Current Issue of JECT

The premiere source of the most current research and information related to extracorporeal technology including Cardiopulmonary Bypass, Extracorporeal Life Support, Mechanical Assist Devices, and Perioperative Blood Management.

Volume 49 / Issue 4 / December 2017 Contents




Low Oxygen Delivery as a Predictor of Acute Kidney Injury during Cardiopulmonary Bypass
Richard F. Newland, BSc, CCP; Robert A. Baker, PhD, CCP

Abstract: Low indexed oxygen delivery (DO2i) during cardiopul- monary bypass (CPB) has been associated with an increase in the
likelihood of acute kidney injury (AKI), with critical thresholds for oxygen delivery reported to be 260–270 mL/min/m . This study aims to explore whether a relationship exists for oxygen delivery during CPB, in which the integral of amount and time below a critical threshold, is associated with the incidence of postoperative AKI. The area under the curve (AUC) with DO2i during CPB above or below 270 mL/min/m was calculated as a metric of oxygen delivery in 210 patients undergoing CPB. To determine the influence of low oxygen delivery on AKI, a multivariate logistic regression model as developed including AUC < 0, Euroscore II to provide pre- operative risk factor adjustment, and incidence of red blood cell transfusion to adjust for the influence of transfusion. Having an AUC < 0 for an oxygen delivery threshold of 270 mL/min/m during CPB was an independent predictor of AKI, after adjustment for Euroscore II and transfusion [OR 2.74, CI {1.01–7.41}, p 5 .047]. These results support that a relationship exists for oxygen delivery during CPB, in which the integral of amount and time below a critical threshold is associated with the incidence of postoperative AKI.

Keywords: Cardiopulmonary bypass, oxygen delivery, acute kidney injury.

Does the Type of Cardioplegic Technique Influence Hemodilution and Transfusion Requirements in Adult Patients Undergoing Cardiac Surgery?
Alfred H. Stammers, MSA, CCP; Eric A. Tesdahl, PhD; Linda B. Mongero, BS, CCP; Andrew J. Stasko, MS, CCP; Samuel Weinstein, MBA, MD

Abstract: During cardiac surgery, myocardial protection is per- formed using diverse cardioplegic (CP) solutions with and without the presence of blood. New CP formulations extend ischemic intervals but use high-volume, crystalloid-based solutions. The present study evaluated four commonly used CP solutions and their effect on hemodilution during cardiopulmonary bypass (CPB). Records from 16,670 adult patients undergoing cardiac surgery with CPB between February 2016 and January 2017 were reviewed. Patients were classified into one of four groups according to CP type: 4–1 blood to crystalloid (4:1), microplegia (MP), del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK). Covariate-adjusted estimates of group differences were calculated using multivariable logistic and linear mixed effects regression models. The primary end point was intraoperative transfusion of allogeneic red blood cells (RBCs), with a secondary end point of intraoperative hematocrit change. Among all patients, 8,350 (50.1%) received 4:1, 4,606 (27.6%) MP, 3,344 (20.1%) DN, and 370 (2.2%) HTK. Both 4:1 and MP were more likely to be used in patients undergoing coronary revasculariza- tion surgery, whereas DN and HTK were seen more often in patients undergoing valve surgery (p < .001). The highest vol- ume of crystalloid CP solution was seen in the HTK group, 2,000 [1,754, 2200], whereas MP had the lowest, 50 [32, 67], p < .001. Ultrafiltration usage was as follows: HTK—84.9%. DN—83.7%, MP—40.1%, and 4:1—34.0%, p < .001. There were no statisti- cally significant differences on the primary outcome risk of intraoperative RBC transfusion. However, statistically signifi- cant differences among all but one of the pair-wise comparisons of CP methods on hematocrit change (p < .05 or smaller), with MP having the lowest predicted drift (27.8%) and HTK having the highest (29.4%). During cardiac surgery, the administration of different CP formulations results in varying intraoperative hematocrit changes related to the volume of crystalloid solution administered.

Keywords: Myocardial preservation, cardioplegia, microplegia, del Nido cardioplegia, hemodilution.

The Influence of Intraoperative Autotransfusion on Postoperative Hematocrit after Cardiac Surgery: A Cross-Sectional Study
Andrew J. Stasko, MS, CCP; Alfred H. Stammers, MSA, CCP; Linda B. Mongero, BS, CCP; Eric A. Tesdahl, PhD; Samuel Weinstein, MD

Abstract: Utilization of intraoperative autotransfusion (IAT)during cardiac surgery with cardiopulmonary bypass (CPB) has been shown to reduce allogeneic red blood cell transfusion. Pre- vious research has emphasized the benefits of using IAT in the intraoperative period. The present study was designed to evaluate the effects of using IAT on overall hematocrit (Hct) drift between initiation of CPB and the immediate postoperative period. We reviewed 3,225 adult cardiac procedures occurring between Feb- ruary 2016 and January 2017 at 84 hospitals throughout the United States. Data were collected prospectively from adult patients un- dergoing cardiac surgery with CPB, and stored in the SpecialtyCare Operative Procedural rEgistry (SCOPE), a large quality improve- ment database. Patients receiving allogeneic transfusion and those with missing covariate data were excluded from analysis. The effect of IAT volume returned to patients on the primary endpoint, hematocrit change from CPB initiation to intensive care unit (ICU)entry, was assessed using a multivariable linear mixed effects regression model controlling for patient demographics, operative characteristics, surgeon, and hospital. Descriptive analysis showed greater positive hematocrit change with increasing autotransfusate volume returned. Those patients with no IAT volume returned saw a median hematocrit change of 12.00%, whereas those with more
than 380 mL/m BSA had a median Hct drift of 15.00% (p < .001). After controlling for known confounds, our regression estimate of the effect of IAT volume returned on Hct drift was 1.0045% per 1 mL/m BSA (p < .001). For a patient with the median autotransfusate volume returned (273 mL/m BSA), and all other co- variate values at their respective medians, this translates to a predicted hematocrit change of 13.6% (95% CI 13.1 to 14.1). These findings lend further support to the notion that auto- transfusate volume is positively associated with increases in post- operative hematocrit.

Keywords: Intraoperative autotransfusion, cell-salvage, cardiopulmonary bypass, post-operative hematocrit change, hematocrit-drift.

Colloid Oncotic Pressure, Monitoring its Effects in Cardiac Surgery
Jeffrey B. Chores, MPS, CCP; David W. Holt, MA, CCT

Abstract: Hemodilution is a common perioperative practice. The deleterious effects of excessive hemodilution and subsequent edema formation have been well documented by numerous au- thors. Colloid oncotic pressure (COP) is a reliable clinical in- dicator of hemodilution in cardiac surgery. The intent of this study is to determine if a correlation exists between COP and various patient outcome variables. It would also be helpful to know if there is a particular COP value to avoid preventing or limiting patient morbidity. Blood samples from 61 adult patients (mean age 5 70 years old) undergoing cardiopulmonary bypass surgery were collected for COP calculation and comparison. Sample collection was performed before heparinization, during cardio- pulmonary bypass, at the conclusion of cardiopulmonary bypass, and in the intensive care unit. The resultant values obtained were used to generate a calculated COP. The lowest sustained COP was then compared with various patient outcome variables such as fluid balance, post-operative weight gain, post-operative blood loss, extubation time, length of stay, and blood products ad- ministered. A statistically significant difference (p < .05) was found between the COP and each of the monitored continuous variables. The data also suggest that maintaining a patient’s COP at or above 15 mmHg could be desirable. Frequent monitoring of a patient’s COP can provide a potential benefit to clinical decision making.

Keywords: Cardiopulmonary bypass (CPB), colloid, colloid oncotic pressure, edema, extubation.

Quantification of Carbon Dioxide Removal at Low Sweep Gas and Blood Flows
Juan de Villiers Hugo, BTech; Ajay S. Sharma, MD, PhD; Usaama Ahmed, MD; Patrick W. Weerwind, CCP, PhD

Abstract: Advancement in oxygenator membrane technology has further expanded the boundaries in the clinical application of extracorporeal carbon dioxide removal (ECCO2R). Despite the advent of modern poly-4-methyl-1-pentene (PMP) membranes, limited information exists on the performance of these mem- branes at low sweep gas and blood flows. Moreover, physiological relationships for CO2 removal at these flows are less explored. Hence, CO2 removal was quantified in an in vitro setting using a PMP membrane oxygenator. ECCO2R was performed using a .8 m surface pediatric oxygenator in an in vitro setting with freshly drawn single-source porcine blood. In this setting, low blood flows of either 200 or 350 mL/min were generated, with sweep gas flow rates of 100, 200, and 400 mL/min, respectively. CO2 transfer ranged from 14.05 6 4.35 mL/min/m to 18.76 +- 4.26 mL/min/m at a sweep gas to a blood flow ratio of .5:1 to 2:1 (p < .01). Decreasing this ratio i.e., increasing the blood flow (.5:1.75 and 2:1.75) resulted in a lower CO2 transfer of 10.00 +- 4.77 mL/min/m to 16.87 +- 5.09 mL/min/m , which was still statistically significant (p < .01). Alternatively, decreasing the sweep gas to blood flow ratio, while maintaining a constant gas flow, did not show a significant increase in CO2 extraction (p > .05). At these test parameters, an increase in sweep gas improved the CO2 transfer, whereas an increase in blood flow resulted in a lower CO2 transfer. These results indicate that CO2 removal in low-flow ECCO2R is mainly sweep gas flow driven. Although these settings might not be applicable for clinical use, this study gives tangible information about the important factor involved in ECCO2R.

Keywords: Extracorporeal carbon dioxide removal, low sweep gas flow, low blood flows.

An In-Vitro Study Comparing the GME Handling of Two Contemporary Oxygenators
Carl J. Gisnarian, MS, CCP, LP; Angela Hedman, MS, CCP, LP; Kenneth G. Shann, CCP, LP

Abstract: Gaseous microemboli (GME) are a potential compli- cation of cardiopulmonary bypass (CPB). Though it is difficult to prove that GME is the only major cause of neurological deficits, it may increase the chance of post-operative cognitive dysfunction if not removed. The objectives of this research were to compare LivaNova-Sorin Inspire (Inspire) oxygenator with a Medtronic arterial filter to the Medtronic Fusion (Fusion) oxygenator with and without a Medtronic arterial filter based on each system’s ability to handle GME. The Inspire and Fusion systems were evaluated in vitro. GME handling was observed by introducing air in the sampling manifold connected to the venous return at a 60 mL bolus or 1 liter per minute (LPM). The emboli detection and classification (EDAC) system measured GME preand post- oxygenator/arterial filter. The Inspire with a filter was able to remove a statistically significant greater amount of total emboli per second during the 60 mL bolus and 1 LPM tests than the Fusion with and without an arterial filter. The Inspire with an arterial filter was more efficient in removing GME during a 60 mL bolus and 1 LPM than the Fusion and Fusion with an arterial filter. However, the Fusion with an arterial filtered performed better than the Fusion system without the arterial filter.

Keywords: GME, fusion, inspire, EDAC, microemboli, AF100, Sorin, Medtronic, LivaNova.

Blood and Blood Product Conservation: Results of Strategies to Improve Clinical Outcomes in Open Heart Surgery Patients at a Tertiary Hospital
Junaid H. Khan, MD; Emily A. Green, MD; Jimmin Chang, PhD, RN; Alexandria M. Ayala, BS; Marilyn S. Barkin, MPH, RN; Emily E. Reinys, MD; Jeffrey Stanton, CCP; Russell D. Stanten, MD

Abstract: Blood product usage is a quality outcome for patients undergoing cardiac surgery. To address an increase in blood product usage since the discontinuation of aprotinin, blood con- servation strategies were initiated at a tertiary hospital in Oakland, CA. Improving transfusion rates for open heart surgery patients requiring Cardiopulmonary bypass (CPB) involved multiple de- partments in coordination. Specific changes to conserve blood product usage included advanced CPB technology upgrades, and precise individualized heparin dose response titration assay for heparin and protamine management. Retrospective analysis of blood product usage pre-implementation, post-CPB changes and post-Hemostasis Management System (HMS) implementation was done to determine the effectiveness of the blood conservation strategies. Statistically significant decrease in packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelet usage over the stepped implementation of both technologies was observed. New oxygenator and centrifugal pump technologies reduced active circuitry volume and caused less damage to blood cells. Individualizing heparin and protamine dosing to a patient using the HMS led to transfusion reductions as well. Overall trends toward reductions in hospital length of stay and intensive care unit stay, and as a result, blood product cost and total hospitalization cost are positive over the period of implementation of both CPB circuit changes and HMS implementation. Although they are multifactorial in nature, these trends provide positive enforcement to the changes implemented.

Keywords: Blood conservation, cardio- pulmonary bypass, CPB equipment, heparin dose response titration.

TEG-Directed Transfusion in Complex Cardiac Surgery:Impact on Blood Product Usage
Kevin Fleming, CCP; Roberta E. Redfern, PhD; Rebekah L. March, MPH; Nathan Bobulski, CCP;* Michael Kuehne, PhD, PA-C; John T. Chen, PhD; Michael Moront, MD

Abstract: Complex cardiac procedures often require blood transfusion because of surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates peri- and postoperatively. All patients who underwent complex cardiac surgery, defined as open multiple valve repair/ replacement, coronary artery bypass grafting with open valve repair/replacement, or aortic root/arch repair before and after implementation of TEG were identified and retrospectively an- alyzed. Minimally invasive cases were excluded. Patient charac- teristics and blood use were compared with t test and chi-square test. A generalized linear model including patient characteristics, preoperative and postoperative lab values, and autotransfusion volume was used to determine the impact of TEG on peri- operative, postoperative, and total blood use. In total, 681 patients were identified, 370 in the pre-TEG period and 311 patients post-TEG. Patient demographics were not significantly different between periods. Mean units of red blood cells, plasma, and cryoprecipitate were significantly reduced after TEG was implemented (all, p < .0001); use of platelets was reduced but did not reach significance. Mean units of all blood products in the perioperative period and over the entire stay were reduced by approximately 40% (both, p < .0001). Total proportion of patients exposed to transfusion was significantly lower after introduction of TEG ( p < .01). Controlling for related factors on multivariate analysis, such as preoperative laboratory values and autotransfu- sion volume, use of TEG was associated with significant reduction in perioperative and overall blood product transfusion. TEG- directed management of blood product administration during complex cardiac surgeries significantly reduced the units of blood products received perioperatively but not blood usage more than 24 hours after surgery. Overall, fewer patients were exposed to allogenic blood. The use of TEG to guide blood product adminis- tration significantly impacted transfusion therapy and associated costs.

Keywords: Cardiopulmonary bypass, blood conservation, point-of-care testing, thrombelastography.


RVAD Support in the Setting of Submassive Pulmonary Embolism
Antonio Salsano, MD; Elena Sportelli, MD; Guido Maria Olivieri, MD; Nicola Di Lorenzo, MD; Silvia Borile, MD; Francesco Santini, MD

Abstract: Patients with submassive pulmonary embolism (PE), although normotensive, are characterized by right ventricular
(RV) dysfunction and elevated levels of biomarkers of cardiac damage. The best treatment option in these cases is still a subject of debate and the use of thrombolysis in submassive PE remains controversial. A 57-year-old Caucasian male with unprovoked PE, normal blood pressure, and elevated troponin I values was referred to the cardiovascular department. In view of the presence of a right atrium thrombus, the patient underwent surgical em- bolectomy under extracorporeal circulation, with the extraction of a huge thrombus together with fragmented thrombi from both pulmonary arteries. The patient developed an acute right heart failure solved with a temporary RV assist device (RVAD) sup- port. The RV recovery was observed after 72 hours following the implantation. RVAD placement should be considered in the management of PE in case of acute right heart failure after reperfusion therapy since it can bring the patient out of a death spiral.

Keywords: Pulmonary embolism, cardiopulmonary by- pass (CPB), circulatory assistance, temporary, echocardiography.

Bloodless Repair for a 3.6 Kilogram Transposition of the Great Arteries with Jehovah’s Witness Faith
Jeffery L. Burnside, BS, CCP, FFP; Todd M. Ratliff, BS, CCP; Ashley B. Hodge, MBA, CCP, FPP; Daniel Gomez, BS, CCP, FPP; Mark Galantowicz, MD; Aymen Naguib, MD

Abstract: Achieving pediatric cardiac surgery using cardiopulmo- nary bypass (CPB) without allogeneic blood transfusion is chal- lenging. There are many clinical and economic factors that point to the importance of avoiding blood transfusions. In some instances, honoring patients or parents beliefs may be the reason for avoiding blood transfusions. For example, patients or parents of the Jehovah’s Witness faith refuse blood transfusion based on their religious beliefs. Over the last decade, our institution has seen a steady in- crease in our pediatric Jehovah’s Witness patient population. Caring for these patients have allowed us to develop specific protocols that enable us to safely provide bloodless CPB in all of our patient populations. The success of such an approach to minimize the need for blood transfusions should not start in the operating room; it must include the preoperative period and the postoperative care by the critical care team in the cardiac intensive care unit (CICU). A multidisciplinary team approach has to be in place with clear communication between the cardiologist, anesthesiologist, cardiac surgeon, perfusionist, and the cardiac intensivist. We present a case of a 7 day old male (3.6 kg) with a preoperative diagnosis of Transposition of the Great Arteries and intact ven- tricular septum who underwent an arterial switch procedure without the transfusion of any blood products throughout his entire hospital stay.

Keywords: Jehovah’s Witness, bloodless, pediatric cardiopulmonary bypass.

Extracorporeal Life Support as a Rescue Measure for Managing Life-Threatening Arrythmia and Brugada Syndrome
Asaad G. Beshish, MD; Allison Weinberg, CCP; Waseem Ostwani, MD; Gabe E. Owens, MD

Abstract: We describe the use of extracorporeal cardiopulmonary resuscitation (E-CPR) to transiently stabilize a 3-month-old patient who presented with ventricular tachyarrhythmias leading to spon- taneous cardiac arrest. The patient required 4 days of extracorporeal life support (ECLS) where he was diagnosed with probable Brugada syndrome (BS). The patient was discharged home in stable con- dition after implantable cardioverter defibrillator placement. This case highlights the importance of early transfer to extracorporeal membrane oxygenation (ECMO) center in the setting of un- explained cardiac arrhythmia in a pediatric patient. BS is an autosomal dominant genetic disorder with variable expression characterized by abnormal findings on electrocardiogram (ECG) in conjunction with an increased risk of ventricular tachyarrhythmias and sudden cardiac arrest (SCA). Early management is critical and early consideration to transfer to an institution where extracor- poreal life support (ECLS/ECMO) is present to support the pa- tient while further diagnostic work up is in progress is lifesaving.

Keywords: Brugada syndrome, extracorporeal membrane ogenation (ECMO), extracorporeal cardio pulmonary resuscitation (E-CPR).


A Dedicated Perfusion Electronic Medical Record with Discrete Epic Integration
James A. Reagor, MPS, CCP, FPP

Abstract: Enterprise electronic medical records (EMR) have largely become a standard since their use was mandated by The American Recovery and Reinvestment Act of 2009. However, perfusion departments have adopted true perfusion EMRs at various rates. In our efforts to integrate with the institutions EMR while enjoying the benefits of an EMR designed specifically for perfusion practice, we developed a discrete data integration solu- tion between Epic and the Spectrum Medical VIPER Perfusion EMR. This report describes our perfusion EMR selection criteria, design challenges, and documentation process.

Keywords: VIPER, electronic medical record, electronic perfusion record, perfusion record integration, Epic. 

Use of a Modified Cardiopulmonary Bypass Circuit for Suction Embolectomy with the AngioVac Device
Cara M. Michelson, MPS, CCP; Cornelius M. Dyke, MD; Douglas J. Wick, MPS, CCP; Rory Guenther, BA; Dylan Dangerfield, BA; Matthew E. Wiisanen, MD

Abstract: The AngioVac suction cannula and circuit were designed for the percutaneous removal of soft thrombus and emboli in procedures requiring extracorporeal circulatory sup- port. We describe a modification of the AngioVac suction catheter and cardiopulmonary bypass (CPB) circuit to effectively remove thrombus while maintaining the ability to rapidly initiate full CPBs during a medical crisis. This article will discuss the design concepts of the modified circuit as well as procedural protocols and considerations. The design modifications of incorporating an oxygenator, reservoir, and bridge allow for an increased flexibility that allows adaption to veno-venous extracorporeal membrane ox- ygenation or full CPB support when required for oxygenation or hemodynamic support.

Keywords: Suction embolectomy, cardiopul- monary bypass, AngioVac.


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