The Journal of extra-corporeal technology
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J Extra Corpor Technol · Mar 2014
EditorialTeamwork, communication, formula-one racing and the outcomes of cardiac surgery.
Most cardiac units achieve excellent results today, but the risk of cardiac surgery is still relatively high, and avoidable harm is common. The story of the Green Lane Cardiothoracic Unit provides an exemplar of excellence, but also illustrates the challenges associated with changes over time and with increases in the size of a unit and the complexity of practice today. The ultimate aim of cardiac surgery should be the best outcomes for (often very sick) patients rather than an undue focus on the prevention of error or adverse events. ⋯ Minor events are as important as major ones. Six approaches to improving teamwork (and hence outcomes) in cardiac surgery are suggested. These are: 1) subspecialize and replace tribes with teams; 2) sort out the leadership while flattening the gradients of authority; 3) introduce explicit training in effective communication; 4) use checklists, briefings, and debriefings and engage in the process; 5) promote a culture of respect alongside a commitment to excellence and a focus on patients; 6) focus on the performance of the team, not on individuals.
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J Extra Corpor Technol · Mar 2014
Comparative StudyComparison of routine laboratory measures of heparin anticoagulation for neonates on extracorporeal membrane oxygenation.
Our objective was to determine the best measure of heparin anticoagulation in neonatal patients on extracorporeal membrane oxygenation. Activated clotting time (ACT), activated partial thromboplastin time (aPTT), and antifactor Xa levels, along with corresponding heparin infusion rates and heparin bolus volumes, were collected from neonates receiving ECMO at our institution from 2008 to 2013. After natural log transformation of antifactor Xa, ACT, and aPTT, overall correlations between antifactor Xa levels and either ACT or aPTT and correlations between these tests and heparin infusion rates were evaluated using linear mixed models that accounted for both within- and between-patient correlations. ⋯ In contrast, between patients, only aPTT maintained a direct correlation with antifactor Xa (r = .61, p = .07), whereas ACT showed a statistically significant inverse correlation with antifactor Xa (r = -.48, p = .04). Compared with ACT, aPTT is more consistently reflective of the anticoagulation status both within each patient on ECMO and between patients treated with ECMO. Future efforts to develop standardized heparin infusion algorithms for patients on ECMO should consider using aPTT levels to monitor anticoagulation.
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J Extra Corpor Technol · Mar 2014
Case ReportsBivalirudin in venovenous extracorporeal membrane oxygenation.
Optimal anticoagulation plays a pivotal role in successful outcome of extracorporeal membrane oxygenation (ECMO). Heparin has been the anticoagulant of choice owing to its advantages like easy monitoring and reversibility. However, if heparin resistance is encountered, one has to decide whether to treat heparin resistance with fresh-frozen plasma or antithrombin concentrates or to choose one of the heparin alternatives for anticoagulation. ⋯ We found a bivalirudin dose of .1-.2 mg/kg/h to be adequate to maintain a target activated clotting time of 200-220 seconds. Platelet counts were stable throughout and no major bleeding or thrombotic complications took place. We found bivalirudin to be a feasible and effective anticoagulant and safe to use for long durations in ECMO without any major complications.
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J Extra Corpor Technol · Mar 2014
Comparative StudyCan the oxygenator screen filter reduce gaseous microemboli?
Gaseous microemboli (GME) define small bubbles as < 200 microm in size. GME are reported to increase morbidity after cardiopulmonary bypass (CPB) and cardiac surgery. To prevent intrusion of GME into the systemic circulation during CPB, arterial line filtration is generally recommended. ⋯ At 6 L/min, the reduction was 97.9% +/- .1% compared with 97.0% +/- .1% (p < .001). In contrast, the reduction of GME counts was less effective after screen filtration compared with controls: 89.6 +/- .6% versus 91.4 +/- .4% at 4 L/min and 55.6% +/- 1.6% versus 76.0% +/- 1.4% at 6 L/min, respectively (p < .001). The tested oxygenator with incorporated arterial screen filter reduced GME activity based on the calculated volume at the same time as counts of GME increased.
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J Extra Corpor Technol · Mar 2014
Does removing Mannitol and Voluven from the priming fluid of the cardiopulmonary bypass circuit have clinical effects?
The Auckland Hospital cardiothoracic unit recently removed Mannitol and Voluven from its Plasma-lyte-based cardiopulmonary bypass (CPB) priming fluid. Like with any change to practice, a comprehensive audit should be performed to identify positive or negative effects. The aim of this retrospective analysis was to investigate the effect of changing the CPB prime constituents on fluid balance and clinical outcome parameters. ⋯ Mannitol and Voluven, like with all drugs, carry their own potential adverse effects. This study demonstrates that removing Mannitol and Voluven from priming fluid did not have any detrimental effect on electrolytes, fluid status, and other important outcomes in this consecutive series of patients having primary isolated CABG surgery. The risk-benefit balance combined with the obvious economic benefit clearly favors removing Mannitol and Voluven from priming fluids.