Portable Pump Research Articles

Apomorphine in the Treatment of Parkinson’s Disease

The majority of patients with Parkinson’s disease (PD) develop motor fluctuations and dyskinesias as their condition progresses. In patients where adjustments of oral (or transdermal) treatment options can no longer adequately control these motor complications, further options include deep-brain stimulation for a minority of selected patients, intrajejunal levodopa (L-dopa) application via a pump or apomorphine infusion therapy. The dopamine agonist apomorphine provides relief from off periods when administered as a subcutaneous injection. When applied continuously via a portable pump system, oral medication can often be reduced considerably and dyskinesias improve in many patients.

５‐フルオロウラシルの充填方法が携帯型ポンプ内薬液濃度の均一性に与える影響

As the effect of the filling process of portable pumps on the homogeneity of drug concentrations had not been investigated,in this study,we examined the influence of the filling process of the anticancer agent 5-fluorourcil (5-FU) and saline in this respect.We used 3 types of pump and filled the pump in 3 different ways (5-FU first and then saline,saline first and then 5-FU,and mixing 5-FU and saline beforehand and then filling).There was a significant variation in the 5-FU concentration when 5-FU and saline were added separately but the drug concentration did not vary when 5-FU and saline were mixed before filling the pumps.The result also varied with the type of pump.Our findings suggested that the drug and saline were not mixed uniformly in some types of pump when 5-FU and saline were added separately.Therefore,it is important to mix the drug and saline well before filling pumps.

Continuous dopaminergic stimulation achieved by duodenal levodopa infusion

Continuous dopaminergic stimulation is the ideal approach for the management of Parkinson's disease (PD); this goal can be partially reached with dopamine agonists, but the need for a therapeutic strategy providing a strong and constant dopaminergic stimulation also in the advanced phase of the disease remains unmet. The application of levodopa/carbidopa-gel suspension directly in the duodenum (Duodopa) allows a continuous delivery by a portable pump, resulting in smoother levodopa plasmatic concentrations, and consequently in a physiologic continuous receptor stimulation. Clinical studies have demonstrated that duodenal infusion was associated with significantly better outcome compared to conventional treatment regarding global functioning, ability to walk, "off" time and motor fluctuations. A retrospective analysis of the long-term clinical experience with Duodopa evidenced that daily dose of levodopa decreased by 5% during follow-up. The profile of pharmacological adverse events of Duodopa was similar to that observed with oral administration; dislocation of the intestinal tube to the stomach was the most common technical problem.

Devices for the treatment of diabetes: today.

Although single or multiple daily subcutaneous injections of insulin with syringes are the mainstay of insulin delivery techniques for the treatment of diabetes mellitus, several other methods are now available. The present paper will review the main problems occurring with the classical subcutaneous insulin therapy and the possible solutions given by the use of new devices, including more particularly insulin jet injectors, pens, and portable pumps. This review has to be considered as an introduction to the presentations of this symposium devoted to implantable pumps, glucose sensors, and artificial pancreas, respectively.

Infusate Contamination in Regional Anesthesia: What Every Anesthesiologist Should Know

Infection can be a devastating complication of regional anesthesia. Contaminated infusate as a cause of infection in neuraxial anesthesia or peripheral nerve blockade has rarely been reported in the literature. However, it may be an important source of morbidity, especially as increasing numbers of patients are being discharged with perineural catheters and portable pumps of local anesthetic, which may infuse for several days at home. Two important issues related to infusate contamination in regional anesthesia are that of "hang-time" and sterile compounding practices. Hang-time can be defined as the maximum length of time during which an admixture preparation (infusate) can be safely administered without risk of microbiological or chemical instability. In the United States, there are currently no national guidelines on the hang-times of regional anesthesia infusates. On the other hand, guidelines for the sterile compounding of infusions used in regional anesthesia are now established by United States Pharmacopeia and The National Formulary Chapter 797, entitled "Pharmaceutical Compounding, Sterile Preparations." These guidelines have significant implications for the anesthesiologist. In this review, we examined the available literature regarding contaminated infusate as a cause of infection in regional anesthesia, to discuss strategies for the prevention of such contamination including the appropriate hang-time for infusates, and to discuss the implications of United States Pharmacopeia and The National Formulary Chapter 797 for anesthesiologists.

Ambulatory Continuous Posterior Lumbar Plexus Nerve Blocks after Hip Arthroplasty

The authors tested the hypotheses that after hip arthroplasty, ambulation distance is increased and the time required to reach three specific readiness-for-discharge criteria is shorter with a 4-day ambulatory continuous lumbar plexus block (cLPB) than with an overnight cLPB. A cLPB consisting of 0.2% ropivacaine was provided from surgery until the following morning. Patients were then randomly assigned either to continue ropivacaine or to be switched to normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation > or = 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cLPB and a portable infusion pump, and catheters were removed on the fourth postoperative day. Patients given 4 days of perineural ropivacaine (n = 24) attained all three discharge criteria in a median (25th-75th percentiles) of 29 (24-45) h, compared with 51 (42-73) h for those of the control group (n = 23; estimated ratio = 0.62; 95% confidence interval, 0.45-0.92; P = 0.011). Patients assigned to receive ropivacaine ambulated a median of 34 (9-55) m the afternoon after surgery, compared with 20 (6-46) m for those receiving normal saline (estimated ratio = 1.3; 95% confidence interval, 0.6-3.0; P = 0.42). Three falls occurred in subjects receiving ropivacaine (13%), versus none in subjects receiving normal saline. Compared with an overnight cLPB, a 4-day ambulatory cLPB decreases the time to reach three predefined discharge criteria by an estimated 38% after hip arthroplasty. However, the extended infusion did not increase ambulation distance to a statistically significant degree.

Side effects of pulsatile GnRH therapy for induction of ovulation

Summary Pulsatile administration of GnRH by means of a portable pump is an efficient and practical method for the induction of ovulation as a treatment of infertility in hypothalamic amenorrhea. It represents a replacement therapy based on physiological observations. Since the feedback mechanisms between the ovary and pituitary gland remain intact, it is associated with a very low risk of multiple follicular devel -opment and multiple pregnancies. However, the results obtained with this method are critically dependent upon the correct selection of patients as far as the diagnosis of hypothalamic amenorrhea is con -cerned. If this is the case, pulsatile GnRH therapy is safe, associated with a very low risk of multiple pregnancy and, therefore, has to be considered as the therapy of choice in hypothalamic amenorrhea. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.

Deux mythes concernant l’exercice chez le diabétique de type 1 : le seuil hyperglycémique de 2,5 g/l de contre-indication à l’effort et le glucose pulse

Aims We addressed the relevance of two usual beliefs about blood glucose response to exercise in insulin-treated diabetic patients. First, that a pre-exercise blood glucose value exceeding 250 mg/dL means that exercise should be avoided because it will result in worsening of hyperglycemia; second, the prediction of carbohydrate oxidation according to the level of exercise “glucose pulse” may have some value to predict how blood glucose levels will respond to exercise. Methods Twenty-four type-1 diabetics (12 men and 12 women, age 19–71 years) treated with basal-bolus or continuous insulin delivery by portable pump performed a steady-state exercise on ergocycle at 50% of their predicted P max (40–200 W) with measurement of blood glucose levels, blood lactate, and exercise calorimetry. This protocol lowers blood glucose ( p < 0.05), with a variable magnitude (−4 to −178 mg/dL [mean: −51 ± 9 mg/dL]), i.e., blood glucose decreased in 21 subjects (87.5%). Carbohydrate oxidation rates do not, however, predict the evolution of blood glucose. Baseline blood glucose G 0 (ranging between 89 and 270 mg/dL, i.e., on average 179 ± 14 mg/dL) was in fact negatively correlated (and not positively) to the variation of blood glucose during exercise ( r = −0.462; p < 0.05), so that the higher is G 0 the more blood glucose decreases. When G 0 is greater than 250 mg/dL blood glucose decreased on average by −97 ± 26 mg/dL ( p < 0.05). During these steady state bouts of exercise, which clearly decrease blood glucose, oxidation of carbohydrates does not predict the decline in blood glucose (minimizing the interest of the concept of “glucose pulse”), and a value of G 0 greater than 250 mg/dL does not predict exercise hyperglycemia so that it is no longer logic to set this value as a threshold for counter indicating exercise.

Development of a two-site enzyme immunoassay based on monoclonal antibodies to measure airborne exposure to (1→3)-β- d-glucan

(1→3)-β- d-glucan is found in cell walls of some fungi, bacteria and plants. It plays a crucial role in bioaerosol-induced inflammatory reactions. To estimate the level of airborne (1→3)-β- d-glucan exposure, a monoclonal antibody-based two-site enzyme immunoassay (mAb-EIA) was developed. The results obtained with the mAb-EIA were compared with the results of a Limulus amoebocyte lysate-based assay for (1→3)-β- d-glucan. Three mAbs produced by mouse immunization with bovine serum albumin-conjugated laminarin were enriched by in vitro production in a modular minifermenter and affinity purified. Two mAbs were selected for the development of a two-site EIA specific for (1→3)-β- d-glucan. Different polysaccharides, fungal and plant seed extracts, and airborne inhalable dust from workplaces (poultry farms, pig stables, grain storage houses, and a laboratory animal facilility) were sampled with portable pumps and measured with both the mAb-EIA and Glucatell ® assay. Using carboxymethylated curdlan as a standard, the mAb-EIA gave a steep dose-response curve for concentrations between 0.36–15 ng/ml. The mAb-EIA was specific for (1→3)-β- d-glucan and was sufficiently sensitive to detect (1→3)-β- d-glucan in airborne dust samples. In comparing the EIA results to the values obtained with the Glucatell ® assay, the correlation was found to be high (coefficient of correlation r 2 = 0.91), and the mean ratio of the values was 1.7. Depending on the dust source, either the Glucatell ® assay or the mAb-EIA gave higher results. The mAb-EIA is sensitive enough to detect (1→3)-β- d-glucan in airborne dust samples collected with portable pumps. Thus, the assay is suited for the investigation of the health effects induced by exposure to this class of biologically active molecules.

Design of an alpha spectrometry system for separated measurement of radon/thoron daughters’ concentration by lexan PC SSNTD

A special system has been designed to measure separately the concentration of radon and thoron alpha emitter's daughters in air. The system components consist of collimators, energy degraders, a filter and a lexan PC (polycarbonate) film, which are integrated and connected to a small portable pump. In this spectrometry method, alpha peaks are resulted from registered track size distribution in a wide energy range of 0.9–5.2 MeV under new electrochemical etching (ECE) conditions. Geometric characteristics of the system components are determined based on the optimization between desirable FWHM and detection efficiency by means of the Monte Carlo simulation method using the Fluka code. The results show that 218Po and 214Po from radon chain and 216Po (which is the representative of thoron concentration), 212Bi and 212Po from thoron chain can be measured separately in a mixed field with the FWHM of less than 0.2 MeV. The sensitivity was calculated to be 8.5 and 0.018 (Track cm −2 kBq −1 m 3 h −1) for radon and thoron, respectively. The radon level can be measured via 218Po concentration using a special measurement setting so that a short-term measurement of equilibrium factor can be performed by this spectrometry method.

A Randomized Double-Blind Crossover Comparison of Continuous and Intermittent Subcutaneous Administration of Opioid for Cancer Pain

ABSTRACT Although the preferred route of opioid administration is oral, patients with cancer often require an alternative route. Options include continuous subcutaneous infusion (CSCI) or regularly scheduled intermittent subcutaneous injections (ISCI). CSCI maintains steady drug levels, theoretically avoiding the "bolus effect" of nausea and sedation immediately post-dose, and breakthrough pain prior to the next dose. However, portable infusion pumps can be costly to use. The Edmonton Injector is an inexpensive portable device for ISCI. CSCI and ISCI have not been directly compared. The objective of this trial was to compare CSCI and ISCI of opioid for treatment of cancer pain. Patients were recruited from two tertiary palliative care units. Eligibility criteria included stable cancer pain requiring opioid therapy, need for parenteral route, and normal cognition. Patients were randomly assigned to receive opioid by CSCI by portable pump or ISCI by Edmonton Injector for 48 hours, followed by crossover to the alternative modality for 48 hours. During each phase, placebo was administered by the alternative modality. The study was closed after 12 patients were entered, due to slow accrual. Eleven patients completed the study. There were no differences between CSCI and ISCI in mean visual analogue score (VAS) for pain, nausea or drowsiness; categorical rating score of pain; number of breakthrough opioid doses per day; global rating of treatment effectiveness; or adverse effects. In all cases, patients and investigators expressed no preference for one modality over another. Further research is required to confirm that opioid administration by CSCI and ISCI provide similar analgesic and adverse effects.

This Month in Anesthesiology

749The goal of in-flight medical assistance is to stabilize the patient and advise the crew as to a diagnosis and treatment.659Breathing hydrogen sulfide induces a “suspended animation-like” state.627Consequences of opioid-induced sleep inhibition are important concerns in postoperative patients.596Iribarren et al . used data obtained from a randomized, double-blind, placebo-controlled study to explore the possible links between genotype and efficacy of tranexamic acid (TA) administered before and after cardiopulmonary bypass surgery. The original 50 study patients (the study had been halted due to a higher rate of excessive bleeding in the placebo group) had been classified according to plasminogen activator inhibitor-1 (PAI-1) genotype. The authors' secondary analysis from this trial revealed that in patients not receiving TA, those with the 5G/5G genotype had significantly higher chest tube blood loss and transfusion requirements compared with other patients. 5G/5G homozygotes who received TA showed the greatest blood-sparing benefit.703Ilfeld et al. compared a 4-day ambulatory continuous femoral nerve block (cFNB) to overnight cFNB in patients who had undergone tricompartment total knee arthroplasty. Compared with those receiving overnight cFNB, patients in the group receiving four days of perineural ropivacaine (via a portable infusion pump) showed a 53% decrease in the time required to reach three important discharge criteria: adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m.634Statins appear to confer greater cardiovascular benefits in diabetic patients. To further elucidate this observed benefit, Gu et al . designed experiments to investigate whether simvastatin improves the beneficial effects of ischemic preconditioning during hyperglycemia in dogs subjected to coronary artery occlusion and reperfusion. Simvastatin restored the cardioprotective effects of ischemic preconditioning during hyperglycemia via nitric oxide–mediated signaling. The results suggest that enhanced cardioprotective signaling could be a mechanism for statin-induced decreases in perioperative cardiovascular risk.568In this issue, McGregor et al . report on their post hoc analysis of data from the large multicenter Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST). In the IHAST, anesthesia was dictated by a limited-options protocol and the decision about using nitrous oxide was left to individual anesthesiologists. Of the 1,000 patients for whom data were available, 373 had received nitrous oxide. According to various instruments used in the IHAST to assess neurologic and neuropsychological outcomes, intraoperative use of nitrous oxide was not associated with delayed ischemic neurologic deficits, long-term neurologic deficits, or neuropsychological deficits. See the accompanying Editorial View on page 553 559This article has been selected for the Anesthesiology CME Program. See the accompanying Editorial View on page 551 .

Ambulatory Continuous Femoral Nerve Blocks Decrease Time to Discharge Readiness after Tricompartment Total Knee Arthroplasty

The authors tested the hypotheses that, compared with an overnight continuous femoral nerve block (cFNB), a 4-day ambulatory cFNB increases ambulation distance and decreases the time until three specific readiness-for-discharge criteria are met after tricompartment total knee arthroplasty. Preoperatively, all patients received a cFNB (n = 50) and perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomly assigned to either continue perineural ropivacaine or switch to perineural normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4. Patients given 4 days of perineural ropivacaine attained all three discharge criteria in a median (25th-75th percentiles) of 25 (21-47) h, compared with 71 (46-89) h for those of the control group (estimated ratio, 0.47; 95% confidence interval, 0.32-0.67; P <0.001). Patients assigned to receive ropivacaine ambulated a median of 32 (17-47) m the afternoon after surgery, compared with 26 (13-35) m for those receiving normal saline (estimated ratio, 1.21; 95% confidence interval, 0.71-1.85; P = 0.42). Compared with an overnight cFNB, a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 53% after tricompartment total knee arthroplasty. However, the extended infusion did not increase ambulation distance the afternoon after surgery. (ClinicalTrials.gov No. NCT00135889.).

Treatment of unstable diabetes with a portable insulin-infusion pump (author's transl)

A portable insulin-infusion pump (Promedos Siemens) was used in 19 patients with unstable or brittle diabetes. Continuous insulin supply was via the intravenous route in nine, subcutaneously in ten patients. The insulin pump was used in those patients in whom, after hospitalization for two to three weeks, the diabetes remained poorly controlled. In all patients the carbohydrate metabolism was normalised. Subcutaneous insulin infusion was as effective as the intravenous one. In all instances it was possible, partly by transferring insulin uptake during the day and night to two subcutaneous injections, to improve conventional control even after the infusion period was over. Continuous, regulated insulin supply - intravenously or subcutaneously - is superior to conventional subcutaneous administration. Portable insulin infusion pumps can be used in individual patients even without glucose sensing.

Enteral Levodopa/Carbidopa Infusion in Advanced Parkinson Disease

In patients with advanced Parkinson disease, levodopa/carbidopa formulated as a gel suspension (Duodopa) permits continuous delivery into the small intestine using a portable pump, resulting in less variability in levodopa concentrations and fewer motor fluctuations and dyskinesias than with oral levodopa administration. This is a retrospective analysis of the long-term clinical experience with this agent. All but 1 of the patients who had received enteral levodopa infusion treatment between January 1, 1991, and June 30, 2002, consented to a review of their hospital charts. Of the 65 patients with initial testing of the treatment, 86% opted for continued treatment via percutaneous endoscopic gastrostomy or gastrojejunostomy. Total exposure to levodopa infusion was 216 patient-years (mean, 3.7 years). Maximum treatment duration was 10.7 years. Fifty-two patients were treated for 1 year or longer. The adverse effect profile of levodopa/carbidopa infusion was similar to that observed with oral administration of levodopa. Seven deaths occurred, all considered unrelated to the treatment. Intestinal tube problems, including dislocation of the intestinal tube to the stomach, were the most common technical problem, occurring in 69% of the patients during the first year. The optimal daily dose of levodopa decreased by an average of 5% during follow-up. The safety of enteral infusion of levodopa/carbidopa formulated as a gel suspension was found acceptable. For most patients, the technical challenges posed by the enteral infusion system were offset by the improvement in motor fluctuations and dyskinesias offered by this technique.

Central Venous Access Port-related Complications in Outpatient Chemotherapy for Colorectal Cancer

The current standard chemotherapy for advanced or metastatic colorectal cancer in Japan is FOLFOX or FOLFIRI therapy. Although both therapies include continuous infusion of 5-fluorouracil (5-FU), outpatient home chemotherapy is possible by placing a central venous access port (CV-port) and using a portable disposable pump. The port system has been placed more frequently since the approval of FOLFOX. Consequently, more complications involving ports and pumps have been encountered. At our hospital, 232 patients with colorectal cancer underwent outpatient home chemotherapy by placing a CV-port and using a portable disposable pump for continuous infusion of 5-FU between 1998 and 2005. Incidence and contents of complications involving ports and pumps were investigated retrospectively. A total of 54 incidents of complications involving ports and pumps were identified in 3142 treatments (1.72%) from among 34 of the 232 patients (14.7%). In 2005, when FOLFOX was introduced, 31 incidents occurred in 1903 treatments (1.63%) for 19 of 149 patients (12.8%). Incidents involved port placement (n = 6), catheter and port system-related complications (n = 15), puncture needle-related complications (n = 3), skin complications related to tape fixation (n = 20) and pump-related complications (n = 10). In 10 patients (4.3%), system-related complications made therapy difficult to continue and system exchange was required. Technical troubles involving ports and pumps occurred at a certain rate, and skin incision was required for system exchange in some cases. When performing outpatient chemotherapy using ports and pumps, thorough prior guidance and double-checking must be implemented, and proper countermeasures must be established.

Effective eradication of oral verrucous carcinoma with continuous intraarterial infusion chemotherapy

We evaluated the effectiveness of intraarterial methotrexate infusion as a primary therapy for oral verrucous carcinoma (VC). Fifteen male patients (mean age, 55 years) were included. By using an implantable port-catheter system and a portable pump, methotrexate was continuously infused to the external carotid artery for a mean period of 7.5 days (50 mg/day), followed by weekly bolus of methotrexate (25 mg) via intraarterial route for a mean period of 10 weeks. The tumor regressed dramatically and disappeared completely after treatment within a mean period of 2.5 months. All patients obtained complete remission and recovered without disfigurement. All patients were alive without disease recurrence at a median follow-up of 43 months. The side effects were tolerable. The results of our treatment modality for oral VC appear to compete favorably with the results of surgical series and even more with those of radiotherapy series.

Stability of Antibiotics in Portable Pumps Used for Bronchial Superinfection: Guidelines for Prescribers

The aims of this study were (1) to collect data on the stability of antibiotics in portable pumps for the treatment of bronchial superinfection in patients with cystic fibrosis and (2) to provide guidelines for prescribers. The stability over 72 hours, in portable pumps stored at 35 degrees C, of piperacillin plus tazobactam, ticarcillin plus clavulanic acid, cefsulodin, cefepime, and aztreonam was checked at 3 different concentrations. Stability was assessed through visual examination, pH measurements, and direct measurements of drug concentrations by using high-performance liquid chromatography. All parameters were measured at time 0, time 0 plus 24 hours, and time 0 plus 72 hours. Degradation rates for penicillin plus beta-lactamase inhibitor combinations remained <10% at time 0 plus 24 hours for all drugs, but the rate for piperacillin reached 12% for the highest concentration tested. The cephalosporins cefepime and cefsulodin had significant respective degradation rates of 18% and 28% at time 0 plus 24 hours and 60% and 68.5% at time 0 plus 72 hours, which were linked to the storage temperature. Aztreonam seemed to be stable over 72 hours. This work provides data on drug stability that were lacking, allowing recommendations for physicians to optimize the safety and efficacy of antibiotic treatment of patients with cystic fibrosis. Piperacillin plus tazobactam and ticarcillin plus clavulanic acid infusions must be limited to 24 hours, and patients receiving cefepime or cefsulodin must wear a cold pack close to the ambulatory drug-delivery device during the infusion.

Muscle infarction in a young woman with brittle type 1 diabetes

We present the first case of muscle infarction in a 30-year-old woman who had a 5-year history of type 1 diabetes mellitus that was not complicated by nephropathy, retinopathy or neuropathy. All common causes of muscle infarction were excluded, particularly microangiopathy and a hypercoagulable state. The differential diagnosis included infection (pyomyositis, necrotic fasciitis), focal inflammatory myositis, vascular events, trauma, tumor and diabetic amyotrophy, all of which were excluded. In spite of good glycaemic control, her diabetes remained brittle; alternating states of transient acute hypoglycaemia and hyperglycaemia may have been responsible for the infarction. Brittleness resumed after treatment with subcutaneous insulin infusion using a portable pump. No recurrence of muscle infarction was observed during a 18-month follow-up.

An Ambulatory Pulmonary and Right Heart Assist Device (OxyRVAD) in an Ovine Survival Model

To develop ambulatory total respiratory and right heart assistance for up to 4 weeks as a bridge to lung transplantation, we coupled a compact gas exchange device with a right ventricular assist device (RVAD), a compact rotary blood pump, to create an "OxyRVAD." Our ambulatory OxyRVAD includes a portable (4 x 4 x 7-cm) centrifugal pump with heparin saline-purged needle roller bearings and an ultra-low-resistant gas exchange device (BioLung, MC3, Ann Arbor, MI). In 6 anesthetized sheep, the main pulmonary artery (PA) and right atrium (RA) were exposed through a left fourth intercostal thoracotomy. A 12-mm outer diameter vascular graft was anastomosed (end-to-side) to the main PA, and a VAD atrial cannula was placed into RA through the RA appendage. The pump and gas exchange device were interposed in circuit for RA-PA support. All 6 sheep survived OxyRVAD insertion. Four sheep survived the 5-day experiment. One was euthanized at 48 hours owing to pump electrical failure (wiring) and another at 72 hours owing to pump bearing failure (broken heparin purge line). One sheep needed replacement of a BioLung due to internal thrombi. OxyRVAD flow was stable (range, 3.57-4.30 liters/min). Carbon dioxide removal was constant during experiment (range, 88.35 +/- 6.12 ml/min at onset to 141.38 +/- 5.48 ml/min at the 96th hour). Oxygen transfer decreased from 161.8 +/- 8.8 to 79.7 +/- 31.4 ml/min at the 96th hour (p = 0.045). Our ambulatory OxyRVAD provided total assistance of right heart and lungs in normal awake sheep for up to 5 days.