Heparin coating and cardiotomy suction in cardiopulmonary bypass

The present thesis addresses various means of reducing inflammatory responses associated with cardiopulmonary bypass (CPB) and retransfusion of pericardial suction blood (PSB) during cardiac surgery. Four (I-IV) prospective randomised controlled clinical trials comprising 475 patients were performed in the following areas: effects of heparin coating on measures of clinical outcome and memory function (I, II), inflammatory reactions in PSB and its systemic effects after retransfusion using cardiotomy suction or cell salvage (III) and effects of retransfusion of PSB on memory function and release patterns of protein S100B (IV). The use of heparin coated CPB-circuits was associated with a decrease of postoperative blood loss (I, II), transfusion requirements (II), shorter stay in hospital (I) decreased postoperative ventilator time (I), lower incidences of atrial fibrillation (II) and neurological deviations (I), reduction in releases of protein S100B (I, II) and lower postoperative creatinine elevation (I, II). PSB contained high concentrations of cytokines, complements, myeloperoxidase, free plasma haemoglobin and protein S100B (III, IV). Retransfusion using cardiotomy suction increased the systemic concentrations of free plasma haemoglobin and protein S100B, whereas retransfusion using cell salvage caused no detectable systemic effects (III, IV). CPB was associated with a small but significant release of protein S100B, despite elimination of PSB-contained protein S100B using cell salvage (IV). Subtle signs of impaired memory function were identified that were not associated with the use of heparin coated CPB-circuits (I, II) or retransfusion of PSB (IV). Key words: cardiopulmonary bypass, oxygenators, heparin, S100 proteins, blood loss, haemostasis, memory, outcome and process assessment

Heparin coating and cardiotomy suction in cardiopulmonary bypass

The present thesis addresses various means of reducing inflammatory responses associated with cardiopulmonary bypass (CPB) and retransfusion of pericardial suction blood (PSB) during cardiac surgery. Four (I-IV) prospective randomised controlled clinical trials comprising 475 patients were performed in the following areas: effects of heparin coating on measures of clinical outcome and memory function (I, II), inflammatory reactions in PSB and its systemic effects after retransfusion using cardiotomy suction or cell salvage (III) and effects of retransfusion of PSB on memory function and release patterns of protein S100B (IV). The use of heparin coated CPB-circuits was associated with a decrease of postoperative blood loss (I, II), transfusion requirements (II), shorter stay in hospital (I) decreased postoperative ventilator time (I), lower incidences of atrial fibrillation (II) and neurological deviations (I), reduction in releases of protein S100B (I, II) and lower postoperative creatinine elevation (I, II). PSB contained high concentrations of cytokines, complements, myeloperoxidase, free plasma haemoglobin and protein S100B (III, IV). Retransfusion using cardiotomy suction increased the systemic concentrations of free plasma haemoglobin and protein S100B, whereas retransfusion using cell salvage caused no detectable systemic effects (III, IV). CPB was associated with a small but significant release of protein S100B, despite elimination of PSB-contained protein S100B using cell salvage (IV). Subtle signs of impaired memory function were identified that were not associated with the use of heparin coated CPB-circuits (I, II) or retransfusion of PSB (IV). Key words: cardiopulmonary bypass, oxygenators, heparin, S100 proteins, blood loss, haemostasis, memory, outcome and process assessment

Can the Oxygenator Screen Filter Reduce Gaseous Microemboli?

Gaseous microemboli (GME) define small bubbles as <200 μm 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. New trends in oxygenator design promote location of arterial filtration as an integral part of the oxygenator housing. The present experimental study aimed to evaluate the GME removal properties of an integrated arterial screen filter in a standard microporous oxygenator. The GME properties of Terumo Capiox® FX25 with an integrated arterial screen filter was assessed in an experimental setup and compared with Capiox® RX25, in which no arterial screen filter is present. A blood analog prime solution was recirculated using a roller pump at 4 and 6 L per minute flow rate, respectively, through a customized CPB circuit comprising oxygenator, reservoir, and connecting tubing. A controlled volume of air was introduced into the circuit. The GME activity was measured and computed using a Gampt BCC200® ultrasonic device placing one probe at the venous inlet and one other at the arterial outlet of the oxygenator. Transmembrane delta values of GME activity were used to calculate the removal efficacy based on counts and volume of GME. Use of screen filtration reduced the GME volume by 99.1% ± .1% compared with 98.0% ± .1% for controls at 4 L/min flow rate (p < .001). 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

Can We Rely on the Activated Clotting Time to Measure Heparin Anticoagulation? A Clinical Evaluation of Two ACT Monitors

The sensitivity to heparin during cardiopulmonary bypass (CPB) is determined by patient-specific characteristics and is assessed by the whole blood activated clotting time (ACT). We aimed to examine reliability measures between two different ACT monitors using Bland–Altman analysis: bias should not exceed 50 ± 50 seconds for measurements performed during CPB or 10 ± 10 seconds before and after CPB. The ACT response should be linear in relation to the concentration of heparin in plasma. Twenty patients (n = 20) aged 20–80 years and admitted for coronary artery bypass surgery were enrolled to this clinical observational study. ACT values and antifactor Xa were sampled: 1) before induction of anesthesia, 2) after heparin bolus, 3) during CPB at the start of rewarming, 4) at weaning from CPB, and 5) after heparin reversal. The evaluation comprised the Hemostasis Management System Plus™ (HMS, Medtronic Inc., Minneapolis, MN) and i-STAT™ (Abbott, Point of Care Inc., Princeton, NJ). Bias for the HMS Plus™ vs. i-STAT™ was +105 ± 119 seconds for measurements during CPB and +2.8 ± 11.7 seconds before and after CPB. Associated limits of agreement for the observed bias were ±235 and ±23 seconds, respectively. Inter-device correlation of ACT values was .46 (p < .001) during CPB; otherwise .48 (p = .02). Both devices produced ACT values unrelated (<10%) to the measured heparin concentration. The use of multivariable regression analysis demonstrated an independent association between the ACT measurement and hematocrit, however, not with the plasma concentration of heparin. ACT monitors demonstrate unacceptable bias differences, combined with wide limits of agreement. The ACT response correlated with hematocrit, but not with the actual heparin concentration

Plasma hyperosmolality during cardiopulmonary bypass is a risk factor for postoperative acute kidney injury : results from double blind randomised controlled trial

Introduction: The study objective was to investigate whether a Ringer’s acetate based priming solution with addition of Mannitol and sodium concentrate increases the risk of cardiac surgery associated kidney injury (CSA-AKI). Methods: This is a double blind, prospective randomized controlled trial from a single tertiary teaching hospital in Sweden including patients aged ≥65 years (n = 195) admitted for routine cardiac surgery with cardiopulmonary bypass. Patients in the study group received Ringer’s acetate 1000 mL + 400 mL Mannitol (60 g) + sodium chloride 40 mL (160 mmol) and heparin 2 mL (10 000 IU) 966 mOsmol (n = 98), while patients in the control group received Ringer’s acetate 1400 mL + heparin 2 mL (10 000 IU), 388 mOsmol (n = 97) as pump prime. Acute kidney injury was analysed based on the Kidney Disease Improving Outcomes (KDIGO 1-3) definition. Results: The overall incidence of CSA-AKI (KDIGO stage 1) was 2.6% on day 1 in the ICU and 5.6% on day 3, postoperatively. The serum creatinine level did not show any postoperative intergroup differences, when compared to baseline preoperative values. Six patients in the Ringer and five patients in the Mannitol group developed CSA-AKI (KDIGO 1-3), all with glomerular filtration rates &lt;60 mL/min/1.73 m2. These patients showed significantly higher plasma osmolality levels compared to preoperative values. Hyperosmolality together with patient age and the duration of the surgery were independent risk factors for postoperative acute kidney injury (KDIGO 1-3). Conclusions: The use of a hyperosmolar prime solution did not increase the incidence of postoperative CSA-AKI in this study, while high plasma osmolality alone increased the associated risk by 30%. The data suggests further examination of plasma hyperosmolality as a relative risk factor of CSA-AKI

Continuous Venous Oximetry: A Comparative Study Between the CDI 100 and the Bentley OxySat II

Two in-line oxygen saturation monitors, the CDI 100 and OxySat II, were evaluated in the clinical setting. Eighty-seven venous blood samples were drawn during 20 elective cardiopulmonary bypass procedures. Monitor readings were compared to OSM III co-oximeter values. The results revealed that saturation(%) determination was biased, -3.16 ± 2.21 SD for the CDI 100 and -0.34 ± 2.17 SD for the OxySat II. Hemoglobin (g/dl) and hematocrit (%) measurement, available only for the CDI 100, resulted in a bias of +5.54 ± 5.68 SD and +1.94 ± 1.78 SD, respectively. It was concluded that both monitors operated within clinically acceptable limits, with a more favorable outcome for the OxySat II

The Relationship Between Oxygen Transfer and FIO

On-line computation of body oxygen consumption (V̇O2) was performed in twelve (n=12) cardiac surgical patients utilizing cardiopulmonary bypass. Two in-line monitors, the CDI 400™ and CDI 100™ were interfaced with a personal computer. Arterial oxygen partial pressure, saturation and temperature from the CDI 400™ and venous saturation and hemoglobin values from the CDI 100™ enabled a real time computerized V̇O2 calculation. Paired V̇O2 and fractions of inspired oxygen (FIO) values made it possible to plot an oxygen transfer equation (OTE) for the AVECOR Affinity™ hollow fiber oxygenator. Regression analysis of 124 V̇O2-FIO2 pairs established the following relationship: V̇O2 = 368.4 * FIO2 - 15.6, with a correlation of 0.89 (p<0.001). This regression line presented as an OTE-plot suggests that the Affinity™ oxgenator is capable of transferring approximately 350 ml/min of oxygen at an FIO2 = 1.0. In conclusion, on-line CPB-monitoring interfaced with a personal computer may be used for real time V̇O2 - calculations and to establish an oxygen transfer equation of a given oxygenator

Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass

Abstract Background: Cerebral blood flow is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor cerebral blood flow autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using reference to data from a series of clinical registrations. Method: Cerebral blood flow was monitored using near infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between cerebral blood flow and blood pressure was calculated as a moving continuous correlation coefficient. A Cox index > 0.4 was regarded as a sign of abnormal cerebral autoregulation. Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls and suggestions of alternative methods. Results and Conclusion: Monitoring of cerebral autoregulation during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice