Initiation Of Cardiopulmonary Bypass Research Articles

Ministernotomy approach for modified Blalock-Taussig shunts in neonates: a feasibility study

BackgroundThe original approach to performing a modified Blalock-Taussig (MBT) shunt is via a left thoracotomy. However, the median sternotomy has become the preferred approach of many surgeons. We think that the upper ministernotomy approach provides several advantages and avoids the disadvantages of both the sternotomy and thoracotomy approaches. Here, we describe our experience in constructing neonatal MBT shunts via upper ministernotomy.MethodsA prospective study was conducted on 50 neonates who underwent modified Blalock-Taussig shunt performed through upper ministernotomy between March 2011 and December 2016. Preoperative characteristics, mortality, and morbidity were recorded.ResultsMean age was 16.9 ± 10.4 days, and weight was 3.5 ± 0.5 kg. All patients received grafts of size 3.5 mm. The mean oxygen saturation increased from 59.5 ± 7.3% preoperatively to 84.8 ± 4.2% postoperatively. There were three cases of mortality (6%). One patient suffered from an unstable sternum (2%). No patients required conversion to full sternotomy. Superficial wound infection occurred in three cases (6%), and there were no cases of mediastinitis. Mean duration of ventilation was 55.64 ± 37.5 h, mean ICU stay was 5.44 ± 3.9 days, and mean hospital stay was 14.7 ± 7.2 days.ConclusionUpper ministernotomy is a safe approach with good early results. It provides adequate exposure with limited surgical trauma. Emergency conversion to full sternotomy and initiation of cardiopulmonary bypass can be achieved easily. It avoids lung compression and respiratory compromise. Additional costs for specific instruments are not necessary.

Improving Outcomes of Iatrogenic Type A Aortic Dissection during Cardiac Surgery.

Background Iatrogenic Type A aortic dissection (IAD) is a rare but devastating complication of cardiac and aortic surgery with reported operative mortality of 30 to 50%. In this study, we report our experience with IAD and propose a standardized approach to management. Methods From January 1, 2000 through December 31, 2016, 23,275 patients underwent cardiac surgery at our institution. We identified 15 patients who developed IAD. Our approach to management included (1) immediate repair, (2) involvement of a second attending surgeon, (3) aggressive monitoring of malperfusion, (4) securing true lumen arterial perfusion access and systemic cooling, and (5) performance of hemiarch or total arch replacement based on the presence of suspected brain malperfusion. The index operation was also completed at the same time. Patient preoperative characteristics, operative sequence and technique, complications, and outcomes were analyzed with chart review. Results The incidence of IAD at our institution was 0.06% ( n = 15). A disproportionate percentage of patients had aneurysmal ascending aortas (33.3%). The index surgery consisted of aortic surgery in five patients (33.3%), coronary bypass in three patients, valve surgery in five patients, and transplantation in one patient. The mechanism of dissection was aortic cannulation in 66.7% and aortic root vent site cannulation in 13.3%. In 46.7% of patients, the IAD was first recognized based on clinical evidence such as aortic hematoma, pericardial bleeding, or abnormal perfusion line pressures. In 40.0%, the diagnosis was made with intraoperative echocardiography without any clinical manifestations. The timing of the diagnosis was at the initiation of cardiopulmonary bypass initiation in 60.0%, while in 40.0% it was recognized after discontinuation of bypass. Hemiarch was done in 73.3% and total arch replacement performed in 13.3%. Isolated ascending repairs were done in two patients. Bypass and cross-clamp times were 229.5 ± 212.7 minutes and 130.5 ± 109.5 minutes, respectively. In-hospital mortality in our cohort was 6.7%. While stroke occurred in one patient, no visceral organ malperfusion was recognized. Conclusions Incidence of IAD is low with cannulation of an aneurysmal aorta being a risk factor. A standardized approach may result in reduced operative mortality.

A Human Model of Whole‐Body Ischemia‐Reperfusion: Changes in Exosome Release

In‐depth knowledge of individual patients' physiology impacts perioperative management, which also impacts efficacy and safety of surgical procedures. Exosomes are a new paradigm in cellular communication, cell stress, and biomarker development that have only recently begun to be addressed in the surgical population. Exosomes, secreted by almost all cells, carry biologically active molecules including DNA, RNA, proteins, lipids, cytokines, growth factors and metabolites. The role of exosomes in the surgical population is not well known and may have major impact on perioperative care and monitoring.Deep hypothermic circulatory arrest (DHCA) is a profound perioperative stress event involving isolation of the systemic vasculature, arrest of the circulation to major organ systems, and whole body ischemia‐reperfusion. DHCA is used for surgical repair of the great vessels including pulmonary thromboendarterectomy (PTE) for which the University of California, San Diego (UCSD) serves as a leading center. Our study tests the novel hypothesis that surgically induced DHCA increases the release of exosomes, alters exosome content and changes the ability of exosomes to affect cellular metabolism and function.Arterial blood was obtained at 5 timepoints in patients undergoing DHCA for PTE: immediately after induction of anesthesia (baseline), after initiation of cardiopulmonary bypass (CPB), at completion of cooling to body temperature of 20C, after circulatory arrests, and after patient is rewarmed and off CPB (chest closure). Blood was centrifuged in heparin tubes to prepare plasma for exosome isolation and nanoparticle tracking analysis (NTA). Additional exosome samples were stored for further immunoblotting, electron microscopic, proteomic, microRNA and in vitro analysis.Particle concentration as measured by NTA immediately after initiation of CPB and at the completion of cooling was decreased from baseline. Thereafter, particle concentration showed an increase after DHCA and a further increase during chest closure at the conclusion of the surgery. Mean particle sizes at each timepoint were within the known size distribution of exosomes.In conclusion, our data show that initiation of CPB and cooling can decrease exosome levels in blood, while whole body ischemia‐reperfusion associated with DHCA in patients is a stimulus for exosome release. Future work will focus on the changes in the proteome and microRNA content of exosomes after DHCA and the physiological consequences of exosome release on intact in vitro cell models. This model also lends itself well to further detailed investigation of tissue and organ specific exosomal responses to ischemia‐reperfusion.Support or Funding InformationR21 AG058174‐01A1 (PI: D Roth) 09/01/2018 – 06/30/2020 Funding Source: NIH/NIA T32 GM121318 (PI: HH Patel; co‐PI: DM Roth) 07/01/16‐06/30/22 Finding Source: NIH/NIGMSThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Changes in Erythrocyte Morphology at Initiation of Cardiopulmonary Bypass Without Blood Transfusion Were Not Associated With Less Deformability During Cardiac Surgery

During cardiac surgery, circulating red blood cells (RBCs) are at risk of exposure to environmental factors during extracorporeal circulation and transfusion of stored RBCs. For this study, the authors observed morphological differences, deformability, density distribution, and erythrocyte indices of RBCs during cardiac surgery with cardiopulmonary bypass (CPB). Prospective study. Tertiary care center affiliated with a university hospital. Adults who underwent elective cardiac surgery requiring CPB. Blood samples were obtained from 13 patients before incision (baseline), at initiation of CPB, after separation from CPB, and at completion of surgery. The morphological index (MI) in RBCs using light microscopy and the maximum deformability index (DImax) using an ektacytometer were evaluated. In addition, the fractionation of RBCs and erythrocyte indices were measured. The MI at initiation of CPB was significantly higher without blood transfusion compared with baseline, although the DImax did not significantly decrease simultaneously. The DImax after separation from CPB and at completion of surgery were significantly lower than that at baseline. This lowered DImax was accompanied by a significantly reduced mean corpuscular volume and elevated mean corpuscular hemoglobin concentration compared with baseline. Dense RBC subpopulations increased after initiating CPB. The MI after separation from CPB and at completion of surgery partially recovered. Administered stored RBCs showed a high MI and the lowest DImax. Morphological changes at initiation of CPB are considered potentially reversible transformations without loss of the membrane surface area and do not have a significant effect on the DImax. A decrease in deformability likely is due to transfusion of stored RBCs.

Effect of Anesthesia on Cardiac Hemodynamics in patients undergoing durable LVAD Implantation: The EACHLVAD Study

Purpose Right ventricular (RV) dysfunction is often unmasked or exacerbated during implantation of a left ventricular assist device (LVAD). Prior to LVAD implantation, the effect of anesthesia induction on RV performance is unknown. We assessed for early hemodynamic changes in the RV after induction, prior to initiation of cardiopulmonary bypass (CPB), in the presence or absence of preoperative temporary mechanical circulatory support (tMCS). Methods We prospectively collected hemodynamic measurements in patients undergoing LVAD implantation at a large academic institution between 9/2017 and 9/2018. Preoperative RV hemodynamics were compared to RV hemodynamics post-induction and intubation but prior to CPB, including central venous pressure (CVP), mean pulmonary artery pressure (mPAP), and pulmonary artery pulsatility index (PAPi). Serial hemodynamics and vasoactive inotropic score (VIS) were analyzed over time using random effects models, adjusting for induction agents and use of pre-operative tMCS. Results There were 41 patients included in this analysis, with 4 intubated prior to induction. There was a significant increase in CVP (3.6 mmHg, p intra-aortic balloon pumps were 14 of 17 tMCS cases and had similar reduction in PAPi at all time points (-2.5, p Conclusion RV hemodynamics acutely worsen after anesthesia induction prior to bypass initiation in LVAD recipients. Patients with preoperative tMCS have worse RV hemodynamics at each timepoint but less significant decline over time.

Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial.

Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

The Preventive Role of Selenium in Inflammatory Response During Coronary Artery Bypass Graft Surgery: A Randomized, Controlled Clinical Trial

Background: Coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB) triggers a profound systemic inflammatory response and sympathetic nervous system activation translated into post-operative adverse outcomes. Objectives: The current study aimed at determining whether preparative use of selenium could reduce the severity of inflammatory reaction to surgery. Methods: The current randomized, double-blind clinical trial was conducted at the Department of Cardiac Surgery of Dr. Heshmat Hospital; a referral center affiliated to Guilan University of Medical Sciences (GUMS), Rasht, Iran. From May 2015 to September 2015 one hundred and fourteen patients who were candidates for elective CABG were randomly recruited to receive either an intravenous bolus of 600 µg Se before induction of anesthesia in the group S (n = 56) or normal saline as placebo in the group C (n = 58). To measure white blood cells (WBC) serum levels, blood samples were collected preoperatively (T0) and three times after CPB initiation immediately after the end of CPB (T1), as well as 24 (T2) and 48 hours (T3) after surgery. Statistical tests including chi-square, the Kruskal-Wallis, and independent t tests, as well as repeated measurement ANOVA were used to analyze the data. Results: There was no significant difference between the two groups regarding the baseline characteristics (P = 0.0512). There was no significant difference between the two groups in other four time points; T0 (P = 0.0512), T1 (P = 0.571), T2 (P = 0.974), and T3 (P = 0.215), although the trend of changes was statistically significant in each group (P = 0.0001), the intergroup comparisons showed no significant changes (P = 0.166). Conclusions: There was no strong evidence that a single-dose of Se could reduce inflammation following CABG surgery.

Elevated Pulse Pressure in Anesthetized Subjects Before Cardiopulmonary Bypass Is Associated Strongly With Postoperative Acute Kidney Injury Stage

To investigate whether pulse pressure (PP) in anesthetized patients undergoing cardiac surgery before and after cardiopulmonary bypass (CPB) is associated with higher postoperative acute kidney injury (AKI) stage. Retrospective cohort of 597 patients undergoing cardiac surgery. Single academic health care center. Adult patients undergoing cardiac surgery requiring CPB (coronary artery bypass grafting, valve, aortic, or combined surgery). Pulse pressure was assessed during 3 time periods: pre- and post-CPB, and in the first postoperative hour in the intensive care unit. Pulse pressure, patient characteristics, and intraoperative variables were evaluated using univariable generalized estimating equation analysis for a relationship with AKI stage. Significant risk factors from the univariable analysis then were evaluated in a multivariable generalized estimating equation analysis. Acute kidney injury stage was defined using the Acute Kidney Injury Network criteria. Stage of postoperative AKI. Intraoperative prebypass PP was associated independently and significantly with postoperative AKI stage (odds ratio 1.0107; 95% Confidence Interval, 1.0046-1.0168; p = 0.0005). For every 1-mmHg increase in PP, the odds of a higher AKI stage increased 1.07%. The 2 other periods were not found to be significant predictors of AKI stage. During general anesthesia prior to initiation of CPB, elevated PP is significantly predictive of postoperative AKI stage. This finding merits further research.

Minimal invasive coronary bypass surgery the robotic total endoscopic approach

The aim of this paper is to present the latest recommendations for practitioners for preoperative preparation, surgical procedures and postoperative treatment in patients with myocardial revascularization using robotic total endoscopic coronary artery bypass grafting (CARG), which is applied as daily clinical routine practice at the Heart and Vascular Institute, Cleveland Clinic Abu Dhabi. Many patients indicated for coronary bypass surgery may be candidates for robotic total endoscopic CARG. The paper illustrates eligibility criteria of this procedure, preoperative assessment and preparation principles, peripheral access for cardiopulmonary bypass and port insertion, then graft harvesting procedure, initiation of cardiopulmonary bypass and application of endoaortic clamping, identification and exposure of the target vessels, anastomosis procedure and postoperative care in this group of patients.

Cerebral Circulation During Retrograde Cerebral Perfusion: Evaluation Using Laser Speckle Flowgraphy

The cerebroprotective effect of retrograde cerebral perfusion (RCP) and selective antegrade cerebral perfusion (SCP) still remains controversial. Laser speckle flowgraphy has shown much promise for novel perioperative neuromonitoring by assessing blood flow of the optic nerve head. This study aimed to evaluate the cerebral microcirculation in humans using laser speckle flowgraphy during simple circulatory arrest, RCP, and SCP under moderate hypothermia and to investigate whether RCP under moderate hypothermia is a reliable method of cerebral protection. A total of 23 consecutive patients who underwent a scheduled aortic arch or hemiarch surgical procedure on thoracic aorta aneurysm were enrolled. The laser speckle flowgraphy measurement that calculates mean blur ratio, a parameter of cerebral circulation, was obtained 6 times: after induction of anesthesia, baseline (T1), after initiation of cardiopulmonary bypass with cardiac arrest (T2), simple circulatory arrest (T3), RCP (T4), SCP (T5), and after the termination of cardiopulmonary bypass (T6). Both mean blur ratios of simple circulatory arrest and RCP were significantly decreased compared with baseline. In contrast, no significant differences were observed between simple circulatory arrest and RCP. The mean blur ratio of SCP was significantly increased compared with both simple circulatory arrest and RCP. In conclusion, no significant difference was observed in the cerebral circulation between RCP and simple circulatory arrest without adjunctive strategy under moderate hypothermia. In contrast, the cerebral circulation during SCP was significantly higher than simple circulatory arrest and RCP. These results suggest that cerebral microcirculation may not be adequate during RCP compared with SCP under moderate hypothermia.

Heparin dose calculated according to lean body weight during on-pump heart surgery.

The aim of this study is to compare heparin dose regimen calculated based on the lean body weight with traditional heparin regimen in terms of ensuring adequate anticoagulation and complications associated with perioperative bleeding. This prospective, single-blind, randomized study included a total of 100 adult patients (42 males, 58 females; mean age 52.7 years; range, 22 to 84 years) undergoing elective valve surgery with cardiopulmonary bypass between June 2016 and January 2017. Prior to cardiopulmonary bypass, heparin dose was adjusted as 4 mg/kg, according to the actual body weight (n=50) and lean body weight (n=50). The minimal activated clotting time target value was accepted as 480 sec for cardiopulmonary bypass initiation. Demographic and hemodynamic data, post-heparin activated clotting time, additional heparin and perioperative transfusion, postoperative drainage volumes, reoperations, and mortality were recorded. Demographic data, cross-clamp and cardiopulmonary bypass times, and intraoperative transfusion requirement were not significantly different between the groups. The initial and total doses of heparin, as well as the total dose of protamine, were significantly higher in the actual body weight group. Postoperative transfusion rates were also higher in this group. None of the patients in the lean body weight group required reoperation, while three patients in the actual body weight group underwent reoperation. Our study results showed that adequate anticoagulation was achieved with the titration of heparin dose calculated according to the lean body weight during cardiopulmonary bypass and reduced total heparin and protamine doses decreased postoperative bleeding and blood product transfusion requirement.

Anesthesia Considerations for Lead Extraction.

The role of the anesthesiologist in lead extraction procedures is multifaceted and highlights the collaborative, multidisciplinary teamwork needed to ensure patient safety and procedural success in these complex cases. Thorough preoperative evaluation and identification of high-risk characteristics enable the anesthesiologist to tailor a comprehensive intraoperative and postoperative care plan for each case. Institutional practices may vary but anesthetic management typically includes general anesthesia with an endotracheal tube, invasive measurement of arterial blood pressure, vascular access for rapid volume expansion, echocardiographic monitoring, preparation for blood transfusion, and initiation of cardiopulmonary bypass in the event of an emergency.

Cutaneous microcirculation during operations with a cardiopulmonary bypass.

Cutaneous microcirculation (cMC) is influenced by many factors. In cardiac surgery, most operations are performed with a cardiopulmonary bypass (CPB) and cardiac arrest induced by cardioplegic solutions. Aim of this study was to examine a correlation between cMC and hemodynamic parameters in patients undergoing heart surgery with two different cardioplegic solutions. 20 patients were included and divided into Histidine-Tryptophane-α-Ketoglutarate solution- (HTK, n = 10) and blood cardioplegia- (BCP, n = 10) groups. With initiation of CPB, cMC was continuously monitored with Laser-Doppler-Perfusion (LDP) until termination of CPB. Additionally, we measured hemoglobin-concentration (HbC) with a Blood-Parameter-Monitoring-System. LDP pulsation was almost equal before and after CPB and decreased during aortic cross clamping. The following factors influenced LDP: central venous pressure (CVP), mean arterial pressure (MAP), total peripheral resistance (TPR) and flow of the heart-lung machine. We measured relative LDP and HbC (RLDP; RHbC). Five and 25 min after administration of cardioplegia, RLDP (1.22±0.8; 1.17±0.94) and RHbC (0.92±0.06; 0.96±0.09) in the HTK-group were lower than in the BCP-group: RLDP (1.58±1.11; 1.58±2.2) and RHbC (1.00±0.05; 0.99±0.13). HTK-patients with a body surface area (BSA) <2 m2 showed a lower RLDP (0.75±0.50), than patients over 2 m2 (RLDP = 1.64±0.97). The cMC is influenced by CPB. Cutaneous LDP monitoring is a non-invasive method, for estimating hemodynamics intraoperatively.

Predictors of Heparin Resistance Before Cardiovascular Operations in Adults

Heparin resistance (HR) is often encountered during cardiovascular operations that require cardiopulmonary bypass. Clinical risk factors and the mechanism underlying heparin resistance are yet to be determined. The aim of this study was to elucidate the clinically valid preoperative predictors related to HR. The study evaluated 489 patients undergoing cardiovascular operations. Of these, 25 patients presented with HR and received antithrombin III for the initiation of cardiopulmonary bypass with an effective activated coagulation time. The remaining 464 patients, who did not receive antithrombin III, served as controls (NHR). Preoperative patient demographic and laboratory data were analyzed to identify risk factors for HR. The preoperative laboratory data showed platelet count, fibrinogen, D-dimer, creatinine, and C-reactive protein were significantly higher in the HR group than in the NHR group. As expected, the antithrombin III level was significantly lower overall in theHRgroup (86.0% vs 95.5%, p= 0.009); however, 80% of the patients in the HR group showed normal antithrombin III levels preoperatively. Multivariable logistic regression analysis identified chronic aortic dissection, chronic obstructive pulmonary disease, smoking, and elevated fibrinogen levels as independent predictors for HR. HR was shown to be associated with preoperative high fibrinogen levels, a smoking habit, and a preoperative diagnosis of chronic, but not acute, aortic dissection, with chronic obstructive pulmonary disease as comorbidity. Administration of antithrombin III resolved HR in all of the affected patients, even when their preoperative antithrombin III level was within the normal limit.

Acute Kidney Injury Biomarkers Predict an Increase in Serum Milrinone Concentration Earlier Than Serum Creatinine-Defined Acute Kidney Injury in Infants After Cardiac Surgery.

Milrinone, an inotropic agent used ubiquitously in children after cardiac surgery, accumulates in acute kidney injury (AKI). We assessed if urinary AKI biomarkers are predictive of an increase in milrinone concentrations in infants after cardiac surgery. Multicenter prospective pilot study of infants undergoing cardiac surgery. Urinary AKI biomarkers were measured in the urine at specific time intervals after cardiopulmonary bypass initiation. AKI was defined using the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Serum milrinone concentrations were measured at specific intervals after drug initiation, dose changes, and termination. Excessive milrinone activity was defined as a 20% increase in serum concentration between 6 and 36 hours after initiation. The temporal relationship between urinary AKI biomarker concentrations and a 20% increase in milrinone concentration was assessed. AKI occurred in 31 (33%) of infants. Milrinone clearance was lower in patients with AKI (4.2 versus 5.6 L/h/70 kg; P = 0.02). Excessive milrinone activity was associated with development of serum creatinine-defined AKI [odds ratio (OR) 3.0; 95% confidence interval (CI), 1.21-7.39; P = 0.02]. Both tissue inhibitor metalloproteinase type 2 and insulin-like growth factor-binding protein type 7 (TIMP-2*IGFBP-7) ≥0.78 at 12 hours (OR 2.72; 95% CI, 1.01-7.38; P = 0.04) and kidney injury molecule 1 (KIM-1) ≥529.57 at 24 hours (OR 2.76; 95% CI, 1.06-7.17; P = 0.04) predicted excessive milrinone activity before a diagnosis of AKI. In this pilot study, urine TIMP-2*IGFBP-7 and KIM-1 were predictive of AKI and excessive milrinone activity. Future studies that include a pharmacodynamics assessment of patient hemodynamics, excessive milrinone activity, and AKI biomarker concentrations may be warranted to integrate this concept into clinical practice.

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study

Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

STS/SCA/AmSECT Clinical Practice Guidelines: Anticoagulation during Cardiopulmonary Bypass

Despite more than a half century of “safe” cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, the Society of Thoracic Surgeons (STS), the Society of Cardiovascular Anesthesiologists (SCA), and the American Society of Extracorporeal Technology (AmSECT) developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered together to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation for CPB using the available evidence. To identify relevant evidence a systematic review was outlined and literature searches were conducted in PubMed® using standardized MeSH terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published prior to 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the AHA/ACCF Task Force on Practice Guidelines. Recommendations were written in the three following areas 1) Heparin dosing and monitoring for initiation and maintenance of CPB, 2) Heparin contraindications and heparin alternatives, 3) Reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and expand upon the evidence base on the topic of anticoagulation for CPB.

The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines-Anticoagulation During Cardiopulmonary Bypass.

Despite more than a half century of "safe" cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation therapy for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of Extracorporeal Technology developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation therapy for CPB using the available evidence. To identify relevant evidence, a systematic review was outlined and literature searches were conducted in PubMed using standardized medical subject heading (MeSH) terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts, which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published before 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Recommendations were written in the three following areas: (1) heparin dosing and monitoring for initiation and maintenance of CPB; (2) heparin contraindications and heparin alternatives; and (3) reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and to expand on the evidence base on the topic of anticoagulation therapy for CPB.

Differences in perioperative femoral and radial arterial blood pressure in neonates and infants undergoing cardiac surgery requiring cardiopulmonary bypass

ObjectiveSeveral reports claim that blood pressure (BP) in the radial artery may underestimate the accurate BP in critically ill patients. Here, the authors evaluated differences in mean blood pressure (MBP) between the radial and femoral artery during pediatric cardiac surgery to determine the effectiveness of femoral arterial BP monitoring. MethodThe medical records of children under 1 year of age who underwent open‐heart surgery between 2007 and 2013 were retrospectively reviewed. Radial and femoral BP were measured simultaneously, and the differences between these values were analyzed at various times: after catheter insertion, after the initiation of cardiopulmonary bypass (CPB‐on), after aortic cross clamping (ACC), after the release of ACC, after weaning from CPB, at arrival in the intensive care unit (ICU), and every 6h during the first day in the ICU. ResultsA total of 121 patients who underwent open‐heart surgery met the inclusion criteria. During the intraoperative period, from the beginning to the end of CPB, radial MBPs were significantly lower than femoral MBPs at each time‐point measured (p<0.05). Multivariate analysis showed that longer CPB time (>60min, odds ratio: 7.47) was a risk factor for lower radial pressure. However, discrepancies between these two values disappeared after arrival in the ICU. There was no incidence of ischemic complications associated with the catheterization of both arteries. ConclusionThe authors suggest that femoral arterial pressure monitoring can be safely performed, even in neonates, and provides more accurate BP values during CPB‐on periods, and immediately after weaning from CPB, especially when CPB time was greater than 60min.

The Influence of Intraoperative Autotransfusion on Postoperative Hematocrit after Cardiac Surgery: A Cross-Sectional Study

Utilization of intraoperative autotransfusion (IAT) during cardiac surgery with cardiopulmonary bypass (CPB) has been shown to reduce allogeneic red blood cell transfusion. Previous 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 February 2016 and January 2017 at 84 hospitals throughout the United States. Data were collected prospectively from adult patients undergoing cardiac surgery with CPB, and stored in the SpecialtyCare Operative Procedural rEgistry (SCOPE), a large quality improvement 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 +2.00%, whereas those with more than 380 mL/m2BSA had a median Hct drift of +5.00% (p&lt; .001). After controlling for known confounds, our regression estimate of the effect of IAT volume returned on Hct drift was +.0045% per 1 mL/m2BSA (p&lt; .001). For a patient with the median autotransfusate volume returned (273 mL/m2BSA), and all other covariate values at their respective medians, this translates to a predicted hematocrit change of +3.6% (95% CI +3.1 to +4.1). These findings lend further support to the notion that autotransfusate volume is positively associated with increases in postoperative hematocrit.