Perfusion Quick Reference Guide

Quick reference guidance

• These cards provide rapid lookup values for intraoperative use.
• Ranges vary by protocol, patient physiology, and monitoring targets.
• Always integrate pressure, NIRS/EEG, and lab trends when titrating flow.
• This tool is not a medical device and does not replace clinical judgment.
• Content is data-driven for easy updates and includes last-reviewed dates.
• Educational use only; follow institutional and surgeon-directed protocols.

ACP right radial pressure rationale

• Most studies and protocols (Annals of Thoracic Surgery, EJCTS, AmSECT) use right radial artery pressure as a surrogate for cerebral perfusion pressure.
• Unilateral ACP (often via innominate or right axillary/subclavian) directly supplies the right carotid/right brain.
• Consensus target: adjust flow to keep right radial pressure ~40–60 mmHg (or 40–70).
• Left radial artery pressure can be lower due to collateral flow and may under-represent left-sided perfusion during unilateral ACP.

ACP detail (adult reference)

• Flow rate: 8–12 mL/kg/min (≈0.6 mL/min/g cerebral tissue in some references).
• Perfusion pressure: 40–60 mmHg (right radial artery reference).
• Temperature: 23–28°C moderate hypothermia.
• pH management: Alpha-stat to support cerebral autoregulation.
• Duration: up to ~80 min reported in selected/elective cases; varies by center, monitoring, and bilateral ACP—if >40–50 min, consider bilateral ACP.
• Monitoring: NIRS/EEG with baseline/trend and bilateral symmetry emphasis.

ACP detail (pediatric reference)

• Flow rate: 40–80 mL/kg/min (reference ~50–64); neonates ~46 ± 6 mL/kg/min.
• Perfusion pressure: titrate (often 20–25 mmHg reported; higher MAP targets used in some centers).
• Perfusate temp: 18–25°C; many ACP programs favor ~25°C moderate hypothermia.
• pH management: pH-stat is frequently used for neonatal/infant cerebral protection during hypothermia.
• Duration: ~20–48 min (reference); prolonged times reported in selected cases—if longer expected, avoid DHCA when possible and plan ACP strategy.
• Monitoring: Bilateral NIRS (trend-focused) ± EEG; TCD optional (availability dependent).
• Hct: neonatal/infant arch ACP + hypothermia commonly uses ~30–35% as a reference range.
• Higher Hct raises O₂ content but increases viscosity—adjust with pressure/flow plus NIRS/EEG response and follow institutional protocols.

RCP detail (reference)

• SVC pressure: 20–30 mmHg (target 20–25); excessive pressure risks brain edema.
• Flow: pressure-driven; 300–500 mL/min commonly cited to maintain SVC pressure <25.
• Monitoring: NIRS/EEG with baseline/trend focus and bilateral symmetry.
• TCD can be added to track cerebral blood flow velocity.

HCA safety-time notes

• Varies by center, patient factors (age, comorbidities), neuromonitoring (NIRS baseline/trend with EEG), and use of ACP/RCP.
• Always minimize circulatory arrest time.
• Cooling time: at least 20–50 min; Rewarming: ≤0.5°C/min recommended.
• Reference: 2024 EACTS/EACTAIC/EBCP Guidelines (conservative estimates).
• Follow institutional protocols and patient monitoring; educational use only.

MUF detail (clinical reference)

• Role / Indication: Pediatric & congenital: Recommended when no contraindications exist. Adult: Selective use for blood conservation and volume management.
• Flow rate (typical practice): Pediatric: 10–20 mL/kg/min. Adult: 150–300 mL/min. Neonates/low-weight infants: Avoid abrupt flow changes; titrate carefully to monitoring trends.
• Monitoring / Titration (practical): Titrate MUF to NIRS + CVP + arterial pressure trends and overall hemodynamics.
• Core safety rule (critical): Maintain positive arterial line pressure at all times to reduce air entrainment/embolism risk. Practical controls may include shunt/clamp management and centrifugal pump RPM adjustments to preserve a favorable pressure gradient.
• Duration / Endpoint: Typical duration: 10–20 min (adult commonly ~10–15 min). Continue until target Hct and/or desired net fluid removal is achieved; adjust to hemodynamics and monitoring trends. Suggested Hct endpoints (reference): Pediatric ≥35–40%; Adult ≥30–35%.
• Stop criteria (immediate): Air detected / air entrainment risk. Inability to maintain positive arterial line pressure. Hemodynamic instability.
• Anticoagulation: Maintain adequate anticoagulation throughout MUF (commonly with ACT monitoring).
• Inflammation mediator removal (current perspective): MUF may reduce circulating cytokines (e.g., IL-6, IL-8), but evidence for meaningful improvement in hard clinical outcomes is limited. Practical emphasis remains fluid removal + hemoconcentration.
• Edema / neurologic note (pediatric): Supports reduction of generalized edema and may reduce cerebral water content, potentially benefiting neurologic recovery.
• Temperature management: Blood can cool in the external MUF loop; for runs >~10 min, monitor core temperature and consider using a heat exchanger to prevent unintended hypothermia.
• References: AmSECT Pediatric & Congenital Standards and Guidelines (2019, section 16.1). 2024 EACTS/EACTAIC/EBCP Adult CPB Guidelines (blood conservation/ultrafiltration-related sections).