ABGs (arterial blood gases), hematocrit, and electrolytes are within the target range. Correct any abnormalities before beginning CPB.
- Equipment Check
- CPB Machine & Circuit: Inspect the heart-lung machine thoroughly, ensuring all tubing is secure, clamps are functional, and pressure settings are correct.
- Cell Saver Machine: Confirm the cell saver is set up and functioning, especially for patients with higher bleeding risks.
- Hemofilters: Ensure that any hemofilter used during CPB is primed and ready for filtration.
- IABP (Intra-Aortic Balloon Pump): If an IABP is indicated, check its calibration, and ensure it is properly positioned and functioning.
- Anesthesia Preparation
- Induction and Sedation: Confirm that the cardiac anesthesia team has reviewed the anesthesia plan and ready access to anesthetic agents.
- Ventilation and Oxygenation: Ensure that mechanical ventilation is calibrated and oxygenation levels are optimized for the patient’s needs.
- Monitoring Systems: Set up continuous monitoring systems, including invasive blood pressure (IBP), central venous pressure (CVP), temperature, and electrolytes. Make sure all alarms and readings are functioning as expected.
- Perfusion and Circulatory Support
- Verify Perfusion Parameters: Ensure cardiac output, mean arterial pressure (MAP), and pulmonary artery pressures are optimized for safe bypass transition.
- Temperature Control: Confirm that the patient’s temperature is stable, and the cooling/heating system is functioning for temperature management during surgery.
- Anticoagulation: Ensure heparin or other anticoagulants are administered to achieve the target ACT before initiating bypass.
- Final Safety Verification
- Cross-check All Patient Information: The surgeon, perfusionist, anesthesiologist, and nurse should reconfirm patient data, the surgical site, and procedure.
- Emergency Protocols: Ensure all team members know their roles in the event of an emergency, whether it’s sudden hypotension, bleeding, or ECMO initiation.
- Communication: Make sure there’s a clear and open line of communication among all team members. A surgical timeout can be beneficial to verbally confirm everything before proceeding.
Essential Tools for Pre-Bypass Safety
- Perfusionists’ Checklist: A perfusionist-specific checklist ensures the heart-lung machine and support equipment are properly set up and ready for use.
- Anesthesia Team’s Checklist: This checklist focuses on anesthetic agents, patient sedation, ventilation settings, and monitoring systems to ensure optimal intraoperative care.
- Surgical Team Checklist: The cardiac surgeon and assisting team ensure surgical instruments, sterile draping, and incision planning are finalized. The surgical timeout allows for final verification of patient identity and procedure.
Pre-Bypass Checklist for ECMO Readiness
Some patients may require ECMO during surgery. In these cases, the pre-bypass safety checklist should include additional considerations:
- ECMO circuit setup: Ensure that the ECMO machine is primed and ready to assist with circulation.
- Access points: Double-check the locations for cannulation and confirm with the surgeon and ECMO team.
- Flow and pump settings: Verify ECMO pump settings to ensure smooth operation, with continuous flow monitoring.
Common Mistakes to Avoid During Pre-Bypass
- Skipping Equipment Checks: Don’t assume everything is working without thoroughly checking all machines and systems. Even small malfunctions can lead to catastrophic consequences during surgery.
- Ignoring Blood Parameters: Incorrect ACT, ABGs, or hematocrit levels can cause excessive bleeding or clotting issues during bypass.
- Underestimating Communication: Clear and continuous communication between surgeons, perfusionists, anesthesia teams, and intensivists is vital. Failing to speak up or double-check may lead to preventable errors.
Call to Action
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Pre-Bypass Safety Checklist
- Patient Identification:
- Verify patient’s identity (name, DOB, procedure) against the surgical and anesthesia team.
- Confirm all pre-operative assessments are complete (labs, imaging, history).
- Venous and Arterial Access:
- Confirm proper placement and patency of venous and arterial cannulas.
- Ensure appropriate sizing and securement of cannulas.
- CPB Machine Setup:
- Oxygenator: Confirm proper function (check gas flow and bubble traps).
- Pump Roller & Flow Sensor: Calibrate and test to ensure functionality.
- Heater-Cooler: Verify temperature probes and connections, calibrate system.
- Suction Line: Check for leaks and secure connections.
- Pressure Monitoring: Ensure accurate pressure transducers for venous, arterial, and line pressures.
- Hemoconcentrator (if used): Verify setup and ensure proper priming.
- Sodium bicarbonate, heparin, blood products, and medications: Ensure availability.
- Prime Solution:
- Verify all fluid components of CPB prime (e.g., crystalloid, blood, albumin, additives).
- Confirm the volume of prime fluid and ensure no air bubbles.
- Document any additives and their concentrations.
- Airway and Ventilation:
- Ensure anesthesia team has confirmed endotracheal tube placement.
- Verify ventilation and oxygenation status.
- Confirm adequate sedation and analgesia to prevent patient awareness.
- Hemodynamic Parameters:
- Confirm baseline blood pressure, heart rate, and other vital signs are documented.
- Review any pre-operative medications that may affect bypass initiation (e.g., anticoagulants, blood pressure meds).
- Hemostasis:
- Verify patient has been pre-heparinized (if applicable).
- Ensure adequate heparin dose is available for immediate use after cannulation.
- Circulatory and Metabolic Status:
- Confirm pre-bypass arterial blood gas (ABG) results and adjust accordingly.
- Monitor glucose, electrolyte balance, and hematocrit before starting bypass.
- Team Communication:
- Confirm roles of team members (surgeon, anesthesiologist, perfusionist).
- Review emergency protocols and contact numbers.
- Ensure a debriefing session has occurred for any specific patient considerations.
- Back-up Plans:
- Verify availability of emergency equipment:
- Cell Saver (to salvage blood if needed).
- Intra-Aortic Balloon Pump (IABP), if applicable.
- Extracorporeal Membrane Oxygenation (ECMO) setup.
- Cannulas (backup set for arterial, venous, and possible cardiotomy cannulas).
- Oxygenator with Tubing (ensure backup oxygenator and tubing are ready in case of malfunction).
- Oxygen Cylinder (confirm backup oxygen supply is available and functional).
- Ensure sufficient availability of blood products.
- Verify availability of emergency equipment:
- Document:
- Record baseline CPB settings, medications, and fluid volumes.
- Double-check any allergy history or known complications.
- Final Verification:
- Ensure all systems are “go” and the team is in agreement to proceed
Conclusion
A comprehensive pre-bypass safety checklist is vital for cardiac surgery teams. By adhering to this checklist, you ensure that cardiac bypass surgery runs smoothly, reducing the risk of complications and enhancing patient outcomes. Whether you’re a cardiac surgeon, cardiac perfusionist, cardiac anesthesiologist, or intensivist, preparing for CPB, ECMO, or IABP support, it’s important to leave no detail unchecked.
By fostering effective collaboration, meticulous planning, and constant vigilance, your surgical team can approach each procedure with confidence, knowing that the patient is in safe hands.
Disclaimer
The information provided in this checklist is for educational and informational purposes only and should not be considered as medical advice. Cardiac perfusion procedures must always be carried out by qualified and trained professionals. The checklist is intended to support clinical decision-making, but it is not a substitute for professional judgment, experience, or institutional protocols. Always refer to your institution’s guidelines, and consult with your surgical and anesthesia teams before proceeding with any medical procedures.
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Welcome to Cardiperf.com, your trusted resource for all things related to cardiac perfusion science and cardiac surgery. Founded by experts in the field, our mission is to provide high-quality educational content, guidelines, and best practices to support professionals working in the world of perfusion, ECMO, IABP, and other advanced heart care technologies. We aim to empower perfusionists, surgeons, and anesthesiologists by offering the latest insights, tools, and knowledge to improve patient outcomes in cardiovascular surgery. Whether you’re an experienced professional or just beginning your journey in perfusion, cardiperf.com is here to support your growth and excellence in patient care.
