Communication... Surgeon n Perfusion Team

It should be apparent from the preceding sections that any medical procedure as invasive, life-sustaining, and complex in execution as CPB depends on close coordination of activities by all team members. Essential and effective communication provides a means to facilitate such coordination. Instructions or announcements from the surgeon to the perfusionist or anesthesia personnel are necessary during conduct of the operation because CPB is being used to facilitate a surgical procedure. Instructions from the anesthesiologist to the perfusionist also often occur during the period of CPB. All instructions or announcements should be followed by an acknowledgment from the person to whom it was directed. In this manner, errors of omission will be minimized and the surgical procedure can proceed expediently. If acknowledgment does not occur, the communication should be repeated until a response is heard, most often by the intended recipient repeating the instruction to avoid possible errors in interpretation.

The perfusionist should communicate to the surgeon activities that are performed according to protocol or according to surgeon preference. Likewise, the anesthesiologist should communicate activities to the perfusionist that also can affect the conduct of CPB and vice versa. An example would be administration of a vasodilator that can alter the circulating volume of blood and CPB reservoir level. Fluid additions to the CPB circuit should be communicated from the perfusionist to the anesthesiologist because of implications for fluid management after CPB.

Both perfusionist and anesthesiologist are obligated to communicate to the surgeon any significant abnormal conditions they observe. Much of the surgeon's attention may be focused on the surgical procedure, and the perfusionist and anesthesiologist are better able to monitor the key parameters outlined earlier.

Some conditions can occur unexpectedly that may potentially jeopardize patient well-being, including: increased CPB arterial line pressure; sustained decreased venous drainage; nonfunctioning vent or sucker; sustained elevated or low patient arterial blood pressure; elevated CVP, LA, or PA pressures; elevated delivery pressure and/or lower than expected flow during cardioplegia administration; and any potentially life-threatening equipment malfunction or failure. In such instances, immediate communication is required.

Often abnormal situations can occur that are less acute but potentially damaging, including: elevated serum potassium; lower than expected hemoglobin or hematocrit (with or without the expected need for blood transfusion that should be ordered by a physician); higher than expected fluid volume requirements; higher than expected use of vasopressors or need for increased systemic blood flow for decreased systemic vascular resistance; lower than expected mixed S_vO₂; resumption of cardiac electrical or mechanical activity during cardioplegic arrest; and air entrainment in the venous line.

If deep hypothermia and low flow or elective circulatory arrest are required, the surgeon should be notified of the duration of cooling, patient temperature(s), and elapsed times of low flow or circulatory arrest. The frequency for such notification should be communicated to the perfusionist before the procedure or at the time of initiation of low flow or circulatory arrest.

Surgical manipulations of the heart or major vessels may affect CPB. For example, retraction of the heart for surgical exposure may restrict venous drainage or allow air to enter the venous line at the venous cannulation site(s) or through side holes in the cannula exposed to atmosphere if the cannula becomes displaced. Such retraction also may distort the aortic valve, causing aortic incompetence with possible left ventricular distention from flow exiting the arterial cannula. Retraction of the heart may increase or decrease vent return. These conditions should be communicated to the surgeon when they occur, and surgeons should alert the perfusionist when they are displacing the unarrested heart such as when a circumflex coronary artery graft anastamoses is checked for bleeding. Collateral blood flow may partially obstruct the surgical field, necessitating a decrease in CPB systemic flow. Application of the aortic cross-clamp usually is preceded by instruction from the surgeon to the perfusionist to momentarily decrease the systemic blood flow to lower pressure in the aorta. The perfusionist should communicate all changes in systemic blood flow, whether in response to direct instruction or by protocol.