The Journal of extra-corporeal technology
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Cognitive deterioration can reliably be measured after procedures requiring anesthesia and surgery. Cardiac surgery has had the spotlight because of the high reported incidence of postoperative cognitive dysfunction in early studies, but such effects occur after other surgical procedures as well. "Early" postoperative cognitive dysfunction should be considered as a different phenomenon, relating to acute pharmacological, physiological, and stress-related recovery. The focus should be on what is affecting patients at 3 months, 12 months, and 5 years later. ⋯ The blood-brain barrier is made vulnerable by both pre-existing disorders (mild cognitive impairment/amyloid; vascular disease) and by the inflammatory response to surgery and cardiopulmonary bypass. Inflammation affecting the brain at this time may set in motion accelerated neurological and hence cognitive decline that, despite an initial recovery and even functional improvement, may proceed to further long-term decline at an accelerated rate in susceptible individuals. Clinical data are emerging from longer-term studies to support this concern, but evidence for effective preventive or therapeutic strategies is limited.
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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
Case ReportsInitial experience with recombinant antithrombin to treat antithrombin deficiency in patients on extracorporeal membrane oxygenation.
Acquired antithrombin (AT) deficiency has been associated with patients on extracorporeal membrane oxygenation (ECMO) as a result of hemodilution, blood coagulation activation, and the use of heparin. Replacement of AT has been typically utilized through the use of fresh-frozen plasma or AT concentrate. Antithrombin alfa (ATryn) is a recombinant form of AT (rAT) with an identical amino acid sequence as that of plasma-derived antithrombin. ⋯ Our findings suggest that the published ATryn dose may be inadequate to reach desired AT activity concentrations for pediatric patients on ECMO. Difference in patient population, use of extracorporeal circuits, and the use of heparin are likely explanations for this finding. We would also recommend frequent checking of AT levels while delivering this drug because making timely adjustments is necessary for achieving and maintaining the target AT activity level.
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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.