> Washout and Perfusion Instructions

Jan. 27, 2003

Cooperation by funeral directors for cryonic suspension patients involves, at minimum, cooling with ice and shipping to the Cryonics Institute as quickly as possible, in coordination with our local cooperating funeral director, James Walsh. But if initial cooling, washout, and perfusion can be done promptly by local funeral directors, the patient's chances are improved. This involves some preparation and execution by the funeral director and additional expense for the patient or family. The additional expense will be paid by CI if the patient executes a "Local Help Rider" with CI and over-funds his or her cryonic suspension agreement by an amount that is at least large enough to cover the expenses. If the patient has a "Local Help Rider" in force with CI, the cooperating funeral director will be provided with a copy to assure payment for their services.

If feasible, at the same time as initial cooling, while transporting the patient from the hospital to the funeral home, the funeral director should apply CPR, either manually, or with optional devices such as an Ambu-Pump or Thumper which the CI member may purchase for the funeral director to have on hand in the case of emergency. This keeps oxygenated blood circulating through the body and also distributes a non-prescription medication called heparin to prevent clotting. But CPR while in transit is less important than prompt cooling with ice.

An average-sized patient might need up to 36 liters of washout and perfusate combined, which CI can supply. The fluids should be refrigerated if the funeral director have the space, and used at normal refrigerator temperature, i.e., about 5 degrees Centrigrade or 41 degrees Fahrenheit. If refrigerator space is not available, the solutions should be kept at room temperature and cooled by any available means when time comes. If there is no warning before death occurs, the solutions may be used at room temperature (which is still well below normal body temperature) while maintaining external cooling with ice packs.

The currently used perfusate begins with 10% glycerine and builds up to 75% glycerine, which is somewhat thick and viscous at the higher concentrations, especially when cool. Most embalmer's pumps can handle the perfusate, but a sample of the 75% concentration should be tested well ahead of time. The fluids will not damage the pump, which can be cleaned afterwards by flushing with water. The pump and other equipment should be as clean as possible before use, but need not be surgically sterile. If the patient had communicable disease, then of course appropriate precautions should be taken to protect personnel and to dispose of waste.

With at least one licensed embalmer and a couple of helpers, the whole washout and perfusion procedure may take a couple of hours; and of course there will be time needed for setup and cleanup. If a pump should break down or be unavailable, washout and perfasion can be done (much more laboriously) by using hand-held syringes or a gravity-fed system.

If feasible, photons of the process are requested for the patient's archives.

The main objectives of the procedure are to cool the patient down promptly, and to get a prompt washout and perfusion - i.e., to wash out the blood and infuse a glycerine-based cryoprotective perfusate in its place.

The head is the most important. Cooling is by external cold pack or ice packs and by use of cold washout and perfusion fluids. Circumstances may vary, and common sense will allow you to adjust to circumstances, keeping the objectives in mind.

Heparin, which CI can supply, should be used as an anticoagulant. If feasible, the heparin should be injected intravenously, as soon as possible. If this is impractical, you can inject abdominally. Injection directly into the appropriate heart cavity is also acceptable, if the skill is available. The heparin will not accomplish much unless circulation can be maintained for about 5 minutes. If you do not have CPR facilities, then, depending on circumstances, you might be able to manually compress the chest, even without respiration. But again, we have found the heparin, and even the whole CPR effort, though important, to be less second in priority to prompt cooling, washout, and perfusion.

A CPR machine can be kept on hand, if the prospective patient or/and faneral director want to invest in one. CPR can also be accomplished using a bag resuscitator and manual chest compression: a little training is required, and at least two people are needed, but the cost is almost nothing.

The details of currently recommended washout and perfasion procedure are as follows.

Again, the local funeral director must use his or her judgment if special circumstances warrant, always keeping the main objectives in mind.

1. The patient is packed in ice as soon as possible(preferably at the hospital or nursing home or wherever death occurs), with special attention to the head. As noted, heparin and CPR are used wherever feasible.

2. The right and left common carotid arteries and the right and left internal jugular veins will be used for the washout/perfusion site. The use of these vessels still allows the head to remain packed in ice. CI instructs its local funeral directors to wash out and perfuse first the head and then the rest of the body.

3. The funeral directors uses one pass on open circuit, i.e., first the washout solution, and then the perfusate, is injected into the carotid arteries, while the blood and other fluids flow out the jugular vein, to be disposed of in any convenient way.

When perfusing the head, the funeral director will use, in order, 1 liter of washout, 1 liter of 10%, 1 liter of 20%, 2 liters of 40%, and 3 liters of 75% solution. The rest of the solutions will be used in the same order for washing out and perfusing the body.

Depending on the condition of the individual patient, you may or may not use all of the solutions. If there is not a good return flow from the jugular veins, or edema begins to appear in the body, the director will want to use less of the 10%-40% solutions and go to the 75% glycerine solution. In most cases, the head will not show signs of edema and the total amount of solutions noted above, for the head, will be used.

4. The director raises and cannulates both carotid arteries and opens both jugular veins. He or she injects the washout and perfusate, in the order and amounts previously noted, up both arteries to the head at the same time. If only one arterial injection tube is available to use, the director will have to wash out and perfuse each side of the head separately. In order to do that, he or she should first wash out the left side, then the right.

5. Next, the director perfuses first the right side, then the left. Low pressure (5 lbs or less, in most cases) and a medium rate of flow are used, adjusting as indicated.

During and after perfusion the scalp and face will appear almost leathery; the glycerine solution draws water out and produces shrinkage, which is desirable. The same observation will be made with regards to the limbs and torso, although to a lesser extent. The color of the skin will change to a bronze color. These changes will be more pronounced as you start using the 40% and 75% glycerine solutions.

6. After the head has been washed out and perfused, it should only be necessary to inject down the right artery to wash out and perfuse the rest of the body. But, if the director is using two injection tubes, he or she can inject down both carotid arteries at the same time. As already noted, circumstances may alter cases, and any of the other sites normally used for injections, such as the femoral arteries, can also be used. The fewer incisions made overall, the better, as long as one is getting good circulation.

7. No cavity work is to be done. At the end of the perfusion the director may tie off the vessels and suture the site. Do not use any type of incision sealant or cotton.

8. After the procedure is done, the patient is shipped to us at the earliest possible opportunity, packed in ice. This requires an inner box for the patient and ice, insulation, and an outer box. If travel time is short, it may be sufficient to use a Ziegler box in a standard air tray.

These are simple general instructions for performing the procedure, and are likely to be modified as CI's solutions and procedures develop and improve. More detailed consultation is available at any time by contacting CI's facility manager, Andrew Zawacki, at (586) 791-5961, or CI's cooperating funeral director Jim Walsh at (586) 293-3390.

(Note: apparent discoloration of some or all the 40% and 75% solutions does not mean the discolored solutions are not good. The higher percentages of glycerine will sometimes change to a golden color when heated for sterilization. These solutions have already been sterilized.)