Perfusion
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Delays in initiating extracorporeal membrane oxygenation (ECMO) in the critically ill pediatric patient may lead to adverse outcomes. Maintaining a primed ECMO circuit can considerably reduce the initiation time. The predominant concerns precluding this practice are a decrease in oxygenator efficiency due to the saturation of microporous hollow fibers and compromised sterility when the oxygenator has been primed for 30 days. ⋯ After 6 hours of use, the average transfer values all decreased to 111.4+/-2.1 (@ 55% SvO2, p <0.05 versus control), 104.0+/-5.6 (@ 65% SvO2, p <0.05 versus control) and 88.4+/-3.2 (@ 75% SvO2, p <0.05 versus control). In conclusion, there was a decrease in the average oxygen transfer values for the test group after 6 hours versus the control. The modest loss of oxygen transfer ability observed can be considered acceptable due to the amount of surface area of the Minimax Plus oxygenator when used on a neonate, making it feasible to adopt the practice of prepriming the Minimax oxygenator for neonatal ECMO.
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Due to the short supply of donor organs available, many patients decompensate or die while waiting for transplantation. Options for mechanical support for infants and pediatrics with congenital heart disease are limited because of the patient's size and device availability. Extracorporeal membrane oxygenation (ECMO) is the most common means of cardiac and respiratory support for these patients. ⋯ Converting the ECMO circuit to an open cardiopulmonary bypass system in the OR minimizes the patient's exposure to new circuitry, decreases further donor exposures and provides continuous support for patients in cardiac and/or respiratory failure. In addition, the ability to use modified ultrafiltration post-bypass aids in reducing extracellular fluid, increasing the hematocrit and improving hemodynamic stability following an extended duration of ECMO and bypass support. The integrity of the ECMO circuit is maintained and can be converted back to ECMO for support postoperatively if needed.
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Routine administration of large amounts of pain and sedative medication is common to critically ill pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) for cardiopulmonary failure. It has been our experience that pediatric patients are the most difficult age group in which to achieve an ideal pain and sedative control due to the narrow margin of safety. The purpose of this study was to determine the general practice guideline used for pain and anxiolytic pharmacotherapy for pediatric patients at ECMO centers. ⋯ Of the 46 responding centers (including telephone follow-ups), 37 (80%) centers had an active pediatric ECMO programs for patients with severe respiratory failure. Fentanyl was the most commonly used pain medication and continuous infusion, administered directly to the patient, was preferred. Subjective effectiveness of various pharmacological agents was variable without clear consensus; however, midazolam was considered to be the most effective agent used.
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To report a single case of oxygenator failure caused by clot embolism originating from the bladder; and to discuss some preventative options. ⋯ There is a need for improvement in the design of small oxygenators and ECMO circuits. Adjustment of the coagulation parameters and lowering the tolerance towards clots in the circuit by electively changing them may reduce the incidence of sudden unexpected oxygenator failure. However, using a slightly larger Medos oxygenator may gain valuable time needed to arrange an oxygenator/circuit change.
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Clinical Trial Controlled Clinical Trial
Use of a dynamic bubble trap in the arterial line reduces microbubbles during cardiopulmonary bypass and microembolic signals in the middle cerebral artery.
Neurological complications remain an important cause of morbidity and mortality of patients following cardiopulmonary bypass (CPB). Microemboli, as well as cerebral hypoperfusion, are the main postulated mechanisms. This study demonstrates that the insertion of a dynamic bubble trap (DBT) into the curcuit reduces microbubbles in the arterial line and microembolic signals (MES) in the middle cerebral arteries (MCAs). ⋯ After inclusion of a DBT, we could register, in the second group, 8496 microemboli proximal and 2915 distal of the DBT, corresponding to 89 MES per operation. The reduction rate of microbubbles in the tubing was 65.7%, corresponding to a reduction in MES of about 86.2%. We conclude that the insertion of a DBT in the arterial line of CPB circuit protects the cerebrovascular system from microembolic events, as demonstrated by lower MES counts.