Perfusion
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We describe a single-centre experience of extracorporeal life support (ELS) for patients with severe and refractory cardiogenic shock, refractory cardiac arrest and severe respiratory failure. ⋯ Our results exemplify the benefits of ELS as a bridge to initial stabilization of critically ill patients. Potentially, the early application of ELS technology can lower mortality and morbidity in patients with a regressive pathology.
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Randomized Controlled Trial
Evidence-based use of FFP: the influence of a priming strategy without FFP during CPB on postoperative coagulation and recovery in pediatric patients.
Although fresh frozen plasma (FFP) is one of the most commonly used hemostatic agents in clinical specialties today, there is little evidence available supporting its administration. Our present study observed the effects of a priming strategy without FFP during cardiopulmonary bypass (CPB) on postoperative coagulation and clinical recovery in pediatric patients, aiming to supply new evidence for evidence-based use of FFP. ⋯ In conclusion, prophylactic use of FFP in the priming solution does not provide clinical benefits as presumed. Artificial colloids, such as Gelofusine, can be used safely and effectively as a substitute for FFP in the pump prime. TEG is an effective assessment tool to evaluate postoperative coagulation function in pediatric patients.
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Clinical Trial
Effects of priming volume reduction on allogeneic red blood cell transfusions and renal outcome after heart surgery.
Excessive hemodilution during cardiopulmonary bypass (CPB) is associated with an increased rate of red blood cell (RBC) transfusion and acute kidney injury (AKI). Minimization of the oxygenator priming volume is a measure to contain hemodilution. In this study, we evaluated the new oxygenator, Sorin Inspire 6™, with respect to its ability to limit hemodilution, RBC transfusion rate and postoperative AKI rate. ⋯ The Inspire 6™ oxygenator allows a significant containment of hemodilution during CPB, reducing the risk of RBC transfusions and postoperative AKI.
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A 30-year-old female gravida 1 (37 weeks + 5 days gestation) underwent a crash Cesarean section for evidence of fetal distress, with the presumed diagnosis of placental abruption. Immediately post-op, the patient had a complete cardiovascular collapse with pulseless electrical activity, requiring cardiopulmonary resuscitation (CPR). Two doses of thrombolytics (Tenecteplase) were administered during the resuscitation, with a presumed diagnosis of a pulmonary embolism. After approximately 45 minutes into the resuscitation, the cardiac surgery team was called to initiate extracorporeal membrane oxygenation (ECMO). ⋯ Veno-arterial (V-A) ECMO was emergently attempted, with difficulty, through a left femoral cut-down approach and was successfully initiated 84 minutes into the resuscitation. Once the patient's blood pressure and oxygen saturations were stabilized, the cannulae were switched to the right groin, using a Dacron graft in an end-to-side fashion. The left groin vessels were small and spasmodic due to CPR, hypotension, hypovolemia and massive inotropes. The switch helped to facilitate repair of the left femoral vessels in order to restore perfusion to the left leg. Computer tomography (CT) demonstrated multiple pulmonary emboli at the sub-segmental branches bilaterally. The patient was transferred to the intensive care unit (ICU) with profound bleeding from all incisions and a massive transfusion protocol was instituted. ECMO flows varied, depending on the intravascular volume status of the patient. The patient was cooled to 33(o)C for cerebral protection. Initial blood work 5 minutes on from the initiation of ECMO revealed a pH of 7.10 and lactate >15 mmol/L. Over the next 12 hours, oxygen saturations in the right arm began to fall (29% right vs. 77% left); as the left ventricular ejection improved, the heart began to eject deoxygenated blood from the impaired pulmonary system. At the same time, the patient was developing an abdominal compartment syndrome from ongoing intraperitoneal bleeding. To avoid hypoxic cerebral and myocardial disruption of arterial ECMO flows from the femoral vessels during laparotomy, the decision was made to switch from the femoral to central right axillary artery cannulation in the hope of improving brain oxygenation for the procedure. The patient's hemodynamics and coagulation status stabilized, but, over the next few days, she developed a right arm compartment syndrome, requiring fasciotomies. At this time, her myocardial function improved and the patient was converted from V-A ECMO to a single, dual-lumen Avalon cannula for veno-venous (V-V) ECMO through the right internal jugular vein. It was felt that the lungs required more time to recover, therefore, V-V ECMO was used. The patient was weaned from V-V ECMO successfully on post-operative day (POD) 4. The duration of ECMO was 3.5 days (81 hours). The patient required 4 cannulation sites to optimize flow and perfusion with changing clinical conditions. On POD 46, the patient was discharged from hospital without any physical or neurological sequelae.
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We evaluate the affect on the hematocrit (Hct) drop and the amount of transfused red blood cells (RBCs) during cardiopulmonary bypass (CPB) in adult cardiac surgery patients due to minimizing the CPB circuit by using integrated components. ⋯ Minimizing our CPB circuit by using integrated components has affected the drop of Hct and the amount of transfused RBCs.