Pediatric and Congenital Perfusion Practice
Standard 1: Development of Institutionally-based Protocols
Standard 1.2: The protocol shall be:
- Approved by the Chairman of Cardiac Surgery, or his/her designee, Director of Perfusion or equivalent, and other relevant clinical governance committees if available.
- Reviewed and revised annually or more frequently when deemed necessary.
Standard 2: Qualification, Competency and Support Staff
Standard 2.2: Perfusionist competency shall be assessed annually to evaluate compliance with departmental protocols. Standard 2:3: The Perfusionist shall attend, participate, and engage in perfusion-related continuing education courses on an annual basis.
Standard 2.4: Support staff shall be available on site to assist the primary Perfusionist during CPB procedures
Standard 2.5: A process to educate, train, and annually evaluate perfusion staff shall be developed and followed.
Guideline 2.1: An individual graduating from an accredited perfusion education program should complete all requirements for American Board of Cardiovascular Perfusion certification within 3 years of graduation.
Guideline 2.2: A standardized process should be developed and followed to identify, orient and educate support staff to ensure they have general knowledge of the duties performed by the Perfusionist, flow of the operation and location of primary and ancillary items required during CPB. Support staff may include a Perfusionist, nursing, technical, or non- technical staff.
Guideline 2.3: American Board of Cardiovascular Perfusion continuing education units (CEUs) should be obtained from pediatric content whenever possible.
Standard 3: Communication
Standard 3.2: The primary Perfusionist shall use a set handoff protocol e.g. SBAR when transitioning the management of the case to a second Perfusionist.
Guideline 3.1: The use of cellular telephone technology in the operating room should be guided by the principles of ST-59 Statement on use of cell phones in the operating room, written by the American College of Surgeons.
Guideline 3.2: Protocol driven communication (e.g. closed-loop), should be utilized to acknowledge verbal commands, verify the content, and reduce ambiguity.
Guideline 3.3: The primary Perfusionist should participate in the post-procedure debrief with the surgical team.
Standard 4: Perfusion Record
Standard 4.2: The record shall include:
- Patient information including demographics and pre-operative risk factors.
- Information sufficient to accurately describe the procedure, personnel, and equipment.
- Patient physiological parameters documented at a frequency determined by institutional protocol.
- Blood gas and anticoagulation monitoring results.
- Signature of the Perfusionist (and all relief Perfusionists) performing the procedure.
Guideline 4.2: The perfusion record should include the signatures of the physician(s) providing oversight for the CPB procedure.
Guideline 4.3: Raw data (e.g. blood flow, pressure and temperature values) contained in electronic perfusion databases should be stored for a time period in accordance with your institution’s policy for retaining electronic patient medical records.
Standard 5: Checklist
Standard 5.2: Checklists shall be included as part of the patient's permanent medical record.
Guideline 5.1: The Perfusionist should use checklists in a read-verify manner where critical steps that should have been performed are confirmed.10 Completion of the checklist should be performed by two people, one person being the primary Perfusionist responsible for operation of the heart lung machine during the intra-operative period.
Guideline 5.2: The Perfusionist should utilize a checklist throughout the entire peri-operative period (e.g. set-up, pre-bypass, initial onset of bypass, prior to cessation of bypass, post bypass, and/or any return to bypass).
Guideline 5.3: The Perfusionist should utilize a checklist for other ancillary perfusion services (e.g. cell salvage, intra-aortic balloon pump, extracorporeal membrane oxygenation).
Standard 6: Safety Devices
- The pressure monitor shall be either servo regulated to control the arterial/cardioplegia pump or to allow interruption to the arterial/cardioplegia flow.
- The pressure monitor shall include an audible and visual alarm.
- The gross/macro bubble detector shall be used to control the arterial pump or to allow interruption of the arterial blood flow.
- The detector system shall include an audible and visual alarm, and be positioned according to manufacturer instructions for use to enable timely identification and action.
- The level sensor shall be either servo regulated to control the arterial pump or to allow interruption of the arterial blood flow.
- The level sensor shall include an audible and visual alarm, and be positioned according to manufacturer’s instructions to allow an appropriate reaction time and a safe operational volume.
- The temperature sensor shall include an audible and visual alarm to prevent high arterial outlet temperatures.
Standard 6.6: A one-way valve in the vent line shall be employed during CPB procedures.
Standard 6.7: A method for retrograde flow avoidance when using a centrifugal pump shall be employed during CPB procedures.
- Examples of retrograde avoidance systems may include the following:
- One way flow valves
- Hard stop detent controls to prevent accidental reduction in pump speed
- Electronically activated arterial line clamps
- Low speed visual and audible alarm.
tandard 6.9: Hand cranks shall be readily available during CPB procedures.
Standard 6.10: A back-up gas supply shall be available during CPB procedures.
Standard 6.11: A back-up battery supply for the CPB machine shall be available during CPB procedures.
Guideline 6.1: A ventilating gas oxygen analyzer should be employed during CPB procedures.
Guideline 6.2: A level sensor should be employed during CPB procedures utilizing a soft shell reservoir.
- The level sensor should be either servo regulated to control the arterial pump or to allow interruption of the arterial blood flow.
- The level sensor should include an audible and visual alarm, and be positioned according to manufacturer’s instructions to allow an appropriate reaction time and a safe operational volume.
- The use of an air bubble detector distal to the outlet can be used utilized as a surrogate level detector.
Standard 7: Monitoring
Standard 7.2: Arterial line pressure shall be monitored continually during CPB.
Standard 7.3: Arterial blood flow shall be monitored continually during CPB.
Standard 7.4: Cardioplegia dose, delivery method, line pressure (antegrade), coronary sinus pressure (retrograde) and ischemic intervals shall be monitored continually during CPB.
Standard 7.5: Patient and device temperatures shall be monitored continually during CPB.
- Patient (e.g. nasopharyngeal, rectal, bladder, esophageal)
- Heart lung machine (arterial, venous and cardioplegia)
- Heater cooler (H20 temperature)
Standard 7.7: Continuous blood gas monitoring shall be used during CPB.
Standard 7.8 Hematocrit (or hemoglobin) shall be monitored continually during CPB.
Standard 7.9: Oxygen fraction and gas flow rates shall be monitored continually during CPB.
Standard 7.10: The percentage of venous line occlusion of the venous occluder shall be monitored continually during CPB.
Standard 7.11: Venous oxygen saturation shall be monitored continually during CPB.
Standard 7.12: Cerebral oximetry shall be monitored during CPB.
Standard 7.13: Arterial blood flow shall be monitored continually at a point in the CPB circuit where it accurately reflects the flow delivered to the patient during CPB (eg distal to intra- circuit shunts).
Guideline 7.1: Carbon dioxide removal should be monitored continually during CPB.
Guideline 7.2: Arterial oxygen saturation should be monitored continually during CPB.
Guideline 7.3: The following patient pressures should be monitored during CPB
- Central venous pressure
Standard 8: Anticoagulation
Standard 8.2: The Perfusionist shall work closely with the surgical care team to monitor and treat the patient’s anticoagulation status before, during, and after the cardiopulmonary bypass (CPB) period.
Guideline 8.1: The surgical care team should determine the target activated clotting time by considering relevant factors; including variability in the measurement of activated clotting time (ACT) attributed to the device’s performance characteristics.
Guideline 8.2: Patient-specific initial heparin dose should be determined by one of the following methods:
- Dose Response Curve (automated or manual)
- Blood Volume
- Body Surface Area
- Heparin level measurement (e.g. heparin/protamine titration or unfractionated heparin level)
- Partial Thromboplastin Time
- Thrombin Time
- Anti Xa
Guideline 8.5: Additional doses of heparin during CPB should be determined by using an ACT and/or Heparin/Protamine titration.
Guideline 8.6: Heparin reversal should be confirmed by ACT and/or heparin/protamine titration.
Standard 9: Gas Exchange
- The individual patient characteristics/risk profile
- Oxygenator type, design and instructions for use.
- Blood flow, temperature, metabolic demand, and cerebral oximetry.
Standard 9.3: Blood gas analysis shall be performed and recorded according to protocol.
Standard 9.4: The use of supplemental CO2 and a microregulator shall be available to optimize blood gas management.
Guideline 9.1: Point-of-Care testing should be considered to provide accurate and timely information for blood gas analysis.
Guideline 9.2: Oxygen delivery and consumption calculations should be utilized to evaluate and optimize gas exchange.
- Oxygen Delivery: DO2 = 10 x CI x CaO2
- Oxygen Consumption: VO2 = 10 x CI x (CaO2 – CvO2)
CaO2 (arterial oxygen content) = (Hb x 1.36 x SaO2) + (0.0031 x PaO2), and CvO2 (mixed venous oxygen content) = (Hb x 1.36 x SvO2) + (0.0031 x PvO2)
Standard 10: Blood Flow
Standard 10.2: Blood flow rates shall be calculated utilizing one of the following methods:
Standard 10.4: Aortic root vent flow shall be monitored and CPB flow shall be adjusted to accommodate for shunting so that total blood flow to the patient is not compromised.
Guideline 10.1: Variance from intended and targeted blood flow should be communicated to the physician-in-charge.
Guideline 10.2: Appropriate blood flow rate should be determined by evaluation of:
- Acid base balance
- Base Excess
- Anesthetic level
- Arterial blood pressure
- Cerebral oximetry
- Lactate burden
- Oxygen delivery and consumption (refer to guideline 10.2 for formula)
- Venous pO2
- Arterial pO2
- Hemoglobin concentration
- Arterial oxygen saturation
- Systemic vascular resistance (SVR)
- Temperature Venous oxygen saturation
Standard 11: Blood Pressure
Standard 11.2: The Perfusionist shall work closely with the surgical care team to maintain blood pressure according to protocol during CPB.
Guideline 11.1: Variance from intended and targeted blood pressure should be documented and communicated to the physician-in-charge to allow for changes in the blood pressure management plan.
Standard 12. Circuitry
Standard 12.2: Both the number and size of shunts within the circuit shall be minimized to prevent steal from arterial blood flow.
Guideline 12.1: The Perfusionist should consider assisted venous return taking into consideration any patient specific contraindications.
Standard 13. Priming
Standard 13.2: When priming with exogenous blood, a circuit prime gas and electrolyte levels shall be obtained prior to initiation of bypass and adjustments made to correct any physiologic abnormalities.
Guideline 13.1: When priming with exogenous blood, the use of prebypass ultrafiltration (preBUF) or washed red blood cells should be used during priming procedure.
Guideline 13.2: The perfusionist should consider matching prime composition to the individual patient values.
Standard 14. Protamine and Cardiotomy Suction
Standard 15: Blood Management
Standard 15.2: The Perfusionist shall minimize the cardiopulmonary bypass (CPB) circuit size to reduce prime volume. See Standard 12. Circuitry
Standard 15.3: The Perfusionist shall calculate and communicate to the surgical team prior to initiating CPB, a patient’s predicted post-dilutional hemoglobin or hematocrit.
Standard 15.4: Minimum acceptable hematocrit during and prior to termination of cardiopulmonary bypass (CPB) shall be maintained according to institutional protocol.
Guideline 15.1: Blood management efforts should include the following:
- Participation in a multidisciplinary blood management team.
- Minimize hemodilution by:
- Matching the size of the CPB circuit to the size of the patient. See Standard 12: Circuitry.
- Autologous priming of CPB circuit, including retrograde arterial and venous antegrade priming
- Biocompatible coating on the surface of all CPB components
- Perioperative blood cell recovery and reinfusion after being appropriately processed.
- CPB circuit blood salvage at the end of the procedure
- Preoperative whole blood removal: Acute Normovolemic Hemodilution (ANH)
- International normalized ratio
- Partial thromboplastin time
- Thrombin time
- Platelet count
- Platelet function analysis
Guideline 15.4: Efforts should be made to reduce the total number of donor exposures and utilize components from the same donor whenever possible.
Standard 16: Fluid Management
Guideline 16.1: The use of modified ultrafiltration (MUF) should be utilized (unless contraindicated) to optimize hemodynamics and hematocrit.
Guideline 16.2: The use of dilutional or zero balance ultrafiltration (ZBUF) should be considered during CPB.
Standard 17: Level of Readiness for Procedures that may require cardiopulmonary bypass
Standard 17.2: One Perfusionist shall be assigned for each such procedure.
Standard 17.3: A heart-lung machine consisting of a sterile extracorporeal set-up and ancillary equipment shall be readily available for the procedure.
Guideline 17.1: The level of readiness for utilizing CPB during a surgical procedure should be determined through consultation with the surgical team.
Guideline 17.2: A heart-lung machine consisting of a sterile extracorporeal set-up and ancillary equipment should be readily available for emergency procedures or as part of disaster planning protocols.
Standard 18: Staffing and On-call
Guideline 18.1: An on-call Perfusionist should be present and clinically ready for unscheduled and emergency procedures within 60 minutes of being called.
Standard 19: Duty Hours
Guideline 19.1: The Perfusionist should receive a minimum of 8 hours of rest period for every 16-hour consecutive work period.
Standard 20: Quality Assurance and Improvement
Guideline 20.1: The Perfusionist should collect data concerning the conduct of perfusion via a clinical registry or database.
Guideline 20.2: The Perfusionist should use such data for quality assurance, and improvement projects.
Standard 21: Maintenance
- Heart lung machine
- Pressure monitors
- Temperature monitors
- Low Level alarm
- Air bubble detector(s)
- Blood flow sensors
- Anesthetic vaporizer
- Oxygen Blender/Flow Meter
- Oxygen analyzer
- Ancillary Equipment
- VAD device
- Cell salvage device
Standard 21.3: The organization shall follow a protocol for perfusion equipment failures
Standard 21.4: Appropriate backup perfusion supplies shall be readily available.
Standard 21.5: The organization shall follow a protocol for acknowledging and addressing perfusion equipment notices (e.g., recalls, warnings, and advisories).
Pediatric and Congenital Perfusion Practice
May 31, 2019
Last Updated Month/Year
September 7, 2023
External Publication Status
Country of Publication
To provide Perfusionists with a framework to guide safe and effective extracorporeal support care to their patients. AmSECT recommends that clinical teams use this document as a guide for developing institution-specific protocols for patients receiving extracorporeal support.
Female, Male, Adolescent, Child
Health Care Settings
Emergency care, Hospital, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
Diagnosis, Management, Treatment
D010477 - Perfusion
congenital heart disease, mechanical ventilation, mechanical circulatory support, Congenital heart disease
American Society of Extracorporeal Technology. American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice. 2017;2(SGEM2016 Conference Proceedings, ISBN 978-619-7105-16-2 / ISSN 1314-2704):1–39.