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INDIAN JOURNAL OF
Extra-CorporealTechnology
Official JournalIndian Society of Extra-Corporeal Technology
(Regd.)
EditorMr. Albert Jayakumar Davis, Chennai
Editorial Correspondence toTHE EDITOR
INDIAN JOURNAL OF EXTRA-CORPOREAL TECHNOLOGYNew no.:38, old no,:
42, P.E. Koil West Mada Street
(Near Don Bosco Church), Ayanavaram,Chennai- 600 023, Tamil
Nadu, INDIA
Contact: +919952447068, +918939299019Email id:
[email protected] & [email protected]
Views expressed by the authors do not reflect those of the
Indian Society of Extra-corporeal Technology. All statements,ideas
expressed in the manuscripts are purely those of the authors and
not of the editor(s), publisher(s). The editor(s)and publisher(s)
disclaim any responsibility for such contents. Moreover, the
editor(s) and publisher(s) neitherguarantee/warrant/endorse any
product or service advertised in the journal, nor do they guarantee
any claim madeby the manufacturer or such products or services.
Associate EditorsMr. Bhaskaran V., ChennaiMrs. Jayanthi,
Chennai
Editorial Review Board MembersMr. Rajendar Raina, ChandigarhMrs.
Meeta Mathur, JaipurMr. Kevin Menezes, MumbaiMr. Prakash,
BangaloreMr. Loknath Tiwari, Kolkata
Assistant EditorsMr. L. John Peter, ChennaiMr. S. Sundar Rajan,
Chennai
Editorial Advisory BoardDr. T. Sunder, ChennaiDr. B. Shashidhar
Rao, ChennaiDr. Akil Govil, KOTADr. A.K. Bisoi, New Delhi
Overseas Review Board MembersMr. Ranil Fernando, Colombo, Sri
LankaMr. Ajith Kumar, Colombo, Sri Lanka
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Indian Society ofExtra-Corporeal
Technology
PresidentDr. Kamala Rana- New Delhi
Vice-PresidentsMr. Sanjeev Wadhera- New Delhi
Mr. Ravindra Pal Singh- New Delhi
Gen. SecretaryMr. Ravinath Swami- Mumbai
Joint SecretariesMr. Naveen Kumar G. HydrabadMr. Debasis Ray-
Kolkata
Moderator WebsiteMr. Suresh C. Yadav- New Delhi
LIST OF OFFICE BEARERS
TreasurerMr. Nilesh Mcwan- Nadiad
AdvisorsMr. S. Anandhan- VelloreMr. K.M. Rao- Hyderabad
Editor, IJECTMr.Albert J. Davis- Chennai
Executive Committee Members
Mr. Rajender RainaMr. Kalaprasad SharmaMr. Bhaskar Chandra
PantMr. Yogendra Singh ChauhanMr. Venkata Krishna MohanMr.
Jaswindar SinghMr. Patel VishalMr. Loknath TiwariMs. M.S. Maya L.
GopalMrs. Mukta Tiwari
Mr. Emmanuel ManoharMr. Yogesh SolankiMr. Alok KumarMr. Saurav
Sen GuptaMr. Shailendhra K. SinghMs. Kinnari ChudasamaMr. Sheikh
Jubair AhmedMr. Angel JonesMr. Srinivasulu ReddyMr. Vijaya L.
Nakade
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From the Editor's DeskMy dear friends, first and foremost, my
sincere gratitude goes to you for electing me as
the Editor of IJECT. I also owe you my earnest apologies for not
bringing out the journal in time.It's a kind of schism within the
society regarding the release of funds for the
immediateexpenditures that retarded the initiation of this work.
Deo volente! (God willing!), I will executemy duties to the best of
my ability in bringing forth good journals during my tenure. I am
verymuch grateful to the former Editors for the valuable advice and
encouragement that they haverendered to me.
On behalf of ISECT, I also convey my best wishes to the
organising committee of ISECTCON2014 in Thiruvananthapuram, the
capital of Kerala for all its success. I feel that everyone
attendingthe conference would surely feel the elegant and serene
atmosphere of the city and witness theheritage of its past
glory.
Thanks and Regards,Editor
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MESSAGEDear Friends
On behalf of the Indian Society of Extra Corporeal Technology
and ISECTCON 2014 TRIVENDRUM, it is a great pleasure and honour to
welcome youto the 14th National Conference of the Indian Society of
Extra CorporealTechnology on 21st -22nd February, 2014
Trivendrum.
The main goal of the Conference thanks to its Scientifific
Programme is toenable Perfusionists to communicate with one
another. This Conference willprovide an excellent platform for
exchanging views and encouraging theevolution of new research in
regards to the future of Extra Corporeal Technologyin the coming
years.
Friends for the formation of Perfusion Council we five members
of our Association appeared beforethe Department related
Parliamentary Standing Committee on Heath and Family Welfare and
madepresentation. A short film presentation and necessary support
material was also place before the saidCommittee showing them the
status of Perfusion around the Globe.Recently we met Directorate
GeneralHealth and Family Welfare with supporting documents for
getting the Perfusion Profession recognisein the Government of
India.In short as per Director of Medical Council, Paramedical
Council and AlliedHealth Services and Directorate General Health
and Family Welfare Perfusion Profession will be soonregistered
under Allied Health Services. I am continous in touch with Director
of Medical Council andother Authorities in this regard and try my
best for Registration of Perfusion Profession in Governamentof
India.
The ultimate success of the Conference depends on you and your
active participation in discussion.I hope many delegates from all
over the world will come to Trivendrum to participate in 14th
NationalConference to make it a successful and memorable view.
I look forward to see you all in ISECT CON 2014 TRIVANDRUM.
DR KAMLA RANAPRESIDENT - ISECT
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Message from the General Secretary, ISECT
Dear Colleagues,
I am happy to present yet another issue of our Journal, this
time under thestewardship of Mr. Albert J. Davis.
Great care has been taken in preparing this issue, and I am sure
that it willbe interesting and informative. Perfusionists are
constantly innovating andadapting newer techniques. We request you
to come forward and share theresults of such modifications as also
your research / study.
Let me also take this opportunity to welcome all the delegates
to the 14thAnnual Conference of ISECT to be held in Trivandrum on
21st and 22nd February, 2014. Our conferenceshave been organized
very well and we have national and international delegates and
faculty. Thisconference too promises to be educative and
innovative.
Finally a big "Thank U" to all of you members who have
participated in the activities of our societyand made it grow from
strength to strength.
With best wishes for the New Year,
RAVINATH SWAMIGeneral Secretary, ISECT
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology6
ContentsVolume 23 2014
INDIAN SOCIETY OFEXTRA-CORPOREAL TECHNOLOGY
Role of Ultrafiltration in Paediatric Cardiopulmonary Bypass
7Alok Kumar*, S.C. Yadav**, Yogender S Chauhan** Lokendra
Kumar**,A.K. Bisoi***, Sandeep Chauhan@, Balram Airan@@.
A comparative study of Albumin versus 6 % Hydroxyethyl starch
used as 13priming solution for Cardiopulmonary Bypass in adults
undergoing Coronary Artery Bypass Grafting
Namita Mishra*, Alok Kumar* S.C.Yadav**, Lokendra Kumar**,
Minati Choudhury@, Milind Hote***,Sandeep Chauhan@, Balram
Airan****
Case Report 20Senthil Kumaran.D**, P.V.S.Prakash***, Sunil
Mekala***, Sunil.L.G*, Dr.Binoy***,Dr.Devi Prasad Shetty****
REVIEW ARTICLE:
Perspectives in Vascular Surgery and other Non-cpb Protocols a
perfusionist can involve 22Hareendran A
FOR YOUR KIND ATTENTION! 30Editor IJECT
Blood Conservation During CPB - Role Of Perfusionist without
↑Cost 32Saurav Sengupta
Modified Cardioplegia for Neonates and Infants' Cardiac Surgery
35Mr. Sunderrajan, Mr. Senthil.Dr. Neville Solomon, Dr. Swapna
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7
Role of Ultrafiltration inPaediatric Cardiopulmonary
BypassAuthor:Alok Kumar*, S.C. Yadav**, Yogender S Chauhan**
Lokendra Kumar**,A.K. Bisoi***, Sandeep Chauhan@, Balram
Airan@@.*Clinical Perfusionist, Department of Cardio-Thoracic and
Vascular Surgery**Senior Perfusionist, Department of
Cardio-Thoracic and Vascular Surgery***Professor, Department of
Cardio-Thoracic and Vascular Surgery@@Professor & Head,
Department of Cardio-Thoracic and Vascular Surgery@Professor,
Department of Cardio-Thoracic and Vascular AnaesthesiaAll India
Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi
Corresponding Author:Alok KumarClinical Perfusionist, Department
of Cardio-Thoracic and Vascular Surgery.
Abstract
Background: Cardiopulmonary bypass (CPB) is associated with a
“whole body inflammatory response”characterized by capillary leak
and increased total body water (1). The development of tissue edema
maycause dysfunction of vital organ systems leading to significant
morbidity and mortality (2,3).
Aim: This prospective, randomized study was designed to
investigate the effects of conventionalultrafiltration in
paediatric patients undergoing corrective surgery for congenital
heart disease using CPB.
Material & Method: One fifty children aged between 2-14
years with Tetralogy of Fallot (TOF) undergoingintra cardiac repair
on CPB were divided into two groups. Group-I comprised of 75
children in whomconventional ultrafiltration (CUF) was performed
intraoperatively and during rewarming period ofcardiopulmonary
bypass. Group-II comprised of 75 children in whom no
ultrafiltration was performed.
Intraoperative urine production, fluid overload (net pump
balance after CPB), electrolyte disbalance, andpostoperative chest
tube drainage, ventilation time, blood and blood component
transfusion requirementfrom the end of bypass procedure until 24
hours in intensive care unit were studied in both groups.
Results were analysed by students paired ‘t’ test, Mann- Whitney
test and Wilcoxon Signed Ranks.To maintain haematocrit level 30%
during CPB, in group-I (n=74) conventional ultrafiltration was
performed and in group-II (n=73) packed red blood cells were
added.In group-I: Urine output (159.77ml ± 69.3ml) during CPB was
not significantly different from group-II
where urine output was (243.2ml ± 85ml). The mean total
haemofiltrate (444.19 ml ± 169.17 ml) volume wereremoved only in
group-I during intraoperative period of cardiopulmonary bypass.
Result: There were significant (p
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology8
Introduction
Paediatric cardiopulmonary bypass (CPB) isassociated with an
increase risk of complications. The“Capillary leak syndrome” occurs
because of increasedcapillary permeability as an inflammatory
responses toCPB leading to sequestration of excess fluid in
tissueinterstitial space causing increase in total body water.The
resultant multiorgan dysfunction remains the singlemost important
post CPB complication in paediatriccardiac surgery (4,5). Lower
body weight, low bodytemperature, long duration of bypass and
haemodilutionare few of the recognized factors implicated for
thecapillary leak syndrome.
Pre bypass use of intravenous crystalloid andColloidal solutions
CPB cicuit prime, and use ofcardioplegic solution put cardiac
surgery patients at riskof fluid overload. Ultrafiltration is a
useful method toreduce the risk of fluid overload after CPB.
The concept of removal of this excess body water
byultrafiltration during CPB was introduced by Ramegnoliet al (8,9)
and popularized by Magilligan (10), in orderto protect the patient
from fluid overload and electrolyticimbalance. Ultrafiltration also
helps to reduce variousinflammatory and complimentary activators
resulting inearly and better postoperative recovery.
Unlike the popular upsurge of ‘no pump’ techniquesin adult
cardiac surgery, CPB remains necessary for mostcongenital heart
defect repairs and these difficultsurgeries are being accomplished
with significantlyreduced mortality and morbidity (2,3).
The systemic inflammatory response evoked by CPBare the ultimate
pathophysiological mechanismresponsible for immunological disorder.
There can be asmuch as more than 20% increase in body weight,
whichis well evident in children because of loose aereolartissue
and is described as ‘Michline baby’ effect (6,7). Itis the
clinically significant multiorgan dysfunction as aresult of the
capillary leak, which is responsible for themost of the CPB related
morbidity and mortality (2,3).
There are various methods to treat established fluidoverload
during and in the early post bypass period.These include,
administering diuretics and steroid forcapillary leak. However use
of diuretics is not reliable,
is not consistent, and may be ineffective during CPB.
We decided to study the beneficial aspects ofhaemofilteration
during CPB to minimize capillary leaksyndrome in paediatric surgery
by reducinghaemodilution and fluid overload.
MATERIAL AND METHODS
After approval from the institute’s ethics committeeand informed
parental consent, this prospectiverandomized and controlled
clinical study was plannedat All India Institute of Medical
Sciences, New Delhi inthe department of Cardiothoracic Vascular
Surgery.
Inclusion Criteria
This study included 150 children aged between 2- 14years with
Tetralogy of Fallot (TOF) undergoing intracardiac repair on CPB.
The patients were randomlydivided into two equal groups.
Group-I comprised of 75 children in whomconventional
ultrafiltration (CUF) was performed duringthe rewarming period of
CPB.
Group-II comprised of 75 children in whom noultrafiltration was
performed.
Exclusion Criteria
Patients with a preoperative renal dysfunction, orwho were
preoperatively on inotropic and ventilatorysupport or who had
neurological dysfunction andemergency surgery were excluded from
the study.
Conduct of Anesthesia and Surgery:
Patients in both group received same premedicationand anesthetic
management. Both group hadstandardized and surgical management by
the sameteam.
Perfusion techniques performed duringcardiopulmonary bypass
Conduct of CPB was also standardized and similarin the both
groups, The pump was primed withCrystalloid (Ringer’s solution) 20
ml/kg, Starch (HES)10 ml/kg, Mannitol 5 ml/kg, Heparin 50 mg/l of
prime,NaHCO3 1 ml/kg, and Packed Red Blood Cell wereadded, whenever
the estimated HCT came down to lessthan 30% during CPB in the both
group. A non pulsatileflow (150-250ml/min/m2) was maintained during
CPBusing a twin roller pump (Sarns, 9000, USA) and ahollow membrane
oxygenator (Capiox SX 10, Terumocorporation, Japan) with a 40
micron arterial line filter.
Address for correspondence:
Alok Kumar1st Floor, C.N. Centre,All India Institute of Medical
Sciences (AIIMS),Ansari Nagar, New Delhi,Email:
[email protected]
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9
Myocardial preservation protocol included moderatesystemic
hypothermia (Nasopharyngeal temperature,32°C-33°C), intermittent
cold (4°C) antegrade St. Thomascrystalloid blood cardioplegia
solution dose was 20 ml/kg followed by half of the initial dose
every 20 minuteand topical cooling of the myocardium was done
withice slush in the pericardial sac.
Arterial blood gas analysis was done every 15 to 30minutes to
maintain pO2, pCO2, pH, BE to normal value.Urine output and
electrolyte composition was noted inperioperative period.
The only difference in management of CPB betweenthe two group
was use of ultrafiltration in group-I.
After completion of surgery, patients were rewarmedto 37°C.
During rewarming phase of cardiopulmonarybypass Conventional
Ultrafiltration (CUF), (circuitdiagram shown in fig.-1) was
performed in group I usinga paediatric haemofilter (Terumo
corporation). Themean haemofiltration rate of 10 ml//min
wasmaintained. The venous reservoir level was keptadequately by the
addition of replacement volume asrequired. CUF was not performed in
group II.
At the termination of CPB in both groups, 1.3mg ofprotamine
sulfate for every 100 IU of total heparin dosewas administered and
confirmed by the return ofactivated clotting time to baseline
values.
In both the groups, patients received Epsilon aminocaproic acid
(EACA) 100 mg/kg during pre CPB, CPBand post CPB period.
Patients were weaned off from bypass with inotropicsupport of
injection Dopamine (5-l0 µg/kg/min) andNitroglycerin (0.5-l
µg/kg/min) which were started oninitiation of rewarming.
After surgery patients were transferred to intensivecare unit
(ICU). In the ICU, postoperative ventilationtime, urine output,
blood and blood productrequirement and chest tube drainage at
intervals of 6 hrwas recorded for first 24 hr.
Statistical analysis:
Statistical comparison of results was made usinganalysis of
variance for non-parametric data. The resultswere expressed as mean
± standard deviation. Thechanges in variables within a group were
evaluated withpaired ‘t’ test, Mann- Whitney test and Wilcoxon
SignedRanks. Inter group comparison between variables wasmade by
the unpaired ‘t’ test, Mann-Whitney test and
Wilcoxon Signed Ranks test. A probability value of lessthan 0.05
was regarded as statistically significant.
Results
Out of 150 patients one patient in group I and twopatients in
group-II were excluded from our studybecause they were found to
have developed low cardiacoutput syndrome due to right ventricular
failure.
Both groups were similar in term of age, weight andsex.
Demographic data is shown in table-l and graph-I.Extra corporeal
circuit (ECC) priming and preoperativebase line values. were also
similar. No significantdifference was found in CPB time (90±15 min
in group-I & 96±18.1 min in group II) and aortic cross clamp
time(40±10 min in group-I and 48±12 min in group-II).
Perioperative data presented in table-2 and graph-2shows that
there was statistically significant (p
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology10
slightly lower values during the intraoperative periodbut failed
to reach statistical significance. Nocomplication related to the
practice of CUF wasencountered in any of the patients.
Postoperative data is shown in table-3 and graph-3shows that
HCT, (39.03% ± 11.1% in group-I increasedsignificantly (p
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11
Discussion
The principle finding of this study was animprovement in
postoperative clinical state associatedwith a reduction in
postoperative bleeding, postoperativeblood transfusion, ventilation
time, anticoagulating timeand lower incidence of marked rise in
body temperatureafter ultrafiltration in children undergoing CPB.
Severalstudies have already reported improvement in
biologicend-points that are believed to reflect beneficial
clinicaleffects. These improvements have been achieved bydifferent
techniques such as haemofiltration (12,13),administration of
anti-inflammatory agents (14) or useof heparin-coated CPB circuits
(15).
We found that there was an increase in HCT levelpostoperatively
in group-I in which ultrafiltration wasperformed during rewarming
phase of CPB as comparedto Hct values in group-II where no
ultrafiltration wasperformed. Our results are similar to the work
done byFrisen RH, Cambell DN, Clark DR, et al (19) whoconducted an
experiment by prophylactic haemofiltrationduring CPB and concluded
that haemofiltration increasethe HCT, reduce some inflammatory
markers and mayincrease the variability of heparin levels. It may
alsoreduce postoperative blood transfusion and possiblyincrease
blood pressure and cardiac index immediatelyafter haemofiltration,
although no difference in morbidityand mortality has ever been
shown.
Our findings were also confirmed by the study ofHuang H et
al.(11). They took 30 patients with congenitalheart defects who
were divided into two groups. In thestudy group I conventional
ultrafiltration, balancedultrafiltration plus modified
ultrafiltration was usedthroughout CPB. Pulmonary function, serum
albumin,some inflammatory mediators where measured. Theyfound that
after ten to fifteen minute MUF the HCT, andserum albumin increased
by 40% and 48% and concedethat the combined use of balanced
ultrafiltration andmodified ultrafiltaration can effectively
concentrate theblood.
The decrease in postoperative blood loss in our studyin
ultrafilterate group-I may be due to thehypercoagulable state at
the microvascular circulationlevel produced by haemodilution.
Ramegboli A, HackerJ, Keats AS et al (9) in his report on effect of
haemodilutionon coagulation demonstrated that a hypercoagulable
stateat the microvascular circulation level is produced
byhaemodilution. They attributed this hypercoagulablestate to a
decrease in concentration of the coagulationinhibitors and lowering
of threshold for positive feedbackoccurring in the coagulation
pathway.
Although our findings were similar Didier J et al (11);who
concluded that haemofiltration can reducepostoperative blood loss
in the absence of major changesin coagulation factor concentrations
(11). They postulatedthat this effect is not due to
haemoconcentration alone.Cytokines have been implicated in altered
coagulationand fibrinolysis, and a reduction in their production
maybe the mechanism involved in reducing blood loss.
Postoperative high body temperature was more oftenpresent during
ICU stay even in the absence of infectionin group-II (38°C, 23/73)
as compared to group-I (35°C,5/74 because some pyrogenic substance
eg.Cytolucine,interleukins may have been filtered outduring
haemofiltration on CPB in group-I. Casey LC: (16)In his study
showed the role of cytokines in thepathogenesis of CPB-induced
multisystem organ failure.They concluded that this phenomenon is
attributed tothe effects of various endogenous pyrogens,
includingIL-l beta IL-6 & IL-8 (17,18). The lower peaks and
meanpostoperative temperature observed in the-ZBUF groupmay reflect
a globally reduced inflammatory response.
Our study, shows that the value of electrolytes didnot show
significant changes postoperatively and it wassimilar to the
baseline value in both groups due to theslow rate of
haemofiltration in which electrolytes arefiltered out and this
findings is similar to that reportedby Magilligan DJ et al (10),
who conducted the study in10 patients with clinical evidence of
fluid over-load.Ultrafiltration was employed during CPB, and
theyobserved a decrease in extra vascular lung water from1,132 ±
183 m1 to 919 ± 267 ml (p>0.209). It was concludedthat the value
of electrolytes and urea nitrogen did notshow significant changes
postoperatively.
The principal findings of our study was the reductionin the
ventilation time seen in group-I due to increasedhaematocrit along
with a reduction in lung water whichcan significantly (p
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology12
as compared to children where ultrafiltration was notperformed,
and we conclude that ultrafiltration providesvaluable benefits
where used in this situation.
Acknowledgement
I would like to thank Dr.Guresh, SeniorScientist,Department of
Biostatistics, AIIMS New Delhifor his valuable cooperation in data
analysis.
References
1. Yamaguehi H, Yarnauchi II, IIa/ma S, et al: Evaluation of
body tluids alter cardiac surgeryusing bioelectrical impedance
analysis.J Curdiovase Surg (Torino) 2000; 41 (4): 559-566.
2. Wan S, LeClerc J-L: Cytokine responses tocardiopulmonary
bypass: lessons learned fromcardiac transplantation. Ann Thorac
Surg 1997;63:269-276.
3. Lidmunds IJ I: Why cardiopulmonary bypassmakes patients sick:
Strategies to control the bloodsynthetic surface interface. Adv
Cardiac Surg 1998;6:131-133.
4. Naik S. Elliott M: Ultrafication: In Jonas RA, ElliottMJ eds
Cardiopulmonary bypass in neonates.Infants and Young children.
Oxford, ButterworthHeinmann 1994; 158-172.
5. Kirklin J. Blackstone F and Kirkline J:Cardiopulmonary bypass
Studies on its damagingeffects. Blood Purif 1987; 5: 168-78.
6. Maehara T, Novak I, Eliot M: Peri-operativechanges in total
body water in Childrenundergoing open heart surgery. Eur J
CardiothoracSurg 1991; 5: 258-65.
7. Eliott MJ: Modified ultrafiltration and open-heartsurgery ill
children Paediatr Anaesth 1999; 9: 1-5.
8. William Gavnor: Use of ultrafiltration during andafter
cardiopulmonary bypass in children. J ThoracCardiovasc Surg 2001;
122: 209-211.
9. Ramegboli A, Hacker J, Keats AS et al:
Externalhaemoconcentration after deliberatehaemodilution. Annual
Meeting of the AmericanSociety of Anesthesiologist Extracts of
ScientificPapers. Park Ridege 1976; 269.
10. Magilligan DJ, Oyama C: Ultrafiltration
duringcardiopulmonary bypass laboratory evaluation
and initioa clinical experience Ann Thorac Surg1984; 37:
33-39.
11. Journois, Didier, et al: High volume, Zero-balanced
Haemofiltration to Reduced DelayedInflammatory Response to
CardiopulmonaryBypass in Children. The Journal of the
Americansociety of Anesthesiologist, 1996; 85(5): 965-976.
12. Andreasson S, Gothberg S, Berggren H, BengtssonA, Eriksson
E, Risberg B: Haemofiltration modifiescomplement activation after
extracorporealcirculation in infants. The Ann Thorac S urg 1993;56:
1515 - 7.
13. Millar AB, Armstrong L, van der Linden J, MoatN, Ekroth R,
Westwick J, Scallan M, Lincoln C:Cyto1cine production and
haemofiltration inchildren undergoing cardiopulmonary bypass.Ann
Thorac Surg 1993; 56: 1499- 1502.
14. Casey LC: Role of cytokines in pathogenesis
ofcardiopulmonary- induced multisystem organfailure. Ann Thorac
Surg 1993; 56: 92-96.
15. Stein B, Pfenninger E, Grunert A, Schmitz JE,Deller A,
Kocher F: The consequences ofcontinuous haemofiltration on lung
mechanicsand extra vascular lung water in a porcineendotoxic shock
model. Intensive Care Med 1991;17: 293-8.
16. Markewitz A, Faist E, Lang S, Endres S, Fuchs D,Reichart B:
Successful restoration of cell mediatedimmune response after
cardiopulmonary bypassby immunomodulation. J Thorac Cardiovasc
Surg1993; 105: 15-24.
17. Fosse E, Moen 0, Johnson E, Semb G, BrockmeirV, Mollness TE,
Fagerhol MK, Venge P: Reducedcomplement and granulocyte activation
withheparin-coated cardiopulmonary bypass. AnnThorac Surg 1994; 58:
472-7.
18. Dinarello CA: Interleukin -1 and tumor necrosisfactor and
their naturally occurring antagonistsduring haemodialysis. Kidney
Int Suppl 1992; 38:S68-77.
19. Frisen RH, Cambell DN, Clark DR, et al:
Modifiedultrafiltration attenuates dilution coagulopathy
inpaediatric open heart surgery. Ann Thorac Surg1997; 64:
1787-1789.
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13
A comparative study of Albumin versus 6 %Hydroxyethyl starch
used as priming solution forCardiopulmonary Bypass in adults
undergoingCoronary Artery Bypass Grafting
Author:Namita Mishra*, Alok Kumar* S.C.Yadav**, Lokendra
Kumar**, Minati Choudhury@, MilindHote***, Sandeep Chauhan@, Balram
Airan****
*Clinical Perfusionist , Department of Cardio-Thoracic and
Vascular Surgery**Senior Perfusionist , Department of
Cardio-Thoracic and Vascular Surgery@ Additional Professor, Cardiac
Anesthesia***Additional Professor, Cardio-Thoracic and Vascular
surgery@ Professor Cardiac Anesthesia****Professor and Head
All India Institute of Medical Sciences (AIIMS)Ansari Nagar, New
Delhi
Abstract
Background: The issue of optimal priming solution for
cardiopulmonary bypass is unclear. Colloids have theadvantages of
maintaining the colloid oncotic pressure and reducing tissue edema.
However the use of colloidsduring coronary bypass surgery has been
limited due to associated increase incidence of
anaphylactoidreactions and clinical coagulopathy.Aim: In this study
we compared the effects of using 20 % Albumin versus 6 %
Hydroxyethyl starch (HES) in theratio of 1:5 and 1:2 respectively
for the priming of CPB circuit in adult patients undergoing
coronary arterybypass grafting (CABG).Methodology: Sixty patients
of either sex in the range of 40-70 years of age undergoing CABG
with the use ofCPB were studied. The patients were randomly divided
in following two groups (A & B). In group A (n=30), 20% Albumin
solution with lactated Ringer’s solution and in group B (n=30), 6 %
HES solution with lactatedRinger’s solution was used for priming
the CPB circuit. All the surgeries were conducted by using same
surgical, anesthetic and perfusion techniques. Variousparameters
compared between the two groups were Hb/HCT, PaO2, PaCO2, SO2 (%),
urine output, serumCreatinine, blood urea, blood sugar, requirement
of blood/ blood products and requirement of any otheradditions like
hemostatic agents.Conclusion: Hospital mortality rate was zero in
both the groups. However it was found that 6 % hydroxyethylstarch
can be used as an alternative along with Ringer’s lactate in the
ratio of 1:2 for priming the CPB circuitwithout any adverse effect
or any contradiction. 6 % HES is a safe alternative colloid for
priming thecardiopulmonary bypass circuit and volume replacement in
patients undergoing coronary artery bypass surgeryas compared to 20
% Albumin.
Key Words: Cardiopulmonary Bypass, Priming solution,
crystalloids and colloids, Albumin, Hydroxyethyl
starch,inflammatory responses.
NAMITA MISHRA : A COMPARATIVE STUDY OF ALBUMIN VERSUS 6 %
HYDROXYETHYL STARCH
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology14
Introduction
The main objective of Cardiopulmonary bypass(CPB) is to provide
a still and bloodless heart with bloodflow temporarily diverted to
an extracorporeal circuitthat functionally replaces the heart and
lung(1).Priming of the CPB circuit is an important task for
theperfusionist. Generally the main objectives of primingare to
deair the CPB circuit, check for any leaks in thecircuit, for
providing sufficient haemodilution and tokeep the volume level of
the reservoir towards the saferside, while on CPB.
It is a standard practice to use a non blood CPBprime because of
benefits of haemodilution and concernsabout blood borne diseases
(2). Haemodilution worksto limit the complications related to CPB
(neurological,renal, and pulmonary), by significantly reducing
bloodviscosity during bypass. A haemoglobin concentrationof 10g/dl
was traditionally accepted as adequate forpatients undergoing non
cardiac surgery (3). There arethree major factors which should be
considered by theperfusionist when selecting a solution to prime
thecardiopulmonary bypass circuit (4):
Address for correspondence:
Ms Namita MishraClinical PerfusionistDepartment of
Cardio-Thoracic and Vascular Surgery (O.T.)1st Floor, C.N.
CentreAll India Institute of Medical Sciences (AIIMS)Ansari Nagar,
New DelhiEmail: [email protected]
a) Osmolarity: isotonic solution preserves
theinterstitial-intravascular fluid balance.
b) Electrolyte: The concentration of the importantelectrolytes
in the prime fluid should approachnormal plasma levels.
c) Dilution: Priming volume should be sufficient toallow for
adequate flow rates.
Generally priming solutions can be classified into twocategories
which are as follows:
Crystalloids (5) are electrolyte solutions with smallmolecules
that can diffuse freely throughout theextracellular space. In
general crystalloids are simplevolume expanding solutions that
mimic the normalplasma electrolyte concentration but they lack
oncoticactivity. Various crystalloids generally used are
dextrose,mannitol, balanced crystalloid fluid, ringer’s
lactatesolution etc.
Colloids (6) are large molecular weight solutions.They are
important in capillary fluid dynamics becausethey are the only
constituents which are effective atexerting an osmotic force across
the wall of thecapillaries. This helps in keeping water in the
vascularspace and prevents tissue edema. Colloids have theadvantage
in maintaining the colloid oncotic pressure(7). Various colloid
solutions commonly used arehydroxyl ethyl starch (HES), albumin,
dextran, gelatinetc. There is no general consensus with regards
ofselecting the priming solution for CPB circuit.
Mw = Weight average molecular weight; Mn = Number average
molecular weight; COP = Colloid osmoticpressure; T1/2 = Half life
of concentration; PVE = Plasma volume expansion; Gelatin-U = urea
linked gelatin;Gelatin-S = succinyl-linked gelatin; HES =
hydroxyethyl starch.
Table 1 : Physicochemical characteristics of priming solutions
forcardiopulmonary bypass (colloids) (8)
ALBUM DEXT DEXT GELA GELA HES HESIN 5% RAN-40 10% RAN-70 6%
TIN-U 3.5% TIN-S 3% 6% 10%
Mw(Daltons) 69,000 40,000 70,000 35,000 35,000 450,000
264,000
Mn(Daltons) 69,000 25,000 39,000 15,000 14,000 71,000 63,000
Osmolality (mmol/kg) 300 308 308 302 310 354
COP(mmHg) 19-20 160 78 - - 25-30 55-60
T1/2(hr) 2-5 25.5 2.5 - 25.5 2.5
Duration of PVE (h) 2-8 2-12 6-48 2-4 - 6-24 2-12
Elimination(h) 17 12-45 - 168 168 24-67 1.9days Days Days
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15
Material and Methods
In this randomized prospective study we included 60adult
patients of either sex in the range of 40-70 yearsold of age
undergoing coronary artery bypass grafting(CABG) with use of
cardiopulmonary bypass.
Exclusion criteria: Patients with a preoperativeserum albumin
level of 30g/l or less and Patients withthe history of renal or
pulmonary disease, knownbleeding disorder and liver dysfunction
were excludedfrom the study. We also did not include patients
withsevere LV dysfunction, patients who had undergonerepeat CABG or
patients who had undergone CABGincidental to heart valve repair or
replacement, resectionof a ventricular aneurysm, or some other
surgicalprocedure.
Study protocol: The patients were randomly dividedinto two
groups (A & B). In group A (n=30), the CPBcircuit was primed
with crystalloid (Ringer’s Lactate)and colloid solution (Albumin)
in 1:5 ratio. Whereas ingroup B (n=30), the solution used for
priming the CPBcircuit consisted of crystalloid prime (Ringer’s
lactate)along with a colloid solution (6 % HES) in the ratio
1:2.
Conduct of CPB: A standardized protocol for theselection of CPB
circuit components was followedthroughout the study period. The
surgical, anesthetictechniques, pump flows, conduct of
bypass,hypothermia was similar in both groups except for thechoice
of priming solution used in the CPB circuit.
Before CPB was initiated, anticoagulation wasachieved by the
administration of 300 IU/kg heparinsodium with the goal of
achieving an activated clottingtime of >480 seconds. The
myocardial preservation donewith St. Thomas based blood
cardioplegia solution wasinfused after cross clamp in an induction
dose of 20 ml/kg and was repeated at an interval of 20-30 minutes
asrequired.
Arterial blood gas samples were done before, duringCPB at
intervals of 15 to 20 minutes and after CPB tomaintain pO2, pCO2,
pH, BE to the normal value. Urineoutput and electrolyte composition
was noted inperioperative period.
After the corrective surgery the patients wererewarmed to a
nasopharyngeal temperature of 37°C. Atthe termination of CPB,
anticoagulation was reversedwith protamine sulphate. After surgery
patients wereshifted to intensive care unit (ICU).
Study Analysis: The following data was recordedintraoperatively:
the type and volume of priming,blood/blood products administered,
duration of aorticcross clamp, and duration of CPB.
Postoperatively,following data was documented: requirement
oftransfusion, diuretic usage, urine and chest tube
output.Postoperative adverse events such as renal events likeacute
renal failure, hemodynamic events like bleeding,re-exploration and
need of extracorporeal membraneoxygenation were recorded. The
duration of ventilatorsupport, length of ICU stay was also
recorded.
Statistical analysis: Statistical comparison of resultswas made
using analysis of variance of non-parametrictest. All the results
are expressed as mean ± standarddeviation. Inter group comparison
between variableswas made by the unpaired ‘t’ test and Mann-
Whitney.A probability value of less than 0.05 was regarded
asstatistically significant.
Results
The two groups (A & B) were comparable in termsof
demographic specifications such as age, height,weight, BSA, and the
risk factors like diabetes,hypertension, number of grafts and left
internalmammary artery (LIMA) usage.
Table 2: Showing demographic data
PARAMETERS GROUP A GROUP B P value
AGE (years) 56.20±7.321 55.40±9.356 0.80
HEIGTH(in cm) 163.87±8.48 163.97±9.39 0.98
WEIGHT (in Kg) 64.6±10.39 68.88±13.91 0.36
BSA (m2) 1.83±0.10 1.70±1.66 0.021
DIABETES 0.67±0.49 0.60±0.51 0.71
HYPERTENSION 0.47±0.52 0.60±0.51 0.74
NO. OF GRAFTS 4.22±5.60 4.22±5.60 1.00
LIMA USAGE 1.00±0.00 1.00±0.00 NS
Mean ± standard deviation values are taken foranalysis; P
value0.05). But base excess was foundstatistically significant
(P=0.010). Need for correcting
NAMITA MISHRA : A COMPARATIVE STUDY OF ALBUMIN VERSUS 6 %
HYDROXYETHYL STARCH
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology16
base deficit was also found significant pre bypass ingroup A
(Figure 3).
Table 3: Showing Preoperative data
PARAMETERS GROUP A GROUP B P value
BP (mm Hg) 141.73±19.33 134.53±21.21 0.340
PULSE 78.67±9.74 78.00±11.81 0.870
Hb (g/dl) 16.53±8.84 14.15±2.77 0.334
HCT (%) 40.79±12.18 39.87±5.73 0.793
PLATELET COUNT(COUNT * 103/ì l) 195.47±91.280 196.80±51.70
0.961
WBC COUNT(COUNT/ì l) 8773.33±3756.42 9853.73±2512.23 0.364
PCV (%) 39.17±3.82 37.81±3.71 0.333
pH 7.41±0.06 7.44±0.043 0.093
PaO2 (mmHg) 186.39±72.47 188.93±79.11 0.928
PaCO2 (mmHg) 37.63±4.778 36.89±4.27 0.661
HCO3- (mmol/l) 24.13±3.51 25.45±2.04 0.221
BE (mmol/l) -0.92±2.45 1.34±2.06 0.011
K+ (mmol/l) 3.73±0.56 3.85±0.544 0.569
Na+ (mmol/l) 135.71±3.39 136.400±3.58 0.594
BLOODSUGAR (mg/dl) 133.80±43.65 122.60±42.05 0.480
CREATININE (mg. %) 0.84±0.23 0.89±0.23 0.581
UREA (mg. %) 29.53±7.63 27.53±9.50 0.530
URIC ACID (mg. %) 6.27±0.74 6.18±0.94 0.782
PHOSPHATE (mg. %) 3.07±0.748 3.53±0.94 0.150
SGOT (AST) I.U 38.53±10.70 50.00±28.73 0.165
SGPT (ALT) I.U 28.00±9.43 37.53±26.86 0.212
TOTAL PROTEIN(gm %) 7.55±0.60 7.37±0.44 0.341
ALBUMIN (gm %) 4.00±0.36 3.71±0.48 0.051
GLOBULIN (gm %) 3.56±0.48 3.72±0.51 0.385
BILIRUBIN (mg %) 0.84±0.46 0.93±0.67 0.706
OSMOLARITY(mOsm/Kg) 272.07±4.49 270.6±6.10 0.489
COP (mmHg) 16.15±0.78 15.82±0.36 0.152
SAT (%) 98.90±1.60 99.14±1.51 0.676
URINE OUTPUT (ml) 256.67±129.38 248.00±145.07 0.864
BP- blood pressure, Hb- Hemoglobin, HCT-Haematocrit, COP-
colloid oncotic pressure.Mean ± standard deviation values are taken
foranalysis. P value < 0.05 is statistically significant
The two group were comparable regarding theparameters during CPB
such as the bypass time, aorticcross clamp time, total cardioplegia
delivery and urineoutput which on analysis showed no
statisticallysignificant differences. It was observed that there
wasno requirement of ultrafiltration during bypass in boththe
groups.
Operative data was collected at 30 minutes, 60minutes and 90
minutes of onset of cardiopulmonarybypass. No statistically
significant difference wasobserved while considering the mean
perfusionpressure (MPP) (mmHg), pH, PaCO3 (mmHg), PaO2(mmHg), HCO3
(mmol/l), Na
+ (mmol/l), K+ (mmol/l)and sugar (g/dl) at perioperative period
of bypass(Table 4).
Table 4: perfusion pressure, acid base status andbiochemical
parameters at 30 minutes of onset of CPB
PARAMETERS GROUP A GROUP B P value
MPP (mmHg) 55.07±11.42 63.27±16.79 0.131
Ph 7.41±0.04 7.42±0.05 0.639
PaO2 (mmHg) 290.80±53.42 261.15±61.14 0.168
PaCO2 (mmHg) 36.34±3.47 37.19±5.25 0.650
HCO3 (mmol/l) 23.27±2.11 23.88±2.75 0.495
BE (mmol/l) -0.94±2.29 -0.41±2.80 0.578
K+ (mmol/l) 4.37±0.77 4.53±0.87 0.602
Na+ (mmol/l) 130.90±2.30 132.00±2.75 0.248
Hb (g/dl) 8.38±1.22 7.36±0.99 0.019
HCT (%) 24.45±3.54 20.11±2.79 0.010
SAT (%) 99.73±0.42 99.99±0.02 0.034
BLOODSUGAR (mg/dl) 140.07±40.42 138.20±39.04 0.899
OSMOLARITY(mOsm/Kg) 264.58±5.88 271.533±5.39 0.002
COP (mmHg) 15.51±0.35 15.93±0.32 0.002
* Mean ± standard deviation values are taken for analysis
However osmolarity (mOsm/Kg) was foundstatistically significant
at 30 minutes of onset of bypass.The group B showed higher mean
osmolarity (mOsm/Kg) values than group A but the mean values
werewithin the normal range.
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17
Also the hemoglobin, haematocrit and saturation (%)were
significant statistically at each of the time intervalsduring CPB.
However Group B showed lower mean Hb(g/dl) and HCT (%) values than
group A but these meanvalues were within the normal range. Whereas
GroupB showed higher mean SO2 (%) values than group A but
again these mean values were also within the normalrange.
Postoperative data analysis at the 1st, 6th , 12th and 24th
hour showed no statistically significant differencebetween the
two groups with respect to PaO2 (mmHg),PaCO2 (mmHg), hemoglobin
(g/dl), haematocrit (%),saturation (%), osmolarity (mOsm/l), COP
(mmHg) andurine output (ml) at these time intervals. K+
(mmol/l)also showed statistically significant difference at 1st
hourpostoperatively (P value
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology18
Use of furosemide in 24th hour postoperatively forrenal support
was more in group B (6 % HES) ascompared to the group A (Albumin)
although it wasstatistically non significant (p=0.619).
WBC count was higher in group A (Albumin) ascompared to group B
(6 % HES) at 24th postoperativelyhour, but the mean values were
within the normal range.It was also statistically nonsignificant
(p=0.946).
A similar finding was also observed for the plateletcount among
the two groups. Time of ventilationpostoperatively and ICU stay was
statistically nonsignificant. There was no mortality in either of
the twogroups.
Discussion
A recent systematic review of randomized clinicalstudies on the
use of fluid therapy in various types ofsurgical procedures found
no evidence to recommendone type of fluid therapy over another.
There was notsufficient evidence to provide guidance on the
optimalamount of fluid to use in elective surgical procedures
(9).Despite the absence of clear recommendations for anyparticular
fluid therapy, there is plentiful debate aboutthe relative merits
of crystalloid or colloid, and evenabout different types of
colloids. As recently remarkedby Boldt in an editorial,
“Researchers who showcrystalloid to be superior always find
crystalloidsuperior, whereas colloid supporters always
favorcolloids” (10). Adequate restoration of intravascularvolume
remains the crucial therapeutic maneuver inmanaging the surgical
patient. It is generally believedthat three to four times more
crystalloid than colloidvolume is needed to achieve an equivalent
plasmavolume expansion. However, in the SAFE trial, (11) inwhich
fluid administration was blinded, the ratio ofalbumin to saline was
1:1.4 and thus much less thanexpected. While the choice between
colloid andcrystalloid solutions continues to generate
controversy,the dispute has been enlarged to a colloid/colloid
debate(e.g., Dextrans, gelatins, HES solutions).
Colloid fluid solutions are frequently used as plasmavolume
expanders in the critically ill. Intravascularvolume overload,
dilutional coagulopathy,extravascular, extravasations across leaky
capillarymembranes, and anaphylactic reactions may all occurwith
administration of any colloid. In addition,individual agents have
unique toxic effects. Renaldysfunction has been associated with
dextran 40,myocardial depression with albumin, hypotension
withpurified plasma protein, and hyperamylasemia with
hetastarch. Because no ideal colloidal solution exists,knowledge
of type, severity, and clinical significance ofadverse effects is
important in determining theappropriate plasma volume expander and
monitoring itseffects. HES130/0.4 is effective for volume therapy
andis less expensive than human albumin. Its effects oncoagulation
and renal function are manageable; it mayameliorate pulmonary
permeability and reduceinflammation and
lipopolysaccharide-inducedmyocardial dysfunction (12).
In contrast, colloids may decrease pulmonary fluidextravasation
and the formation of pulmonary edemabecause of their capacity to
increase Colloidal OncoticPressures (COP).
The so-called colloid-crystalloid controversy includesthe
relative propensity of fluid types to evokepulmonary edema, which
is not yet settled in theabsence of direct permeability and edema
measurementsin most studies (13).
Our study did not show any difference in durationof ventilation
in both the groups. As with all forms oftrauma, surgery triggers a
systemic inflammatoryresponse with the release of inflammatory
mediators intothe systemic circulation. It was found that 6%
HESproved to be better regarding the additional volumerequirement
during CPB as compared to Albumin. Therewas no significant
difference established between thetwo groups regarding the
intensive care duration andmortality rate. Nevertheless it was
demonstrated that themean value of ICU stay was shorter in group B
(6%HES).
The Hemoglobin and Haematocrit values tendedtowards the lower
limits in the group B (6% HES) duringCPB. Although the mean values
were within the normalrange, this significant difference between
the two groupsfavours the use of Albumin along with Ringer’s
Lactateon CPB.
The difference in post operative chest tube drainagealthough not
statistically significant, was more in groupA (Albumin) as compared
to group B (6% HES). Thedifference in the platelet count between
the two groupswas not statistically significant but the count was
foundlower in group A (Albumin) as compared to group B (6% HES).
The platelet count was decreased after thesurgery in both the
groups but it was much lower ingroup A (Albumin) as compared to
group B (6 % HES).Whereas the WBC count was more in group
A(Albumin) as compared to Group B (6 % HES) but it wasnot
statistically significant. The WBC count was
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19
increased after the surgery in the 24th postoperative hour,and
it was found higher in group A (Albumin) patientsthan in group B (6
% HES) patients showinginflammatory responses of the body to the
naturalcolloid (Albumin) to be more as compared to that ofsynthetic
colloid (6 % HES). This may be because of thelarge molecules of
Albumin being retained in thereticuloendothelial system of the
body. But the meanvalues for WBC count was within the normal range
soit may not cause any serious deleterious effects to
thepatients.
The effect of colloidal solutions on the renal functionis a
point of discussion. In our study, it was found thatmean values for
Urea and Creatinine were within thenormal range in both the groups
and were comparableas the difference was not statistically
significant.However cautions must be taken while using it
inpatients with renal insufficiency.
The cost of Albumin has lead to an increase in anoverall
expenditure of the surgery in group A, where asthe cost of 6 % HES
though high as compared to the costof crystalloid but was much
lower than that ofAlbumin.
Conclusion
6% HES can be used as an alternative along withRinger’s Lactate
in the ratio of 1:2 for priming theCardiopulmonary bypass circuit
without any adverseeffect or any contradictions. 6 % HES is safe to
use forplasma substitution next to albumin for CPB circuit.Albumin
because of its high cost and possibility of theanaphylactic
reaction that it may cause is not usedfrequently for priming the
CPB circuit. 6 % HES helpsto maintain osmolarity during CPB and
preserve plateletcount after the surgery. Anaphylactoid reactions
are notobserved with 6 % HES as compared to albumin. Useof 6 % HES
is found cost effective as compared toalbumin. But cautions must be
taken while using it inpatients in acute or chronic renal
failure.
References
1. Charles C Reed BS, Traudi B Stafford BS. CCPCardiopulmonary
bypass conduct of perfusion.2nd Edition, Texas 1985-399-415.
2. Boonstra PW, GU YJ. Priming fluids forcardiopulmonary bypass.
In Kay PH and MunchCM, editors. Techniques on
extracorporealcirculation, 4th Edition. London: Arnold.2004;
99-107.
3. Carson JL poses RM, Spence RK et al. Severity ofanemia and
operative mortality and morbidity.Lancet 1998; 1 (8588):
727-729.
4. Charles C Reed B S, Traudi B Stafford BS CCP.Cardiopulmonary
bypass-fluid, balance andselection. 2nd Edition, Texas
1985-258-263.
5. Jackson EV Jr.Weise J Sigal B, et al. effects ofcrystalloid
solution on circulating lactateconcentration part I: implication
for the properhandling of blood specimens obtained fromcritically
ill patients. Crit Care Med 1997; 25:1840-1846.
6. Tigchelaar I, Gallandat Huet RC, Korsten J,Boonstra PW, van
Oeveren W. hemostatic effectsof three colloids plasma substitutes
for primingsolution in cardiopulmonary bypass. Eur JCardiothorac
Surg 1997; 74:1447-1451.
7. Tolofsrud S, Svennevig JL, BreivikHet et al. Fluidbalance and
pulmonary functions during and aftercoronary artery surgery:
Ringer’s acetatecompared with dextran, poilygeline or albumin.Acta
Anaesthesiol Scand 1995; 39:671-7.
8. Y John Gu and Piet W Boonstra. Selection ofsolution for CPB
in adult C 2006. EuropeanAssociation of Cardiothorasic surgery.
9. Holte K, Kehlet H. Fluid therapy and surgicaloutcomes in
elective surgery: A need forreassessment in fast-track surgery. J
Am Coll Surg.2006; 202:971–989.
10. Boldt J. Pro use of colloids in cardiac surgery.
JCardiothorac Vasc Anesth. 2007; 21:453–456.
11. Finfer S, Bellomo R, Boyce N, French J, MyburghJ, Norton R.A
comparison of albumin and salinefor fluid resuscitation in the
intensive care unit. NEngl J Med. 2004; 350:2247–2256.
12. Boutros AR, Ruess R, Olson L, Hoyt JL, Baker WH.Comparison
of hemodynamic, pulmonary, andrenal effects of use of three types
of fluid aftermajor surgical procedures on the abdominal aorta.Crit
Care Med. 1979; 7:9–13.
13. Sibbald WJ, Driedger AA, Wells GA, Myers ML,Lefcoe M. The
shortterm effects of increasingplasma colloid osmotic pressure in
patients withnon-cardiac pulmonary edema. Surgery. 1983;
93:620–636.
NAMITA MISHRA : A COMPARATIVE STUDY OF ALBUMIN VERSUS 6 %
HYDROXYETHYL STARCH
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology20
Case Report
Introduction
A 58 yr old man was taken for elective pulmonarythrombo
endarterectomy.
On technically the procedure was straight forwardand all the
thrombus from both sides were removed,while coming off CPB severe
bleeding from ET tube wasnoticed, hence a double lumen tube was
placed to isolatethe lungs. As the bleeding was torrential, it was
decidedto put him on VA ECMO and give full dose protamine,this
brought down the ACT level to 176 sec. Then thebleeding stopped
within the first12 hrs and the patientwas weaned off from ECMO
after 24 hours.
Although the refinement in technique of cardiopulmonary bypass
has progressively improved thecurrent surgical trends yet the
outcome of diseases andpost operative CPB induced lung problems
still remainas a serious complication that could lead to
lifethreatening problems
Case Report:
A 58 yr old man was diagnosed with- chronicthrombo embolic
pulmonary hypertension (CTEPH) andsevere right ventricular
dysfunction. Severe tricuspidregurgitation, H/O DVT, normal LV and
normalcoronaries, was admitted for pulmonary thromboendarterectomy
surgery. Regular central cannulationwas planned for this patient
Aortic-24Fr Edwardscannula, 20Fr and 24 Fr Rt angled metal tip DLP
venouscannulae were used. CPB was initiated and cooling wasstarted.
When patient’s temperature reached 22’C, aorticcross clamp was
applied. 20ml/kg blood cardioplegiawas given by using blood
cardioplegia delivery system
Address for correspondence:
Senthil kumaran, Junior consultant, Perfusion DepartmentNarayana
Hrudayalaya Institute of medical sciencesE-mail:
[email protected]*Perfusionist, **junior consultant Perfusionist ,
***consultantsenior Perfusionist, ****senor consultant cardiac
surgeon
Novel technique for managing intrapulmonary massive haemorrhage,
following Pulmonary ThromboEndarterectomy
Senthil Kumaran.D**, P.V.S.Prakash***, Sunil Mekala***,
Sunil.L.G*, Dr.Binoy***,Dr.Devi Prasad Shetty****
Abstract
A 58yr old gentleman with chronic pulmonary embolism underwent
PTE. While weaning off CPB, hehad a massive and intractable
bleeding which was observed through the endotracheal tube. ET
suction wasdone and weaning off CPB was tried, but the saturation
was not being maintained and bleeding persisted.Hence CPB was
reinstated.
The only option to get the patient out of CPB was to first stop
the bleeding and this was not possiblebecause the ACT was
maintained above 480 seconds. It needs to be brought down to less
than 200 sec. Sothe patient was put on ECMO with same cannulation
and protamine was given to neutralise heparin. ACTwas brought down
to 150 seconds .The patient was stabilised on ECMO and the ECMO
support wascontinued to rest the lungs till the bronchial bleeding
totally stopped. .After 24hrs patient was taken to OTand
re-explored, bronchoscopy showed a clear field. No bleeding was
found in the endotracheal tube.Patient was weaned off, ECMO shifted
to ITU.
Key Words: Management of intrapulmonary massive haemorrhage,
ECMO.
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21
at 8’C. Myocardium was protected well, patient wascooled to
19’C, arterial blood gases were maintained inalpha stat (higher
PCo2). Cerebral protective drugs weregiven (barbiturates like
thiopentone-2-5mg/kg) andintermittent TCA was performed, all the
thrombi fromboth sides were removed and rewarming was startedand
continued up to normal temperature.
• Blood froth flooding in the ET tube was makingventilation
difficult.
• On bronchoscopy-it was identified that the rightlung was
bleeding massively, the source ofbleeding could not be found.
• The right lung was first isolated with a doublelumen tube-but
it was difficult to come off bypassdue to profuse bleeding and
there was a loss ofvolume in the right lung and PA pressures
werehigh.
(Haemodynamics were alright)
Perfusionist was getting ready to wean OFF CPBas per
anaesthetist protocols with ET tubesuctioning. At that time they
encountered massivebleeding via the endotracheal tube. ET suction
wasdone. Once again wearning off CPB was tried butpressures and
saturation were not holding.Bleeding was persistent, so CPB was
restored.There was only one option to get the patient outof CPB,
this was to stop the bleeding and bringdown the ACT levels to less
than 200 sec. Patientwas put on ECMO with the same cannulae
andpartial protamine was given.
Management
• Balance must be maintained belowanticoagulation to avoid
circuit thrombi andcoagulation to avoid bleeding.
• 2 units of packed cells and 1 unit of whole bloodwere given to
bring up Hct from 19.2% to 32%.
• 8 units of cryoprecipitate were used
1V dose-1-10 units (1 units/5 kg)
Discussion
Various techniques had been followed in order totackle post
cardiotomy bypass bleeding, especially thatwhich follows pulmonary
endarterectomy poses a biggerchallenge because of persistent
hypothermia,uncorrected hemodilution, low platelet count
andfibrinogen levels leading to DIC, prolonged CPB,prolonged
ACT>220 sec.
Finding out reason for bleeding and treating the samewould be a
correct treatment for the patients with theabovementioned
symptoms.
Hence ECMO with low level ACT was maintainedand hemodynamics was
taken care of. ECMO wassuccessfully weaned off.
• After 22hrs the patient was taken to OT and re-explored.
• Bronchoscopy was done. No bleeders were foundin endotracheal
tube. Patient was successfullyweaned off ECMO, he was
hemodynamicallystable and shifted to ITU.
What would be the causes of intrapulmonary bleeding:
• Endothelial injury
• SIRS-(leukocyte mediated)
• Pulmonary hypertension
• Catheter induced (Swan Ganz and vents)
Conclusion
• Pulmonary arterial bleeding after pulmonarythrombo
endarterectomy is a difficult problem.
• Early recognition inside the OR and promptmanagement of
pulmonary artery bleeding isimportant in rectifying the
situation.
• ECMO offers an additional strategy to facepulmonary and
circulatory failure, reducing therisk of recurrent bleeding and
avoidingpulmonary resection.
• This technique can provide favourable support inthe management
of such a complication.
SENTHIL KUMARAN : CASE REPORT
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology22
Perspectives in Vascular Surgery and other Non-CPBProtocols a
perfusionist can involve
Introduction:
Innovations in Cardiopulmonary Bypass that tookplace during the
middle of the 20th century opened newavenues in cardiac surgery.
With the advent of HeartLung Machine and Blood oxygenator, intra
cardiacrepairs and heart valve replacements became possible.In a
conventional setup; cardiothoracic surgery had tobe contented
either one operating room or had to shareon weekday basis with
other specialties; mostly withNeurosurgery. Cases done under
cardiopulmonarybypass (CPB) were a few and there were instances
that aperfusionist was assigned as a physician assistant
whoassisted the surgeon in minor procedures as well as attendclinic
or assist investigations on non-operating days.
Major vascular surgeries like Excision of Aneurysmof the Aortic
Arch, cranial surgeries involving Bacillary
Hareendran A, BSc, DPTech.
Abstract:
Advent of Heart Lung Machine and the innovations in CPB
variegated the concept of Cardio-thoracic intoCardiac Surgery and
Vascular Surgery. Many veteran surgeons continued to practise both
the specialtieseither on academic interest or limited number of
cardiac cases admitted in a general hospital or even somemedical
college hospitals having a few hundreds of cases per annum.
Perfusionist also may take care ofIntra-Aortic Balloon Pump in the
post-operative period. Ultrafiltration continued after the
termination of CPBwas a turning point in clinical involvement.Even
though Offcab and interventional procedures of septal closures and
even valve replacements took awaythe role of a perfusionist,
receding to standby, various vascular surgical procedures demand
require ourservice. Perfusionists gained insight in other fields
such as Life support systems viz. Intra-aortic BalloonPump, RV and
LV Assist Devices, Extracorporeal Membrane Oxygenation, Isolated
Organ Perfusion etc.Analysis of Blood Gases and Activated Clotting
Time became a part of the perfusion protocol. Someperfusionists
assisted the surgeon in various procedures like Doppler study etc.
With the development ofHeart Transplant for which donor heart has
to be fetched from distant place, a new category as
Transplantcoordinator paves more insight for a perfusionist.
Key words: Aortic Arch Aneurysm, Assist Devices, Auto
transfusion system, Bacillary Artery Aneurysm,Extra-corporeal Life
Support, Hemoconcentrator, Intra-Aortic Balloon Pump, Isolated
Organ Perfusion, ModifiedUltrafiltration, Off cab, Retrograde
Cerebral Perfusion, Selective Ante-grade Cerebral Perfusion,
Ultrasonic DopplerStudy.
Review Article:
Artery Aneurysm etc. opened a broad avenue forperfusion
management beyond the horizons of open heartsurgery. Involvement of
vasculature makes the task of aperfusionist more conspicuous.
Excision and Repair ofaortic arch aneurysm often demands total shut
down ofblood flow to vital organs still continues as a
greatchallenge to the perfusion team. I recall that, some
thirtyyears back, a perfusionist required a six module pumpwhile
even Cardioplegia was not a standard practice; andmany surgeons
followed intermittent clamping andadministering potassium solution.
Perfusionist had to setup the multiple bifurcation circuits for
Aortic ArchAneurysm Repairs (AAAR), where, the upper and
lowerportions required to be perfused separately [1].
Later on, Total Circulatory Arrest (TCA) under deephypothermia
also referred as Deep HypothermicCirculatory Arrest (DHTCA) got
adopted, incorporating
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23
a recirculation line to the then prevailing bubbleoxygenator
circuit to avoid platelet aggregation in thestagnated blood.
Another challenge was the ischemicsafety period where there had
been arguments on safeduration without circulation. Introduction of
ContinuedRetrograde Cerebral Perfusion which was first institutedin
1997 for removal of massive air embolism became acharm for AAAR for
a few years, but the distribution ofblood flow into both arms made
a second thinking onthe adequacy of blood flow to cerebral area and
itsquantitation methods like Internal Jugular venousPressure,
frequent assessment of desaturation level incarotid artery etc.
gave a second thought [2] and SelectiveAnte-grade Cerebral
Perfusion incorporated with axillary[3] / innominate artery
cannulation [4] which has beenused when pathology precludes
standard cannulation ofthe ascending aorta. Moreover, cannulation
of the leftcommon carotid artery technique for proximal
aorticrepair was followed in the patients in whom a
femoralcannulation was not feasible [5] came back into
practice.
Thoraco-Abdominal Surgical Procedures generally donot require
the service of a perfusionist. Supra-renalabdominal aortic aneurysm
(AAA) having a great riskfactor of postoperative renal
dysfunction/acute renalfailure is overcome by renoplegia [6]
administered by theanaesthesiologist. Whereas, depending the
magnitude ofbleeding, either a cell saver or an Auto
TransfusionSystem (ATS) is set up to minimize
allogenicperioperative transfusion. Use of a conventionalcardiotomy
reservoir (BCR) which had been establishedfor post-operative
re-infusion of mediastenal blood [7]whereas a BCR, can be used for
perioperative collectionand transfusion. Since the outlet is 3/8",
it can beconverted to appropriate size using 3/8" x ¼” reducerand a
¼ x Luer male Cardioplegia connector. Blood canbe transferred into
citrated bags via 3 way for cell wash.Partially citrated blood may
be used for immediatetransfusion. Gravity collection to blood bag
can bemanaged by an assistant, whereas, rapid transfusionthrough a
pump requires an experienced perfusionist.Hemodynamic effects of
cardiotomy blood may resultvasodilation which is proportional to
the inflammatoryactivation of suction blood. This can be reduced
byprocessing suction blood with a cell-saving device
beforere-transfusion [8].
III POST-BYPASS PROCEDURES:Modified Ultrafiltration
Ultrafiltration (UF) differs from dialysis which is apassive
that works on the principle of gradient ofcomponents using a
dialysate; whereas a Hemofilterfunctions by pressure difference.
Even though
ultrafiltration conforms to an optional component in theCPB
circuit, where, Zero balance Ultrafiltration (ZBUF)used for
replacing prime with blood as well asinflammatory media removal
during CPB [9] orConventional Ultrafiltration (CUF) performed
duringCPB to remove excess circulating fluid, its modified useafter
termination of CPB has been dealt here.
Modified Ultrafiltration (MUF) is an establishedmethod in
removing inflammatory mediators, reducingthe need for homologous
donor blood and decreasingpulmonary vascular resistance after CPB
[10]. MUF circuitexcludes the venous reservoir and the oxygenator
hasbeen summarized herein. Arterial blood is withdrawn ata speed of
less than 10 ml/kg. Body weight, and passedthrough the Ultra
filter. Either a partial resistance withoverpressure cutoff or a
controlled vacuum of is applied.Hemoglobin improves as the water is
removed. Thisconcentrated blood in infused back to the venous
linethrough the cardioplegia system to maintain the
patienttemperature [11].
IV LIFE SUPPORT SYSTEMS:
CPB is a Life support that temporarily substitutes the
Figure 1: CPB Circuit Diagram of Modified Ultrafiltration
HAREENDRAN : PERSPECTIVES IN VASCULAR SURGERY AND OTHER
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology24
functions of heart and Lungs while the patient is undergeneral
anesthesia for cardiac surgery. RetrogradeCerebral Perfusion (RCP)
and Selective Ante gradeCerebral Perfusion (SACP) comes as a
portion of theprocedure under Circulatory Arrest. Other Life
Supportsystems include Intra-Aortic Balloon Pump (IABP),
Extra-corporeal Membrane Oxygenation (ECMO), CirculatorySupport
devices like Left / Right Heart AssistDevices(LVAD), Isolated Organ
Perfusion etc. which maybe under local anesthesia.
1. Isolated Organ Perfusion
The lung is the site of many neoplasms includingsarcoma,
melanoma, renal cell cancer, and metastaticgastrointestinal disease
that, because of location, size, ormultiplicity, are un-resectable.
ILuP is conducted aftercannulation of the concerned Pulmonary
Artery and twopulmonary veins and done under Normothermia
orhyperthermia of 42°C. Staged thoracotomies are done forbilateral
disease, staged with an interval of 4-8 weeks [12].Hyperthermic
isolated limb perfusion (HILP) in locallyadvanced soft tissue
sarcoma and progressive desmoid-
Figure 2: Table showing Life Support System
Figure 3: Isolated Limb Perfusion of Left Leg
type fibromatosis with TNF 1 mg and melphalan (T1-MHILP) is safe
and efficient. Some patients were previouslyirradiated or had
received systemic chemotherapy beforeHILP [13].
2. Intra-Aortic Balloon Pump
Intra-Aortic Balloon Pump IABP and Left VentricularAssist
Devices (LVAD) are viewed as escalating methodsalong with hydraulic
considerations which allow non-invasive determination of stroke
volume [14]. Intra-aorticballoon pump counter-pulsation (IABP) is
currently themost commonly used mechanical assist device
forpatients with cardiogenic shock due to acute
myocardialinfarction [15]. IABP Console triggers from the ECG
orPressure wave and inflate the balloon insertedpercutaneously into
the descending aorta. The Ballooninflated by Helium and squeezes 40
ml volume of bloodout of the aorta. Heart Muscles dilated during
diastoletakes up more blood. Owing to low solubility in
aqueousmedium, it was a chosen to minimize decompressionsyndrome,
and became the chosen gas due to the diffusionproperties. It cannot
safeguard an event of BalloonRupture, and only precaution is to
avoid reuse of theBalloon. Picture shows the screen displays all
parametersincluding the amount of Helium in the tank.
3. Extra Corporeal Membrane Oxygenation
Since a positive pressure needs to be maintainedduring the use
of an oxygenator, the pump in a Veno-Venous ECMO (VV-ECMO)
functions as a supportivedevice, and this type of ECMO provides
only respiratorysupport. It has been reported that ECMO via
subclavian
Figure.4: IABP Screenshot
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25
catheter has been successfully performed for severepostoperative
bacterial pneumonia unresponsive toconventional treatment following
a failed renaltransplant, and the patient was placed on low flow
VV-ECMO as an adjuvant to antibiotic therapy and maximalventilatory
support. Venous ECMO resulted in rapidimprovement and the patient
was successfully weanedafter 48 hours [16]. Sometimes VV ECMO may
exert somedisadvantages such as a longer operative time to placethe
cannulas, groin wound problems, and persistent leg
swelling necessitate conversion to VA ECMO. [17].ECMO is said to
be superior to Right Heart assist devices[18].
4. Left Ventricular Assist devices
Left ventricular assist devices (LVAD) are analyzedas
extravascular in-series or parallel volume-capturing/ ejecting
devices and as true blood pumps which can beimplanted. Centrifugal
Blood Pump (Heart Ware) can beimplanted as LVAD by hemi-sternatomy
combined withanterio-lateral thoracotomy [19]. The abdominal
leftventricular assist device (ALVAD) is implanted in theabdomen,
and is driven by a pneumatic pump [20]. TheLVAD functions as a
bridge for heart transplant untilsuitable donor heart is obtained
[21]. Sometimes, a LVADmay impair RV function [22]. Extracorporeal
life support(ECLS) is indicated following left ventricular assist
device(LVAD) implant for right heart failure or
pulmonarydysfunction [23].
Figure 5: Veno-Venous ECMO
Figure: 6: LVAD
5. Right Ventricular Assist Devices:
Disastrous complication of LVAD leading to Rightheart impairment
necessitates a secondary right heartassist device (RVAD) [24].
right ventricular failure stilloccurs in about 44 % of patients
after continuous-flowleft ventricular assist device
insertion.[25].
Figure 7: Right Heart Assist Device Implanted
HAREENDRAN : PERSPECTIVES IN VASCULAR SURGERY AND OTHER
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology26
V CLINICAL / LABORATORY INVESTIGATIONS:
1. Ultrasound Doppler
Ultrasound Doppler is non-invasive equipment thatcan be used for
Blood flow Studies and Blood Pressuremeasurement when Echo lab or
pressure transducerswere uncommon. Ether stand required Patient's
arm incaudad position (opposite to head end) making thebrachial
region inaccessible for stethoscope or palpationof pulse. has a
pair of peizo-electric crystal among whichone vibrates at a
frequenzy of 10 MHz. (20 kHz isinaudible to human ears, and termed
as Ultrasonic.)whereas the second one detects blood flow velocity
byDoppler shift ( Change in in frequency caused by themoving
medium).
Adult and Pediatric models of flat probes used foroperating room
use, whereas a pencil probe used forDoppler studies. The study
includes the Assessment ofBlood flow Velocity in Axillary, Brachial
and radio-ulnarregions of the upper extremities, and femoral,
popliteal,dorsalis pedis and Posterior Tibial Arteries; as well
asupper and lower limb pressure assessments. Owing to
Figure 8: Ultrasound Doppler made by Parks MedicalElectronics
Inc, USA
various reasons such as resonance and higher readingscaused by
standard pressure cuff, a 12 cms wide cuff asrecommended by the
manufacturer may be used [26].Since vascular diseases involve
blockage of blood vessels,a drop in temperature is detected in case
of arterialdiseases, whereas an increase in ankle temperature
ofreturning blood, stated as an important nursingassessment
parameter to evaluate worsening orimpending CVI complications
[27].
2. Activated Clotting (Coagulation) Time
Activated Clotting Time (ACT) was first establishedby Hattersly
in 1966 based on the principle of contactactivation using glass
beads to detect hemorrhagicdiatheses [28]. Many Cardiothoracic
procedures requirethe patients to be anticoagulated to prevent
clotting andthrombotic complications. Blood Clotting is time
isartificially prolonged using Heparin. ECMO) therapy alsorequire
anticoagulation. There are several bedside wholeblood
microcoagulation systems available to determineactivated clotting
time (ACT) levels. Hemocron ACT
Figure 9: Chart: Doppler study Chart
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27
machines have Celite Glass Mixture [29]. Kaolin used inmany
other models are proven to be superior in accuracyand
reproduciblilty [30]. Even though ACT have been astandard protocol
in Cardiovascular surgery for overthree decades,
Thromboelastography became a turningpoint in coagulation management
[31].
VI Conclusion:
Developments in pediatric heart surgery diversifiedthe specialty
of Cardiovascular and Thoracic surgery intothree groups namely,
Acquired Heart Surgery,Congenital Heart Surgery and Vascular &
ThoracicSurgeries. Further developments took place in
CoronaryArtery Bypass Graft (CABG) Surgery. Coronary Artery,being
the Blood Vessel catering the walls of the heart iscategorized as a
major cardiac procedure. Aortic ArchAneurysm Repair, considered as
a Thoracic procedure,the involvement of Coronary Root Replacement
are donewith the support or guidance of coronary
surgeons.Thoraco-abdominal procedures, even though do notrequire
cardiopulmonary bypass; chances of massivebleeding requiring
auto-transfusion is managed by theperfusion team. The perfusionist
gets involved with Auto-transfusion for vascular procedures; where
the shedblood is transfused after getting the cells washed
andconcentrated in the Blood Bank. Blood collected in aReservoir is
either transfused through pump ortransferred into blood bags and
sent to blood bank withentries for dispatch and follow up.
Continuous Cell andPlasma Separators brought the whole work into
theoperation room.
Development of tissue stabilizers made CABG feasiblewithout CPB
that derived a term OPCAB reduced thefunctional role of a
perfusionist into standby. Impact ofinterventional procedures
further reduced the need forcardiopulmonary bypass took the major
portion of workout of the hands of the perfusionist. A
Modernperfusionist has to take of advanced equipment andnewer
concepts. Apart from CPB, a perfusionist may getinvolved with
various means of life support system. Someare circulatory support
systems. Intra-Aortic BalloonPump, which is sometimes required for
CABG patientswho cannot be weaned off, is often managed by
theperfusion team. The system functions on the principleinflation
of a balloon which is inserted into the descendingaorta. The
inflation is synchronized with diastolic so thatmore blood flows
through the coronaries.
Extra Corporeal Life Support (ECLIS) became a newmeans of
therapy for failing lungs, especially in patientssuffering from
avian flu. Extra Corporeal MembraneOxygenation and Left Heart
support Devices which is a
bridge for Heart Transplantation became a new tool forthe modern
perfusionist. With development of HeartTransplant for which donor
heart has to be fetched fromdistant place, a new category as
Transplant coordinatorcame to exist. Perspectives of organ
preservation withemphasis to the beneficial effects of
normothermicperfusion over hypothermic storage is an awesome
topicfor a perfusionist [32]
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JEPPSSON A.;Hemodynamic effects of cardiotomy suction
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blood; J Thorac Cardiovasc Surg. 2006Jun;131(6):1352-7.
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versus conventional arteriovenousmodified ultrafiltration during
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12. J. M. H. HENDRIKS, S. ROMIJN, B. VAN PUTTE,B. STOCKMAN, P.
TEN BROECKE, P. VANSCHIL; Isolated Lung Perfusion for the
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13. BONVALOT S, RIMAREIX F, CAUSERET S, LEPÉCHOUX C, BOULET B,
TERRIER P, LE CESNEA, MURET J., Hyperthermic isolated limbperfusion
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fibromatosis withTNF 1 mg and melphalan (T1-M HILP) is safe
andefficient. Ann Surg Oncol. 2009;16(12):3350.
14. NORMAN JC, IGO SR, Mechanical circulatoryassistance:
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SEYFARTH M, DEWAHA A, OHMAN EM, BUERKE M,HAERTING J, WERDAN K,
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16. CALDERÓN M, REYES P, TOVAR A, NUÑEZ E,LAGUNAS J, SOBERANES
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17. M D KLEIN, A F ANDREWS, J R WESLEY, JTOOMASIAN, C NIXON, D
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24. STRAUCH JT, FRANKE UF, MADERSHAHIANN, WAHLERS T. Right
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25. Fukamachi K, Shiose A, Massiello AL, HorvathDJ, Golding LA,
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27. KELECHI TJ, HAIGHT BK, HERMAN J, MICHELY, BROTHERS T, EDLUND
B.; Skin temperatureand chronic venous insufficiency. J WoundOstomy
Continence Nurs. 2003 Jan;30(1):17-24.
28. PAUL G. HATTERSLEY, MD; ActivatedCoagulation Time of Whole
Blood ; JAMA. 1966;196(5):436-440.
29. COLBY CE, SHEEHAN A, BENITZ W, VANMEURS K, HALAMEK LP, MOSS
RL. ;Maintaining adequate anticoagulation onextracorporeal membrane
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Activated clotting time (ACT)testing: analysis of reproducibility.
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Contact Address:
Hareendran A, Sharanya, TC12/1756, Poonthi Road,Medical College
PO, Thiruvananthapuram 695011.Phone: 04712553922; Mob: 09446178885;
Email:[email protected]
HAREENDRAN : PERSPECTIVES IN VASCULAR SURGERY AND OTHER
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology30
FOR YOUR KIND ATTENTION!
This is for your kind notice that there is an article that had
been published in VOLUME 22of the Indian journal of extra corporeal
technology (IJECT) of 2012 which is calling forremedy now. The
article entitled "Modified circuit for 1:4 blood cardioplegia
delivery"whose authorship or co-authorship is perhaps controversial
and demands rectification oreven deletion. An email is addressed to
me by DR.SHIV CHOWDHARY whose name wasin the list of co-authors in
the aforesaid article. I received this mail on 13th February
2014.Hedisclaims his co-authorship from the article as his consent
according to him, was not soughtbefore its publication. The past
editor and co-author of the article MR.RAJEEV GUPTAalso sent me an
email with regret asking for DR.SK CHOUDHARY'S name to be
removedfrom its coauthor's list on the 14th February. However, I
sent a reply to DR.SKCHOUDHARY promising him that I would do the
needful very soon. Although thisincident which is claimed by them
happened during the previous tenure and now a neweditor and
editorial committee has assumed office and we are neither directly
nor indirectlyimplicated in that issue, yet we cannot connive at
it. After a serious discussion with someexperienced members in the
editorial committee, a decision is taken to remove or excludeDR.SK
CHOUDHARY's name from the co-authors list from the above article
(the article isrepublished in the next page with the
rectifications) for everyone's notice.
Thus it makes inevitable that in future the signatures of the
author and co-authors areindispensable for an article before its
publication. This discipline would be stringentlyreviewed
henceforth. Moreover it would help to avoid further undesirable
precipitationof matters in these kinds of issues.
Thank you
RegardsEditor IJECT
(N.B.: This is the first issue of the journal during my tenure,
please refer to the letter from theeditor's desk)
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31FOR YOUR KIND ATTENTION!
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology32
Blood Conservation During CPB - Role OfPerfusionist without
↑Cost
Modifications are:-
1. ↓Prime volume by Circuits design &
OxygenatorPlacement;
2. ↓Prime volume by retrograde/anterogradeautologous
priming;
3. Ultrafiltration with Cost Effective Method.
4. Microplegia.
And also use the devises i.e.Vacum assist
device,Ultrafiltration. But In the view business accept,
introducethe modern device is directly effect to ↑cost of
Surgery-Package that’s why Patient is also suffer for same. Ouraim,
without ↑Surgery cost blood should be conserve forpatient
benefit.
Saurav Sengupta,Sr Clinical Perfusionist Desun Hospital &
Hesrt Institution Kolkata, Westbengal
Abstract:
Objectives:In cardiopulmonary bypass Extreme haemodilution due
to crystalloid priming? transfusion ofstored Blood in small adult
cardiac surgical patients. And homologousblood transfusion during
cardiacsurgery?morbidity and mortality.Therefore we examined
whether some modification ofour self to reducinghemodilution andred
cell transfusion
METHODS: 96 patientsof 2011-2012 with a bodysurface area of ~
1.3m2 -1.5m2 undergoing first-time,cardiac surgerywere randomized
to either the Standardgroup or the Modified group.
1. Reduction in prime volume using a reduced bypasscircuit
Reduction in prime volume is a major factor in
bloodconservation.
Phase – I Before Reduce the Circuit
We assume a blood volume of adult patient is 70 mL/kg & in
general Priming volume is around 1650(Circuit+ Oxygenator+
Heat-exchanger+ filter+ with 200 mlminimum Reservoir level)
The two membrane oxygenators Sorin EVO & Affinity NT are in
major use in our institute.
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33
Phase – II After Reduce the Circuit
We assume a blood volume of adult patient is 70mL/kg & in
general Priming volume is around ↓ 300,total PV is 1350(Circuit +
Oxygenator+ Heat-exchanger+filter+ with 200 ml minimum Reservoir
level), But heredrastically ↓ the circuit volume due to the
PlegiaTechnique.
2. Plegia Technique.
Microplegia:The original composition of bloodcardioplegia
described by Buckberg was a 4:1 ratio (BCDChamber) blood
-crystalloid; this has become thestandard for cold blood
cardioplegia. And also some usethe Kolies Chamber but both the
methods are ↑ volumerelated. Alternatively we proposed to use a
type ofsolution which can ↓volume requirement & also the↓ prime
which is Microplegia.
Microplegia is one type of blood plegia and itsClassical
technique for continuous or discontinuous withperfusion temperature
is identical for ↓ Priming.
TECHNIQUE:
The cardioplegia circuit is very simple. The cardioplegicline is
composed of pvc tubing with an internal diameterof 1/4inch. Make
with a Y connector (fig 1).
The total prime volume of the cardioplegia circuit isbetween 25
ml for neonates and 35 ml for older Adult.Oxygenated warm blood is
withdrawn directly from theoxygenator or from the origin of the
arterial line by anocclusive roller pump. The cardioplegic solution
isdelivered by an electrical syringe pump that is connectedto the
cardioplegic circuit via a Y type connectordownstream of the
occlusive roller pump (fig 2).
Figure 2 - Cardioplegic circuit. Roller on the left isthe
arterial pump, performing the total bypass flow.Roller on the right
is the cardioplegia pump, diverting
the blood component of the warm blood microplegia.The syringe
pump injects the CP solution.
The crystalloid component each ml Contain / Flowratio:
Figure 1 - Cardioplegic circuit made by ¼ inch PVC with
Yconnectors.
SAURAV SENGUPTA: BLOOD CONSERVATION DURING CPB - ROLE OF
PERFUSIONIST WITHOUT COST
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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology34
3. Autologous priming
Retrograde or antrigrade autologous priming consistsof total or
partial replacement of the crystalloid primeby using the patient’s
blood being drained from thearterial and venous lines (mean volume
withdrawal:650 ±100 ml). During this drainage, the bloodless
primeis collect to Empty RI/RL bottle.
Thus, the total crystalloid Priming Volume becameis average 700
±100 ml.
Perfusion and anesthetic techniques wereotherwiseidentical for
the two groups.
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RESULTS:
Patient characteristics and operative parameters wereequal for
patients in both groups. With autologouspriming, a mean crystalloid
Priming Volume is 700 ±100ml. This allowed a significantly higher
haematocrit valueduring cardiopulmonary bypass. Red blood
celltransfusion was necessary in approx. 78 % of patientsof the
standard priming group on pump; whereas only16.5% of patients of
the modified group requiredtransfusion .The overall transfusion
rate of the modifiedgroup was significantly less than that in the
standardpriming group during the hospitalization.
CONCLUSION
There are many ways to ↓ the number of stored
bloodtransfusions.
The major techniques are as follows:
(1) ↓bypass circuit which decreases dilution anddilutional
coagulopathy;
(2) Microplegia;
(3) Retrograde or antrigrade autologous priming.
These three techniques are simple, inexpensive, safeand
efficient in all patients regardless of age or weight.The other
techniques (cell-salvage, ultrafiltration,Vacuum assist device)
could be used in combinationwith the major t