The Journal of extra-corporeal technology
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J Extra Corpor Technol · Sep 2014
Case ReportsUsing Zero Balance Ultrafiltration with Dialysate as a Replacement Fluid for Hyperkalemia during Cardiopulmonary Bypass.
Avoiding or managing hyperkalemia during cardiac surgery, especially in a patient with chronic renal insufficiency, can be challenging. Hyperkalemic cardioplegia solution is usually administered to achieve and maintain an electrical arrest of the heart. ⋯ Current strategies to avoid or manage hyperkalemia include minimizing the volume of cardioplegia administered, shifting potassium from the extracellular into the intracellular space (by the administration of sodium bicarbonate when the pH is low and/or dextrose-insulin when effects relatively independent of serum pH are desired), using zero-balanced ultrafiltration (Z-BUF) with normal saline as the replacement fluid (to remove potassium from the body rather than simply shift the electrolyte across cellular membranes), and, occasionally, hemodialysis (1). We report the application of Z-BUF using an electrolyte-balanced, low potassium dialysate solution rather than isotonic saline to avoid a high chloride load and the potential for hyperchloremic acidosis to successfully treat hyperkalemia while on cardiopulmonary bypass.
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J Extra Corpor Technol · Jun 2014
Case ReportsBloodless pediatric cardiopulmonary bypass for a 3.2-kg patient whose parents are of Jehovah's Witness faith.
Patients and parents of Jehovah's Witness (JW) faith present multiple challenges to a medical team, especially in the neonatal and pediatric population. The medical team must balance honoring the parents' request of not receiving blood products and fulfilling our commitment as advocates for the child's wellbeing. ⋯ These protocols include: preoperative erythropoietin, preoperative iron administration, selection of a CPB circuit specific to the patient's height and weight, acute normovolemic hemodilution, retrograde autologous prime and venous autologous prime, tranexamic acid administration, zero-balance ultrafiltration, flushing of the pump suckers post-CPB, modified ultrafiltration, and cell salvage. We present an 8-day-old, 3.2-kg patient of JW faith with aortic valve stenosis and regurgitation and a patent foramen ovale who underwent a bloodless left ventricle-to-aorta tunnel repair and aortic valve repair on CPB.
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J Extra Corpor Technol · Jun 2014
Peritoneal dialysis: an alternative modality of fluid removal in neonates requiring extracorporeal membrane oxygenation after cardiac surgery.
Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for patients with cardiopulmonary failure after cardiac surgery. Fluid overload (FO) is associated with increased morbidity and mortality in this population. We present our experience using peritoneal dialysis (PD) as an adjunct for fluid removal in eight consecutive neonates requiring ECMO after cardiac surgery between 2010 and 2012. ⋯ Six of eight patients were successfully decannulated. These results suggest PD safely and effectively removes fluid in neonates on ECMO after cardiac surgery. PD may increase total fluid removal potential when combined with other modalities.
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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.