Dreher M, Min J, Mavroudis C
… +6 more, Ryba D, Ostapenko S, Melchior R, Rosenthal T, Nuri M, Blinder J
J Extra Corpor Technol
· 2023 Sep · PMID 37682209
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BACKGROUND: Acute kidney injury after pediatric cardiac surgery is a common complication with few established modifiable risk factors. We sought to characterize whether indexed oxygen delivery during cardiopulmonary bypa...BACKGROUND: Acute kidney injury after pediatric cardiac surgery is a common complication with few established modifiable risk factors. We sought to characterize whether indexed oxygen delivery during cardiopulmonary bypass was associated with postoperative acute kidney injury in a large pediatric cohort. METHODS: This was a retrospective analysis of patients under 1 year old undergoing cardiac surgery with cardiopulmonary bypass between January 1, 2013, and January 1, 2020. Receiver operating characteristic curves across values ranging from 260 to 400 mL/min/m were used to identify the indexed oxygen delivery most significantly associated with acute kidney injury risk. RESULTS: We included 980 patients with acute kidney injury occurring in 212 (21.2%). After adjusting for covariates associated with acute kidney injury, an indexed oxygen delivery threshold of 340 mL/min/m predicted acute kidney injury in STAT 4 and 5 neonates (area under the curve = 0.66, 95% CI = 0.60 - 0.72, sensitivity = 56.1%, specificity = 69.4%). An indexed oxygen delivery threshold of 400 mL/min/m predicted acute kidney injury in STAT 1-3 infants (area under the curve = 0.65, 95% CI = 0.58 - 0.72, sensitivity = 52.6%, specificity = 74.6%). CONCLUSION: Indexed oxygen delivery during cardiopulmonary bypass is a modifiable variable independently associated with postoperative acute kidney injury in specific pediatric populations. Strategies aimed at maintaining oxygen delivery greater than 340 mL/min/m in complex neonates and greater than 400 mL/min/m in infants may reduce the occurrence of postoperative acute kidney injury in the pediatric population.
J Extra Corpor Technol
· 2023 Sep · PMID 37682208
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BACKGROUND: Systemic anticoagulation with heparin during cardiopulmonary bypass (CPB) should be neutralized by protamine administration to restore normal hemostasis. Our previous study showed the protamine-to-heparin rat...BACKGROUND: Systemic anticoagulation with heparin during cardiopulmonary bypass (CPB) should be neutralized by protamine administration to restore normal hemostasis. Our previous study showed the protamine-to-heparin ratio (P-to-H) of 1:1 (1 mg protamine:100 IU circulating heparin; 1.0 Ratio) is likely an overestimation. Thus, we reduced the P-to-H in the HMS Plus Hemostasis Management System to 0.9:1 (0.9 Ratio) for 5 months and then to 0.8:1 (0.8 Ratio). We monitored post-operative (post-op) bleeding in the setting of reduced protamine dose (PD). METHODS: We performed a retrospective study of 632 patients (209 for the 1.0 Ratio, 211 for 0.9 Ratio, 212 for 0.8 Ratio group) who underwent cardiac surgery to measure the reduction of PD and how it affects 24-hour (24 h) post-op chest tube output. We also analyzed the entire data set to explore whether further reduction of P-to-H is warranted. RESULTS: While there was no difference in the indexed heparin dose among the three groups, we achieved a significant reduction in the indexed actual protamine dose (APDi) by 24% (0.9 Ratio) and 31% (0.8 Ratio) reductions compared to the 1.0 Ratio group. On average, APDi was 88 ± 22, 67 ± 18, and 61 ± 15 mg/m in the 1.0, 0.9, and 0.8 Ratio groups, respectively. We found no significant difference in 24 h post-op bleeding among the three groups. CONCLUSION: 1.0 Ratio at the completion of CPB is likely an excessive administration of protamine. With the stepwise reduction of PD, we observed no increase in post-op bleeding, which may indicate that no meaningful increase in heparin rebound occurred. In addition, further analysis of the entire data set demonstrates that a 0.75 Ratio is likely sufficient to neutralize the heparin completely.
Strickland A, Chianella DA, Kavarana M
… +1 more, Savage A
J Extra Corpor Technol
· 2023 Jun · PMID 37378443
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BACKGROUND: ABOi heart transplant has become routine for the majority of children <2 years old. An 8-month-old child with complex congenital heart disease presented to the Medical University of South Carolina Shawn Jenki...BACKGROUND: ABOi heart transplant has become routine for the majority of children <2 years old. An 8-month-old child with complex congenital heart disease presented to the Medical University of South Carolina Shawn Jenkins Children's Hospital in need of transplantation. METHODS: This case report describes the use of ABOi transplantation and describes the details of the total exchange transfusion prior to cardiopulmonary bypass. RESULTS: After a successful intraoperative total exchange transfusion following the ABOi protocol, the patient's isohemagglutinin titers were 1 VC on postoperative day (POD) 1, and isohemagglutinin titer was <1 VC on POD 14. The patient had no signs of rejection and continued to recover. CONCLUSIONS: Successful ABOi transplantation requires planning, an interdisciplinary approach, and clear closed-loop communication. Planning with the surgical and anesthesia teams is necessary for the hemodynamic stability of the patient during the total volume exchange as well as precautions put in place to ensure the blood products used in this procedure are correct. Planning with the lab and blood bank is also necessary to ensure they are prepared with enough blood products and can run isohemagglutinin titers.
J Extra Corpor Technol
· 2023 Jun · PMID 37378442
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A 35-year-old unvaccinated woman, pregnant with twins at 22 weeks and 5 days of gestation presented with worsening hypoxia, due to COVID-19 pneumonia (PNA) with acute respiratory distress syndrome (ARDS). The patient was...A 35-year-old unvaccinated woman, pregnant with twins at 22 weeks and 5 days of gestation presented with worsening hypoxia, due to COVID-19 pneumonia (PNA) with acute respiratory distress syndrome (ARDS). The patient was placed on V-V ECMO (veno-venous extracorporeal membrane oxygenation) and delivered twin babies by cesarean section (C-section) at 23 weeks and 5 days of gestation. The patient was successfully weaned off ECMO 42 days after initiation, and the twins were also extubated in NICU.
Quach HK, Scott BL, Lopez-Domowicz DA
… +3 more, Gambino RM, Evans AE, Ozment CP
J Extra Corpor Technol
· 2023 Jun · PMID 37378441
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Congenital tuberculosis is a rare infectious disease with less than 500 cases documented worldwide. Mortality is significant, ranging from 34 to 53%, and death without treatment is inevitable. Patients exhibit nonspecifi...Congenital tuberculosis is a rare infectious disease with less than 500 cases documented worldwide. Mortality is significant, ranging from 34 to 53%, and death without treatment is inevitable. Patients exhibit nonspecific symptoms such as fever, cough, respiratory distress, feeding intolerance, and irritability which can make appropriate diagnosis challenging in Peng et al. (2011) Pediatr Pulmonol 46(12), 1215-1224. Tuberculosis prevalence is particularly high in developing countries where access to resources can be limited in World Health Organization (2019) Global tuberculosis report 2019, Geneva. We present a 2.4-kg premature male infant with acute respiratory distress syndrome secondary to congenital tuberculosis caused by Mycobacterium bovis and tuberculosis-immune reconstitution inflammatory syndrome who was successfully supported with veno-arterial extracorporeal membrane oxygenation.
Branigan B, Brown S, Zavala R
… +1 more, Merritt H
J Extra Corpor Technol
· 2023 Jun · PMID 37378440
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Intracardiac thrombi such as pulmonary emboli represent a high risk of mortality. In this case study, we review two cases of intracardiac thrombi occurring within 24 h of one another and managed differently by the same c...Intracardiac thrombi such as pulmonary emboli represent a high risk of mortality. In this case study, we review two cases of intracardiac thrombi occurring within 24 h of one another and managed differently by the same cardiothoracic surgical team, highlighting the importance of an individualized approach as well as an understanding of current guidelines and contemporary management techniques.
Hanekop G, Kollmeier JM, Frahm J
… +6 more, Iwanowski I, Khabbazzadeh S, Kutschka I, Tirilomis T, Ulrich C, Friedrich MG
J Extra Corpor Technol
· 2023 Jun · PMID 37378439
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BACKGROUND: Blood loss is common during surgical procedures, especially in open cardiac surgery. Allogenic blood transfusion is associated with increased morbidity and mortality. Blood conservation programs in cardiac su...BACKGROUND: Blood loss is common during surgical procedures, especially in open cardiac surgery. Allogenic blood transfusion is associated with increased morbidity and mortality. Blood conservation programs in cardiac surgery recommend re-transfusion of shed blood directly or after processing, as this decreases transfusion rates of allogenic blood. But aspiration of blood from the wound area is often associated with increased hemolysis, due to flow induced forces, mainly through development of turbulence. METHODS: We evaluated magnetic resonance imaging (MRI) as a qualitative tool for detection of turbulence. MRI is sensitive to flow; this study uses velocity-compensated T1-weighted 3D MRI for turbulence detection in four geometrically different cardiotomy suction heads under comparable flow conditions (0-1250 mL/min). RESULTS: Our standard control suction head Model A showed pronounced signs of turbulence at all flow rates measured, while turbulence was only detectable in our modified Models 1-3 at higher flow rates (Models 1 and 3) or not at all (Model 2). CONCLUSIONS: The comparison of flow performance of surgical suction heads with different geometries via acceleration-sensitized 3D MRI revealed significant differences in turbulence development between our standard control Model A and the modified alternatives (Models 1-3). As flow conditions during measurement have been comparable, the specific geometry of the respective suction heads must have been the main factor responsible. The underlying mechanisms and causative factors can only be speculated about, but as other investigations have shown, hemolytic activity is positively associated with degree of turbulence. The turbulence data measured in this study correlate with data from other investigations about hemolysis induced by surgical suction heads. The experimental MRI technique used showed added value for further elucidating the underlying physical phenomena causing blood damage due to non-physiological flow.
Naguib AN, Carrillo SA, Corridore M
… +6 more, Bigelow AM, Walczak A, Tram NK, Hersey D, Galantowicz M, Tobias JD
J Extra Corpor Technol
· 2023 Jun · PMID 37378438
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BACKGROUND: Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM) has been shown to reduce the administration of blood products i...BACKGROUND: Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS: We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS: The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION: The utilization of ROTEM may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.
Messarra BT, Wang Y, Smith PA
… +3 more, Peak P, Adams DL, Crane TN
J Extra Corpor Technol
· 2023 Jun · PMID 37378437
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BACKGROUND: Simulator training is important for teaching perfusion students fundamental skills associated with CBP before they start working in the clinic. Currently available high-fidelity simulators lack anatomic featu...BACKGROUND: Simulator training is important for teaching perfusion students fundamental skills associated with CBP before they start working in the clinic. Currently available high-fidelity simulators lack anatomic features that would help students visually understand the connection between hemodynamic parameters and anatomic structure. Therefore, a 3D-printed silicone cardiovascular system was developed at our institution. This study aimed to determine whether using this anatomic perfusion simulator instead of a traditional "bucket" simulator would better improve perfusion students' understanding of cannulation sites, blood flow, and anatomy. METHODS: Sixteen students were tested to establish their baseline knowledge. They were randomly divided into two groups to witness a simulated bypass pump run on one of two simulators - anatomic or bucket - then retested. To better analyze the data, we defined "true learning" as characterized by an incorrect answer on the pre-simulation assessment being corrected on the post-simulation assessment. RESULTS: The group that witnessed the simulated pump run on the anatomic simulator showed a larger increase in mean test score, more instances of true learning, and a larger gain in the acuity confidence interval. CONCLUSIONS: Despite the small sample size, the results suggest that the anatomic simulator is a valuable instrument for teaching new perfusion students.
Sleasman JR, Hijawi U, Alsalemi A
… +13 more, Rabie M, Noorizadeh M, Stead A, Cooley C, Donnelly C, Haft JW, Abrams D, Stead C, Ryan KR, Rycus P, Fox AD, Ogino MT, Alexander PMA
J Extra Corpor Technol
· 2023 Mar · PMID 37034103
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: The Extracorporeal Life Support Organization Supplies Platform (https://Supplies.ELSO.org) was created out of Extracorporeal Membrane Oxygenation (ECMO) disposable product shortage prior to and during the Coronavirus D...: The Extracorporeal Life Support Organization Supplies Platform (https://Supplies.ELSO.org) was created out of Extracorporeal Membrane Oxygenation (ECMO) disposable product shortage prior to and during the Coronavirus Disease 2019 (COVID-19) pandemic. This novel Platform supports Centers in obtaining disposables from other Centers when alternative avenues are exhausted. : Driven by the opportunity for increased patient care by using the product availability of the 962 ELSO centers worldwide was the motivation to form an efficient online supply sharing Platform. The pandemic created by COVID-19 became a catalyst to further recognize the magnitude of the supply disruption on a global scale, impacting allocations and guidelines for institutions, practice, and patient care. : Records kept on the Platform website are helpful to the industry by providing insights into where difficulties exist in the supply chain for needed equipment. Yet, the common thread is awareness, of how critical situations can stretch resources and challenge our resolve for the best patient care. ELSO is proud to support member centers in these situations, by providing a means of attaining needed ECMO life support products to cover supply shortages.
Yamada Y, Iemura J, Kambara A
… +5 more, Tateishi N, Kozaki Y, Yamada M, Maruyama J, Azuma E
J Extra Corpor Technol
· 2023 Mar · PMID 37034101
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: Postoperative atrial fibrillation (POAF) is defined as new-onset AF in the immediate postoperative period. The relatively high incidence of POAF after cardiac surgery is well described, but pathophysiological mechanism...: Postoperative atrial fibrillation (POAF) is defined as new-onset AF in the immediate postoperative period. The relatively high incidence of POAF after cardiac surgery is well described, but pathophysiological mechanisms underlying the initiation, maintenance, and progression of POAF may be multifactorial and have not yet been comprehensively characterized. One of the mechanisms includes altered Ca kinetics. Accumulating evidence has suggested that altered atrial cytosolic calcium handling contributes to the development of POAF, protamine reversibly modulates the calcium release channel/ryanodine receptor 2 (RyR2) and voltage-dependent cardiac RyR2. However, it is currently unknown whether such abnormalities contribute to the arrhythmogenic substrate predisposing patients to the development of POAF. : We have retrospectively analyzed 147 patients who underwent cardiac surgery with cardiopulmonary bypass support. Of these, 40 patients were excluded from the analysis because of pre-existing AF. All patients received heparin followed by protamine at different dosing ratios of protamine-to-heparin, depending on the periods studied. : The dosing ratio of protamine-to-heparin = 1.0 was compared with higher dosing ratios of protamine-to-heparin >1.0 up to 1.7. POAF developed in 15 patients (15/107 = 14%), of these, 5 out of 57 patients (33.3%) in the dosing ratio of protamine-to-heparin = 1.0 and 10 out of 35 patients (66.7%) in the higher dosing ratios of protamine-to-heparin. Statistical significance was observed in patients with higher dosing ratios of protamine-to-heparin, compared with the dosing ratio of protamine-to-heparin = 1.0 (odds ratio = 3.890, 95% CI = 1.130-13.300, -value = 0.031). When types of diseases were analyzed in terms of higher dosing ratios of protamine-to-heparin, only valvular disorders were significantly associated with POAF ( = 0.04). : Protamine is clinically utilized to reverse heparin overdose and has been shown to display immunological and inflammatory alterations. However, its association with POAF has not been reported. Our results provide evidence that higher dosing ratios of protamine-to-heparin may increase the incidence of POAF.
Blanco-Morillo J, Salmerón Martínez D, Arribas-Leal JM
… +4 more, Farina P, Puis L, Sornichero-Caballero AJ, Cánovas-Lόpez SJ
J Extra Corpor Technol
· 2023 Mar · PMID 37034100
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: New era of cardiac surgery aims to provide an enhanced postoperative recovery through the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact...: New era of cardiac surgery aims to provide an enhanced postoperative recovery through the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact of cardiopulmonary bypass (CPB). Hematic Antegrade Repriming (HAR) provides a standardized procedure combining several measures to reduce haemodilutional priming to 300 mL. Once the safety of the procedure in terms of embolic release has been proven, the evaluation of its beneficial effects in terms of transfusion and ICU stay should be assessed to determine if could be considered for inclusion in Enhanced Recovery After Cardiac Surgery (ERACS) programs. : Two retrospective and non-randomized cohorts of high-risk patients, with similar characteristics, were assessed with a propensity score matching model. The treatment group (HG) ( = 225) received the HAR. A historical cohort, exposed to conventional priming with 1350 mL of crystalloid confirmed the control group (CG) ( = 210). : Exposure to any transfusion was lower in treated (66.75% vs. 6.88%, < 0.01). Prolonged mechanical ventilation (>10 h) (26.51% vs. 12.62%; < 0.01) and extended ICU stay (>2 d) (47.47% vs. 31.19%; < 0.01) were fewer for treated. HAR did not increase early morbidity and mortality. Related savings varied from 581 to 2741.94 $/patient, depending on if direct or global expenses were considered. : By reducing the gaseous and crystalloid emboli during CPB initiation, HAR seems to have a beneficial impact on recovery and reduces the overall transfusion until discharge, leading to significant cost savings per process. Due to the preliminary and retrospective nature of the research and its limitations, our findings should be validated by future prospective and randomized studies.
Lohbusch B, Olson K, Magowan B
… +5 more, Cherichella R, Wolverton J, Dell'Aiera L, Likosky DS, Fitzgerald D
J Extra Corpor Technol
· 2023 Mar · PMID 37034099
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: Cardiovascular perfusion is a dynamic healthcare profession where new practices are frequently introduced. Despite the emergence of evidence-based clinical practice guidelines, little is known about their dissemination...: Cardiovascular perfusion is a dynamic healthcare profession where new practices are frequently introduced. Despite the emergence of evidence-based clinical practice guidelines, little is known about their dissemination at the institutional level. Clinical practice surveys have been used to identify current trends in perfusion practice in the areas of equipment, techniques, and staffing. This survey aims to describe clinical perfusion practices across adult cardiac surgical programs located in a large, single, geographical region of the United States. : Following Institutional Review Board (IRB) approval, an 81-question survey was distributed to 167 adult perfusion programs across the Zone IV region of the American Society of Extracorporeal Technology (AmSECT), a non-profit professional society representing the extracorporeal technology community. Surveys were distributed to chief perfusionists through the Research Electronic Data Capture (REDCap) web-based survey response system. : Responses were received from 58 of 167 centers across (34.7% response rate). Centrifugal pumps were used at 81% ( = 47) of centers and 96.6% ( = 56) use an open venous system or hard-shell venous reservoir. Del Nido was the most frequently used cardioplegia strategy with 62.1% ( = 36) of centers reporting its use. The use of electronic medical records was reported in 43% ( = 25) of centers, while 84.5% ( = 49) reported using Cardiopulmonary Bypass (CPB) protocols (>75% of all CPB activities). Extracorporeal Membrane Oxygenation (ECMO) support was reported in 93.1% ( = 54) of programs, with 59.2% of programs ( = 34) employing a perfusionist as ECMO Coordinator. The + 1 staffing model was reported by 50% ( = 29), with 24% supporting the + 1 staffing for after-hours and on-call procedures. : Clinical practice surveys can be effective tools to inform clinicians about contemporary perfusion practice and identify deviations from professional standards and guidelines. Subsequent surveys may describe trends over time, assess standardization of practice, measure adherence to evidence-based guidelines, and foster improved patient care and outcomes.
J Extra Corpor Technol
· 2022 Sep · PMID 36742222
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For nearly 20 years, prominent perfusionists have called for a perfusion-centric prospective incident-reporting system to collect near-miss and patient harm incidents that occur during clinical practice in the United Sta...For nearly 20 years, prominent perfusionists have called for a perfusion-centric prospective incident-reporting system to collect near-miss and patient harm incidents that occur during clinical practice in the United States. In this article, we describe the development of a widely available prospective incident-reporting system for use by perfusionists in the United States. The system was developed in three phases: literature review, system incorporation, and submission for listing as a Patient Safety Organization (PSO). It is anticipated that the knowledge gained from analysis of events contributed to this PSO-protected reporting system will lead to improvements in safety and quality of perfusion services, as well as expanding the understanding of best practices in training, equipment use, system design, and simulation scenarios.