Current Issue of JECT

The premier 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 51 / Issue 1 / March 2019 Contents

 


ORIGINAL ARTICLES


Massive Air Embolism Caused by a Central Venous Catheter During Extracorporeal Membrane Oxygenation 
Akshay Kumar, MD; Suresh Keshavamurthy, MD; Jesus Gomez Abraham, MD; Yoshiya Toyoda, MD 

Abstract: Extracorporeal membrane oxygenation (ECMO) has become an integral treatment option for patients as a bridge to transplant, management of post cardiotomy cardiogenic shock, and for rescue after cardiopulmonary arrest. Significant strides in ECMO technology and management cannot, however, replace the importance of maintaining and following a comprehensive safety checklist. We herein report a case of massive air entrainment from an inadvertently disconnected port of a central venous catheter (CVC) in the neck which culminated in an airlock of the ECMO circuit. Ascertaining the relative position of the tip of the CVC with respect to the venous cannula on chest X-ray, tightly securing all its ports, and appraising and educating the health-care team can prevent this rare but devastating complication of fatal air embolism. 

Keywords: extracorporeal membrane oxygenation, bridge to transplant, post cardiotomy syndrome, cardiopulmonary arrest, central venous catheter, massive air entrainment. J Extra Corpor Technol. 2019;51:9–11

Effects of ECMO Simulations and Protocols on Patient Safety
Fedelyne Thomas, BS, MS, CCP; Sunyoung Chung, BS, MS, CCP; David W. Holt, MA, CCT

Abstact: The use of extracorporeal membrane oxygenation (ECMO) has greatly increased over the years; however, the survival rate is only above 56%. There has been a drastic increase in ECMO centers and cases. ECMO has become a popular therapy route for patients with respiratory and cardiac complications; however, patient safety is a major concern. Perfusion and non-perfusion students from the University of Nebraska Medical Center were recruited to participate in three simulation trials. The trials consisted of five different tasks that are required for managing or preventing catastrophic events on ECMO. Students were evaluated for the time it took to complete each task, number of errors made, and protocol referencing. The data indicated that there was a decrease in time for the 1st vs. 2nd trial (p = .02) for perfusion students and a decrease from the 1st to 3rd trial (p = .001) for the circuit set-up simulation. There was a decrease in priming time from the 1st to 3rd trial (p = .02) and for the pump change (p = .0098) for the perfusion students as well. The nonperfusion students had a significant decrease in time for the circuit set-up in the 1st vs. 2nd (p = .004) and 1st vs. 3rd trial (p = .002). There was a decrease in time for priming (.004), pump change (p = .002), tubing change (p = .0098), and errors during the tubing change (p = .02) in the non-perfusion students. Both groups felt more confident after the simulations and the nonperfusion students specifically felt like they were more familiar with the purpose of ECMO after the simulation. ECMO simulations and protocols may improve patient safety by strengthening the skills needed for rapid management, fewer errors, and higher levels of confidence during the management of ECMO and catastrophic events. 

Keywords: cardiopulmonary bypass (CPB), extracorporeal membrane oxygenation (ECMO), education, simulation, protocols, patient care. J Extra Corpor Technol.2019;51:129

Flow Awareness as a New Safety Device for Cardiopulmonary Bypass 
Jacki Brolhorst, MPS; Brittney Peterson, MPS, CCP; David W. Holt, MA, CCT

Abstract: Safety devices such as bubble detectors and level detectors have been in use for more than 40 years and initially reduced the risks associated with gaseous emboli during cardiopulmonary bypass; however, the risks have not been eliminated. This research explored a new safety device designed to further reduce these risks: Flow Awareness Technology. This device visually alerts the perfusionist when the ratio of venous return does not equal the amount of arterial flow. To determine the efficacy of this device, 33 participants with no perfusion background were randomly assigned to Group A (flow awareness only), Group B (level detector only), or Group C (control). These participants were instructed to turn off the arterial pump when they noticed that the fluid in the venous reservoir had begun to drop or if their assigned safety device was triggered. The venous line was fully occluded at times unknown to the participants. These times coincided with before, during, or after times that the participants were expected to paper-chart known values. Each participant’s amount of fluid lost (in milliliters) from the reservoir and reaction time (in seconds) to shut off the arterial roller pump were measured. Group A lost an average of 80.8 mL, Group B lost an average of 173.6 mL, and Group C lost an average of 140.3 mL. Average measured time for each group is as follows: Group A took 2.16 seconds, Group B took 4.31 seconds, and Group C took 4.09 seconds to shut off the arterial pump. Statistics support the hypothesis that Flow Awareness Technology significantly reduces the reaction time to an adverse event such as a sudden occlusion of the venous line, thus reducing the amount of fluid lost during such an event. 

Keywords: cardiopulmonary bypass, CPB, equipment, patient safety, perfusion. J Extra Corpor Technol. 2019;51:205

CASE REPORT


Bivalirudin Anticoagulation for an Infant with Hyperbilirubinemia and Elevated Plasma-Free Hemoglobin on ECMO 

Chidiebere Ezetendu, MD; Angela Jarden, MSN; Mohammed Hamzah, MD; Robert Stewart, MD 

Abstract: Heparin has been used for decades as an anticoagulant in patients on mechanical circulatory support, which includes extracorporeal membrane oxygenation (ECMO) and ventricular assist devices. Bivalirudin is a direct thrombin inhibitor that can be used as an alternative anticoagulant in neonates and infants demonstrating inaccurate heparin monitoring. We report a case of a 2-month-old male child who was placed on ECMO for severe acute respiratory distress syndrome. His ECMO course was complicated by severe hemolysis and hyperbilirubinemia, which precluded accurate monitoring of heparin activity. Bivalirudin was successfully used for anticoagulation in this patient. 

Keywords: extracorporeal membrane oxygenation, bivalirudin, heparin, partial thromboplastin time, heparin anti-Xa level. J Extra Corpor Technol. 2019;51:26–8

TECHNIQUE ARTICLES


Microfluidic Point-of-Care Ecarin-Based Clotting and Chromogenic Assays for Monitoring Direct Thrombin Inhibitors 
Benjamin Alouidor, MS, MLS, CCP; Robin E. Sweeney, PhD; Trinny Tat; Raymond K. Wong, PhD, CCP; Jeong-Yeol Yoon, PhD 

Abstract: Direct thrombin inhibitors (DTIs), such as bivalirudin and dabigatran, have maintained steady inpatient and outpatient use as substitutes for heparin and warfarin, respectively, because of their high bioavailability and relatively safe “ontherapy” range. Current clinical methods lack the capacity to directly quantify plasma DTI concentrations across wide ranges. At present, the gold standard is the ecarin clotting time (ECT), where ecarin maximizes thrombin activity and clotting time is evaluated to assess DTIs’ anticoagulation capability. This work focused on the development of a microfluidic paper analytic device (mPAD) that can quantify the extent of anticoagulation as well as DTI concentration within a patient’s whole blood sample. Capillary action propels a small blood sample to flow through the nitrocellulose paper channels. Digital images of whole blood migration are then captured by our self-coded Raspberry Pi and/or the Samsung Galaxy S8 smartphone camera. Both the flow length and the blue absorbance from the plasma front on the mPAD were measured, allowing simultaneous, dual assays: ecarin clotting test (ECT) and ecarin chromogenic assay (ECA). Statistically significant (p < .05) changes in flow and absorbance were observed within our translational research study. Currently, there are no quantitative, commercially available point-of-care tests for the ECT and ECA within the United States. Both the ECT and ECA assays could be instrumental to differentiate between supratherapeutic and subtherapeutic incidents during bridging anticoagulant therapy and limit the unwarranted use of reversal agents.

Keywords: ecarin clotting time, ecarin chromogenic assay, paper microfluidics, DTI, bivalirudin, dabigatran. J Extra Corpor Technol. 2019;51:29–37

Establishing a VentilatorHeart Lung Machine Communication Bridge to Mitigate Errors when Weaning from Bypass
Geoffrey Rance, BS, CCP; David Arney, MS; Rithy Srey, MS, CCP; Julian M. Goldman, MD; Marco A. Zenati, MD 

Abstract: If a perfusionist weans a patient off the heart lung machine (HLM) and the anesthesiologist has not re-started the ventilator, the patient will become hypoxic. The objective of this project was to create a redundant safety system of verbal and electronic communication to prevent failure to ventilate errors after cardiopulmonary bypass. This objective could be realized by building an electronic communication bridge directly between the HLM and ventilator. A software application was created to retrieve and interpret data from the pump and ventilator and trigger a programmed smart alarm. The software is able to interpret data from the pump and ventilator. When both are off simultaneously (defined as a pump flow of 0 L/min with a respiratory rate of 0 breaths/min), the application will raies an alarm. Communication between a pump and ventilator is possible, enabling the deployment of a safety system that could exist in the operating room (OR) as a standalone alarm. A device dataset can be used to optimize clinical performance of the alarm. The application could also be integrated into smart checklists and computer-assisted OR process models that are currently in development. 

Keywords: cardiopulmonary bypass, ventilation, perfusion, patient safety. J Extra Corpor Technol. 2019;51:38–40

REVIEW ARTICLE


Non-Invasive Tissue OximetryAn Integral Puzzle Piece
Nousjka P. A. Vranken, PhD; Patrick W. Weerwind, CCP, PhD 

Abstract: Non-invasive tissue oximetry is a monitoring method for continuous assessment of tissue oxygenation, which may aid in detection of hemodynamic instability and otherwise unnoticed hypoxia. Numerous studies focused on using noninvasive tissue oximetry intraoperatively, proposing its predictive value in relation to clinical outcome. Tissue oximetry may be part of standard monitoring practice for brain monitoring during cardiac surgery in many clinical centers; however, the monitoring method can be deployed in numerous clinical settings. This succinct overview aims to determine the role of non-invasive tissue oximetry in current clinical practice.

Keywords: patient monitoring, tissue oximetry, near-infrared spectroscopy, cardiopulmonary bypass. J Extra Corpor Technol. 2019;51:41–5

PROCEEDINGS from Manpower, Burnout, and PTSD Symposium
David Fitzgerald, section Guest Editor

Perfusion Manpower Survey
Bradley Kulat, CCP, LP, FPP

Healthcare Provider Burnout
Robert Lippy, PhD, ABPP, CDR, MSC, USN

Trauma on the Job: Lessons Learned in a Combat Hospital 
Heidi S. Kraft, PhD

Discussion 

Letter from the Editor - Ray Wong, PhD, CCP

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