The Journal of extra-corporeal technology
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J Extra Corpor Technol · Sep 2015
Perioperative Hemoglobin Trajectory in Adult Cardiac Surgical Patients.
Preoperative anemia and nadir hemoglobin (Hb) during cardiopulmonary bypass (CPB) have been identified as significant risk factors for blood transfusion during cardiac surgery. The aim of this study was to confirm the association between preoperative anemia, perioperative fluid management, and blood transfusion. In addition, the proportion of elective cardiac surgery patients presenting for surgery with anemia was identified to examine whether the opportunity exists for timely diagnosis and intervention. ⋯ This study identifies a high prevalence of preoperative anemia with sufficient time for elective referrals to undergo appropriate diagnosis and interventions. It also confirms that low red cell mass (anemia and low BMI) and renal impairment are predictors of perioperative blood transfusion. Perfusion strategies to reduce hemodilution are effective at minimizing the intraoperative fall in Hb concentration but did not influence transfusion rate.
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J Extra Corpor Technol · Sep 2015
Practice GuidelineThe Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass-Temperature Management during Cardiopulmonary Bypass.
To improve our understanding of the evidence-based literature supporting temperature management during adult cardiopulmonary bypass, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiology and the American Society of ExtraCorporeal Technology tasked the authors to conduct a review of the peer-reviewed literature, including 1) optimal site for temperature monitoring, 2) avoidance of hyperthermia, 3) peak cooling temperature gradient and cooling rate, and 4) peak warming temperature gradient and rewarming rate. Authors adopted the American College of Cardiology/American Heart Association method for development clinical practice guidelines, and arrived at the following recommendation.
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J Extra Corpor Technol · Jun 2015
Review Historical ArticleThe History of Goal-Directed Therapy and Relevance to Cardiopulmonary Bypass.
Goal-directed therapy is a patient care strategy that has been implemented to improve patient outcomes. The strategy includes aggressive patient management and monitoring during a period of critical care. Goal-directed therapy has been adapted to perfusion and has been designated goal-directed perfusion (GDP). ⋯ Data from these studies was compiled to document improvements in patient outcomes. Goal-directed therapy has been demonstrated to improve patient outcomes when performed within the optimal time frame resulting in decreased complications, reduction in hospital stay, and a decrease in morbidity. Based on the successes in other critical care areas, GDP during cardiopulmonary bypass would be expected to improve outcomes following cardiac surgery.
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J Extra Corpor Technol · Jun 2015
Using Daily Plasma-Free Hemoglobin Levels for Diagnosis of Critical Pump Thrombus in Patients Undergoing ECMO or VAD Support.
Patients supported with extracorporeal membrane oxygenation (ECMO) or short-term centrifugal ventricular assist devices (VADs) are at risk for potential elevation of plasma-free hemoglobin (pfHb) during treatment. The use of pfHb testing allows detection of subclinical events with avoidance of propagating injury. Among 146 patients undergoing ECMO and VAD from 2009 to 2014, five patients experienced rapid increases in pfHb levels over 100 mg/dL. ⋯ Two of the three patients who survived to discharge also experienced acute kidney injury, which was attributed to pfHb elevations. The kidney injury resolved over time. The architecture of centrifugal pumps may have indirectly contributed to red blood cell damage due to thrombus, originally from the venous line or venous cannula, being snared in the pump fins or pump head.
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J Extra Corpor Technol · Mar 2015
Editorial20 Years On: Is It Time to Redefine the Systemic Inflammatory Response to Cardiothoracic Surgery?
The "systemic inflammatory response" has never been defined from a cardiothoracic surgery perspective, but borrowed its definition from the critical care field at a landmark 1992 definition conference on sepsis. It is unclear why the diagnostic criteria for the Systemic Inflammatory Response Syndrome (SIRS) were adopted in isolation, ignoring other potentially more useful definitions for Severe Septic Shock or Secondary Multiple Organ Dysfunction Syndrome. The 1992 SIRS definition for sepsis has since been updated at a conference in 2001 advocating PIRO (Predisposition, Infection, host Response, Organ dysfunction) as a hypothetical model to better link sepsis with clinical outcome. ⋯ The name "inflammatory response" is also problematic; it is too narrow and might be replaced with host response (the R in PIRO) to better convey the wide spectrum of host defensive pathways activated during heart surgery (i.e., complement, coagulation, fibrinolysis, kinins, cytokines, proteases, hemolysis, oxidative stiess). A variant on PIRO could allow these elements of the host Response (R) to be anchored within the context of Premorbid conditions (P) and the inevitable Insult (I) from surgery, to better link risk exposures to Organ dysfunction (O) in heart surgery. The precedent of PIRO suggests the following steps will be required to redefine the systemic inflammatory response: 1) buy-in from the leading societies for cardiothoracic surgery, anesthesia, and perfusion on the need for a re-definition conference, 2) assigning relative risk scores to different premorbid exposures, operative insults, and host response factors on clinical outcome, 3) validation of the risk model in a prospective cohort, and 4) development of algorithms or "apps" to facilitate rapid diagnosis and staging of care at bedside.