bluuebunny/crossref_metadata_2025 huggingface dataset:
2004 Survey of ECMO in the Neonate After Open Heart Surgery: Circuitry and Team Roles
Authors: Searles Bruce , Gunst Gordy , Terry Bryan , Melchior Richard , Darling Edward
Published: July 2023

Over the past 20 years, the bulk of the literature and texts published about extracorporeal membrane oxygenation (ECMO) has been written by physicians and nurses. The consensus of this body of printed information would suggest, among other things, that (1) despite significant advancements in extra-corporeal technology, the standard ECMO circuit has remained fundamentally unchanged since originally described in 1982, and (2) perfusionists are nearly absent from the staffing algorithm at most centers. While these conclusions may be representative of the extracorporeal life support (ELSO) reporting centers, they may not be representative of the field as a whole. We hypothesized that the use of modern extracorporeal equipment and the involvement of perfusionists in ECMO patient care is largely underreported in previous studies. To study this hypothesis, we developed a standard survey instrument and queried perfusion teams from the hospitals listed on the American Society of Extra-Corporeal Technology Pediatric Registry. All centers were contacted by phone and were asked questions regarding their caseload, circuitry, and staffing algorithms. Data are reported as a percentage of respondents. ECMO is used as a method of mechanical support after neonatal open heart surgery in 94% of centers surveyed. For 60% of the centers, a silicone membrane oxygenator is used exclusively, whereas 40% of the centers have used a hollow fiber oxygenator (HFO), and of that group, 19% use a HFO routinely for neonatal post-cardiopulmonary bypass ECMO. Roller pumps are used exclusively at 65% of the centers, whereas centrifugal pumps are used routinely in 12%, and 23% have used both. Perfusionists are responsible for set-up/initiation (79%) and daily rounding/troubleshooting (71%), and provide around-the-clock bedside care (46%) at the surveyed centers. These data suggest that previously published ELSO-centric ECMO studies may significantly underestimate the contemporary application of modern technologies and the involvement of perfusionists.
Stability of Human Thrombin Produced From 11 ml of Plasma Using the Thrombin Processing Device
Authors: Kumar Vijay , Madsen Trista , Zhu Haihong , Semple Elisabeth
Published: July 2023

Autologous thrombin can be produced by activating the patient’s own plasma. By adding calcium chloride (CaCl2) to the anticoagulated plasma, the coagulation cascade will be initiated, and active thrombin will be produced. However, thrombin obtained by this method degrades very quickly and is not practical for use during surgery. The aim of this study was to investigate the stability of the thrombin produced using the thrombin processing device (TPD; Thermogenesis Corporation). The TPD consists of a tubular chamber containing a negatively charged surface for activation. Plasma (11 ml) and reagent (CaCl2and ethanol, 3.75 ml) were added to the TPD, and active thrombin was harvested after a 20-minute incubation. The production of thrombin was done at 18°C (64°F), 24°C (75°F), and 27°C (81°F) (n= 4/group). The produced thrombin was stored at the production temperature, 4°C (39°F), and 35°C (95°F). The thrombin activity was assessed by time to clot formation, using a fibrinogen concentrate as substrate, after 2, 4, and 6 hours of storage. Thrombin produced at 18°C had clot times of less than 5 seconds for 2 hours (4.42 ± 1.3 seconds) when stored at 4°C, but 4 hours (4.1 ± 1.3 seconds) when stored at 35°C. In contrast, when thrombin was produced at 24°C, the clot times were 4.3 ± 0.7 and 4.6 ± 1.6 seconds at 4°C and 35°C, respectively, for up to 6 hours. Similar results were obtained for thrombin produced at 27°C. Active thrombin produced by the TPD is dependent on both the production temperature and the storage temperature. Autologous human thrombin with a stability of up to 6 hours can be obtained using the TPD when produced at 24°C or 27°C and stored at 4°C.
An Isolated Limb Infusion Technique: A Guide for the Perfusionist
Authors: McDermott Patricia , Lawson D. Scott , Walczak Richard , Tyler Douglas , Shearer Ian R.
Published: July 2023

Isolated limb perfusion with the administration of cytotoxic drugs has been successfully used to treat melanomas of the extremity since it was first introduced in 1958. The use of hyperthermia (40°C) combined with chemotherapy agents, primarily melphalan, has resulted in greater cytotoxicity in laboratory studies, which led to the application of hyperthermia in clinical studies during the 1960s. The effectiveness of this regional technique and the absence of any good systemic therapy made hyperthermic-isolated limb perfusion (HILP) the main treatment for patients with regionally advanced melanoma. HILP involves open surgical dissection and cannulation of the peripheral vessels and is associated with moderate morbidity rates. Blood transfusions, systemic drug leak, infection, and damage to the blood vessels and nerves are all potential hazards associated with this technique. Recently, however, there has been increased interest in an alternative technique termed isolated limb infusion (ILI), which was first reported in 1994 from the Sydney Melanoma Unit in Australia. Based on a few single institution experiences, it was found that there are fewer morbidities associated with HILP than with ILI but no compromise in patient outcomes. ILI is a less invasive procedure involving the use of angiographically placed catheters inserted percutaneously through the femoral vessels that does not require blood donor exposure or use of a heart lung machine. Preliminary data suggest that the resultant local hypoxia and acidosis induced by this procedure potentiates the cytotoxic effects of melphalan. Response rates comparing ILI to HILP seem similar, and both are markedly better than systemic chemotherapy. ILI may be a more desirable option because morbidity is greatly reduced and outcomes appear similar. There is a potential role for the perfusionist in the application of ILI, an evolving area of cancer therapy.
SMART Tubing Presents an Increased Risk of Disconnection During Extracorporeal Circulation
Authors: Newling Ross , Morris Richard
Published: July 2023

A number of products exhibiting biocompatible features have been developed for use in extracorporeal blood circuits during cardiopulmonary bypass procedures. While attention has been focused on biocompatibility features of the blood-circuit interface, a number of issues applicable in clinical use of these circuits have arisen. Surface Modifying Additive Technology (SMART; Cobe Cardiovascular, Arvarda, CO) is one such technology. In this product, the structure of normal polyvinylchloride (PVC) tubing is altered through the blending of two copolymers to give a more biocompatible blood to plastic interface. In this study, we examined the in vitro mechanical ability of random samples (n = 10) of SMART and standard PVC tubing to withstand axial tension when the tubing was placed over a single barb of a connector. The tension required to remove the SMART tubing from the connector (83.3 ± 7.3 [SD] N), was significantly less than standard PVC tubing (115.6 ± 15.9 N; p < .0001, unpaired t test). The SMART tubing exhibited a 28% reduction in tubing to connector adhesion, which may have a significant effect on extracorporeal circuit disconnection and overall patient safety.
In Vivo Comparison Study of FDA-Approved Surface-Modifying Additives and Poly-2-Methoxyethylacrylate Circuit Surfaces Coatings During Cardiopulmonary Bypass
Authors: Ask Angela , Holt David , Smith Lynette
Published: July 2023

The purpose of this double-blind prospective and randomized study was to examine the effects of surface-modifying additives (SMAs) and poly-2-methoxyethylacrylate (PMEA) circuits on platelet count, platelet function (Sonoclot), postoperative chest tube drainage volume, peri- and postoperative blood product use, extubation time, and intensive care time. Terumo noncoated, Terumo-coated (PMEA), Cobe noncoated, and Cobe coated (SMA) circuits were evaluated to find the most cost-effective way to improve patient outcomes. We aimed to find if an additional charge for a coated CPB circuit would be recovered by reducing other patient costs (blood transfusions, intensive care unit time, and bring back postoperative bleeding). An initial literature review revealed the comparison of PMEA circuits vs. noncoated circuits and SMA circuits vs. noncoated circuits in both adult and porcine models. Both SMA- and PMEA-coated circuits decreased platelet consumption, platelet factor release, and the overall perioperative inflammatory response while on cardiopulmonary bypass (CPB). The question not answered in an initial search was simply, “which coated circuit is best for the patient: SMA or PMEA?” Research comparing the above coated circuits each other was not found. The study was approved by the Institutional Review Board. Thirty patients were scheduled for elective coronary artery bypass grafting and/or valvular repair or replacement surgery. These 30 patients were randomized as 10 patients to Terumo X-Coating (PMEA surface coating) (CT), 10 patients to Cobe Smart-X coating (SMA surface coating; CC), 5 patients to Terumo noncoated tubing (NCT), and 5 patients to Cobe noncoated tubing (NCC). Informed consent was obtained from each patient before surgery. The data showed no statistically significant relationship between platelet counts, platelet function (Sonoclot), postoperative chest tube drainage volume, peri- and postoperative blood products, intensive care unit time, or total hospital length of stay. Analysis revealed statistically significant clinical associations of extubation time and protamine dose with treatment group. This study provided evidence that SMA- and PMEA-coated circuits do not improve platelet consumption or decrease blood product use for patients undergoing CPB. There was statistical significance with a reduction in extubation time and total protamine requirement needed to return activated clotting time (ACT) to baseline post-CPB. Although the use of SMA and/or PMEA circuits during CPB has clinical benefit to the CPB patient, an additional charge for the specialty circuit may not be realized.
Heparin-Coated Adult ECMO vs. Ventricular Assist Devices: A Decision Analysis Modeling Approach
Authors: Nance Jason R. , Sistino Joseph J.
Published: July 2023

Postcardiotomy failure requiring ventricular assist occurs in about 1% of adult patients undergoing cardiac surgical procedures. One method of support is a short-term ventricular assist device. This incurs the cost of the device, which is substantial, and allows for reduced anticoagulation in the first 24 hours. Another option is a heparin-coated extracorporeal membrane oxygenation (ECMO) circuit. This also allows for reduced anti-coagulation and can support the lungs if necessary. The use of a heparin-coated ECMO circuit requires 24-hour monitoring, but the cost of disposables is considerably less than the cost of ventricular assist devices. This decision analysis uses a Markov model to evaluate the relative outcomes and costs associated with selection between these modalities of support. Data from the past 5 years of patients who received postcardiotomy support will be used to develop the Markov model. The hypothesis is that supporting the patient on heparin-coated ECMO before instituting ventricular assistance will reduce cost and allocate resources in a more cost-effective manner. The model was used to determine the optimal economic time for initiation of ventricular assist devices in postcardiotomy patients. The total costs associated with support begin to level out between postoperative days 6 and 10 using an Abiomed BVS5000 ventricular assist device. The largest decline in costs occurs after postoperative day 3. This model suggests that patients should be supported on heparin-coated ECMO for 2–3 days to evaluate their potential for recovery before instituting more expensive ventricular assist devices.
Autologous Priming Technique to Reduce Blood Transfusion in Pediatric Cardiopulmonary Bypass
Authors: Ostrowsky Jacob , Henderson Mark , Hennein Hani
Published: July 2023

Excessive hemodilution during cardiopulmonary bypass is associated with decreased oxygen carrying capacity, edema, and organ dysfunction. The use of blood products is often necessary to prime the extracorporeal circuit for pediatric cardiac surgical patients. However, the use of blood products carries serious risks both in the acute and long-term aspects of patient care. Autologous priming of the extracorporeal circuit used in conjunction with ultrafiltration, pharmacologic manipulation, and cell salvage may decrease the need for blood transfusion in the pediatric cardiac surgical population. We have developed a technique that enables us to perform transfusionless complex congenital heart repair targeting patients as small as 5 kg.
Mitigation of Device-Associated Thrombosis and Thromboembolism Using Combinations of Heparin and Tirofiban
Authors: Meola Stacy , Burns Gregory , Sukavaneshvar Sivaprasad , Solen Kenneth , Mohammad Syed
Published: July 2023

Combined anti-platelet–anticoagulant therapy is increasingly being used to reduce the risk of device-induced thrombosis and thromboembolism. However, direct quantitative confirmation of the effectiveness of this combination approach is lacking. This study was undertaken to quantify the effects of various combinations of heparin (anticoagulant) and tirofiban (antiplatelet agent) on device-induced thrombosis and thromboembolism using a coronary stent as a prototype device. Adult sheep were implanted with ex vivo carotid–carotid shunts containing replaceable tubing segments in which nitinol stents were deployed. Nine combinations of heparin (average activated clot time = 129, 199, and 355 seconds) and tirofiban (0%, 50%, and 100% platelet inhibition) were tested at random with three replicates per animal. Thrombus weight on the stent at the end of each experiment (1 hour) was measured, and emboli released from the stent were continuously monitored during the experiment using a light scattering microemboli detector. With no tirofiban, increasing the heparin concentration was associated with a decreased endpoint thrombus weight (p < .05) but with a slight (non-significant) increase in the number of downstream thromboemboli. However, the presence of tirofiban decreased both thrombus weight and thromboemboli numbers (p < .05), regardless of the heparin concentration. In the presence of medium or high tirofiban, an increase of heparin from low to medium levels also decreased both thrombus weight and thromboemboli numbers (p < .05). Heparin alone does not provide adequate protection against thromboembolism (and may actually increase it by reducing thrombus cohesive strength). However, the combination of heparin and tirofiban is effective in reducing both thrombus and thromboemboli, and an optimal combination may exist.
Use of the Hemobag® for Modified Ultrafiltration in a Jehovah’s Witness Patient Undergoing Cardiac Surgery
Authors: Moskowitz David M. , Klein James J. , Shander Aryeh , Perelman Seth I. , McMurtry Kirk A. , Cousineau Katherine M. , Ergin M. Arisan
Published: July 2023

Modified ultrafiltration is an important technique to concentrate the patient’s circulating blood volume and the residual whole blood in the extracorporeal circuit post-cardiopulmonary bypass. The Hemobag system is a device cleared by the US Food and Drug Administration and represents a novel and safe modification of traditional modified ultrafiltration systems. It is quick and easy to operate by the perfusionist during the hemoconcentration process. Hemoconcentration is accomplished by having the Hemobag “recovery loop” circuit separate from the extracorporeal circuit. This allows the surgeons to continue with surgery, decannulate, and administer protamine simultaneously while the Hemobag is in use. The successful use of the Hemobag in a Jehovah’s Witness patient has not been previously described in the literature. This case report describes how to set up and operate the Hemobag in a Jehovah’s Witness patient undergoing cardiac surgery that requires an extracorporeal circuit.
Cardiopulmonary Bypass in a Glaucoma Patient
Authors: Singh Jaswinder , Dhaliwal Rajinder Singh , Das Debasis , Luthra Suvitesh , Singh Harkant
Published: July 2023

Cardiopulmonary bypass (CPB) in a patient with glaucoma is a challenge. The glaucomatous eye is at risk during CPB. We report a case of ostium secundum atrial septal defect that was not amenable to device closure. The unique feature in the patient was the presence of congenital glaucoma. She was blind in the left eye, and the visual acuity in the other eye was decreased because of glaucoma. She underwent direct closure of the atrial septal defect under CPB and fibrillatory arrest, with intraoperative monitoring of intraocular pressure. There was no change in visual acuity after 1 year of follow-up.
Intraoperative Assessment and Quantification of Coronary Artery Graft Patency Performed on or off Cardiopulmonary Bypass
Authors: Rauch Eric D. , Leach Christopher , Barnes Terry , Driscoll Kurt , Strutz Kurt , Holt David W.
Published: July 2023

Within the last 10 years, the incorporation of off-pump coronary artery bypass grafting (OPCAB) into many surgical practices has grown. OPCAB requires the surgeon to operate on a beating heart, and it is generally accepted that OPCAB procedures are more technically demanding. Concerns of possible incomplete revascularizations and decreased graft patency have been noted in the literature. The objective of this study was to evaluate and compare on-pump and off-pump intraoperative coronary artery bypass graft (CABG) flow parameters. Intraoperative flow studies conducted with the Butterfly (Medi-Stim Norge AS, Oslo, Norway) flow meter were analyzed retrospectively on 74 patients. Comparisons were completed between patient groups having had their revascularizations performed on or off cardiopulmonary bypass. Our study revealed significant differences in the mean flow rate through saphenous vein grafts (SVG) to the obtuse marginal artery (OM; p = .014), to the diagonal artery (Diag; p = .003), to the right coronary artery (RCA; p = .001), and to the posterior descending artery (PDA; p = .001). Total blood product use showed significantly increased use of both platelets (PLTs) and cryoprecipitate (Cryo) in the on-pump group (p = .027 and .012, respectively). No differences were found for transfusions of red blood cells (RBCs) or fresh frozen plasma (FFP). Additional findings showed a significantly decreased median length of stay (LOS) for the off-pump group. The on-pump patients had a median hospital stay of 7 days (range, 4–24 days), whereas the off-pump patients had a median stay of 6 days (range, 3–22 days; p = .049). Although we were able to show some significance in the mean flow data supporting increased graft flow with the on-pump technique, we were not able to show an overall increase in all recorded flow characteristics to support one method over another.
Evidence-Based Algorithm for Heparin Dosing Before Cardiopulmonary Bypass. Part 1: Development of the Algorithm
Authors: McKinney Mark C. , Riley Jeffrey B.
Published: July 2023

The incidence of heparin resistance during adult cardiac surgery with cardiopulmonary bypass has been reported at 15%–20%. The consistent use of a clinical decision-making algorithm may increase the consistency of patient care and likely reduce the total required heparin dose and other problems associated with heparin dosing. After a directed survey of practicing perfusionists regarding treatment of heparin resistance and a literature search for high-level evidence regarding the diagnosis and treatment of heparin resistance, an evidence-based decision-making algorithm was constructed. The face validity of the algorithm decisive steps and logic was confirmed by a second survey of practicing perfusionists. The algorithm begins with review of the patient history to identify predictors for heparin resistance. The definition for heparin resistance contained in the algorithm is an activated clotting time <450 seconds with >450 IU/kg heparin loading dose. Based on the literature, the treatment for heparin resistance used in the algorithm is anti-thrombin III supplement. The algorithm seems to be valid and is supported by high-level evidence and clinician opinion. The next step is a human randomized clinical trial to test the clinical procedure guideline algorithm vs. current standard clinical practice.
An Innovative Simple Technique of Blood Conservation in Adult Patients with Tetralogy of Fallot and Severely Raised Hemoglobin
Authors: Neema Praveen Kumar , Manikandan Sethuraman , Rathod Ramesh Chandra
Published: July 2023

The adult patients of tetralogy of Fallot often present with high hemoglobin levels. High hemoglobin and hematocrit on cardiopulmonary bypass (CPB) are associated with increased hemolysis, plasma free hemoglobin, renal dysfunction or failure, postoperative bleeding, exploration for bleeding, and increased requirement of allogeneic blood and blood products. Despite the presence of high hemoglobin and its association with adverse outcome, blood conservation is rarely practiced in these patients because of the fear of possible hemodynamic instability, and hypoxemic spell. We describe an innovative, simple technique of blood conservation for adult patients of tetralogy of Fallot with severely raised hemoglobin. With this technique, hemoglobin can be normalized on CPB; moreover, there is no fear of hypoxemic spell or hemodynamic instability. Furthermore, the blood conserved is readily available for transfusion in the perioperative period, if needed.
Large Multicenter Trials: What Do They Achieve and What Should Be Done in Perfusion?
Authors: Myles Paul
Published: July 2023

There have been a vast number of publications in the perfusion and cardiac surgical literature suggesting possible therapeutic benefits from many perfusion interventions. Most of the reports are case series and other observational studies; few are randomized trials, and most of these are small, focusing on surrogate endpoints. We know there are many factors that can affect outcome after cardiac surgery, and some of these can bias results of clinical studies. Evidence-based medicine has highlighted the importance of avoiding bias with good study design, critical appraisal, and careful application into clinical practice. Associations shown in observational studies do not provide reliable evidence of effect (causation). Random allocation to treatment groups accounts for many sources of bias, but small randomized trials can still be unreliable because they may identify a spurious positive finding by chance (type I error), as well as providing imprecise estimates of effect, as shown by wide confidence intervals. Obtaining data on actual outcomes with enough study power requires a large number of patients. Meta-analysis of small randomized trials can increase power, but this introduces other sources of bias. Large randomized pragmatic trials, using straightforward interventions reflecting routine clinical practice, can optimize the ability to generalize and therefore are clinically relevant and reliable. They thus provide the best evidence of effectiveness.
On-Line Autotransfusion Waste Calculator
Authors: Riley Jeffrey B. , Samolyk Keith A.
Published: July 2023

Cell concentrating and washing techniques are widely accepted and believed to be beneficial to cardiac surgery patients. During cell processing, platelets, proteins, and clotting factors are wasted as the plasma is washed away by saline. Beneficial and costly plasma constituents are sacrificed for the sake of removing potentially harmful drugs, debris, and naturally activated cells and chemical mediators. An interactive Microsoft Excel spreadsheet was designed to input patient and autotransfusion system (ATS) reservoir blood values, processed centrifugal bowl data, and hospital allogeneic blood product concentration and cost information. The spreadsheet calculates the number of wasted platelets, grams of protein, and milligrams of fibrinogen. The calculator further estimates the number of units and cost of allogeneic blood products needed to replace the wasted blood components. The simulation allows for variable levels of platelet activation and protein removal during centrifugal cell processing. Specific case scenarios may be simulated with the calculator. If a known volume of residual extracorporeal circuit blood with a known hematocrit, platelet count, and protein concentration is diverted to the ATS reservoir to be processed and washed after bypass, the number of units of fresh frozen plasma, platelet packs, and albumin concentrate needed to replace the wasted proteins and platelets may be calculated. When typical end-bypass patient and blood bank product values are input, the cost to replace the wasted blood components in 1550 mL of residual circuit blood with allogeneic blood products is about US $2097. There are risks and costs associated with replacing the platelets, proteins, and clotting factors wasted during cell washing compared with other techniques such as whole blood ultrafiltration.
Methylene Blue-induced Methemoglobinemia during Cardiopulmonary Bypass? A Case Report and Literature Review
Authors: McRobb Craig M. , Holt David W.
Published: July 2023

The guanylate cyclase (GC) and inducible nitric oxide (iNOS) inhibitor methylene blue (MB) has been used in cardiac surgery patients for the treatment of a variety of conditions. Methylene blue has been successfully used for the prevention and treatment of vasoplegia syndrome (VS) in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Vasoplegia syndrome occurs in up to 10% of cardiac surgery patients and is associated with poor clinical outcomes. Vasoplegia syndrome is described along with the results of studies that have shown benefits of MB in the treatment of VS. These studies include the use of MB prior to CPB, when added to the CPB prime and when given into the CPB circuit during the operation. We report a case of emergency CPB on a 55-year-old male with bacterial endocarditis, scheduled for an AVR/MVR who arrested on arrival to the operating room. Once on CPB the patient developed a profound hypotension despite normal to high pump flows, with low systemic vascular resistance (SVR), which was refractory to vasopressors—consistent with a diagnosis of VS. Unbeknownst to the perfusionist, the patient was treated with MB which was immediately followed by an apparent sudden arterial desaturation, despite oxygenator ventilation with 100% oxygen (O2), and development of severe metabolic acidosis. Troubleshooting the cause of the apparent desaturation and eventual diagnosis of a false indication of arterial oxygen desaturation and methemoglobinemia (MHgb) due to MB injection is described. Methemoglobinemia is explained as well as its presentation and treatment with MB. The importance of intraoperating room communication and knowledge of drug effects are discussed.
Clinical Efficacy of Two-Phase Leukocyte Filtration in High-Risk Patients Undergoing Coronary Revascularization with Cardiopul monary Bypass
Authors: Gunaydin Serdar , Modine Thomas , Sari Tamer , Zorlutuna Yaman , Gourlay Terence
Published: July 2023

The purpose of this study was to investigate the clinical outcome, inflammatory response and myocardial function in high-risk patients undergoing three different leukocyte depletion strategies. Over a four-month period, forty patients (EuroSCORE 6+) undergoing coronary revascularization were prospectively randomized to one of the four perfusion protocols: Group 1 (N = 10): Conventional circuits (ECC) + two leukocyte filters (LG6B, Pall, USA) with the method of two-phase (continuous + strategic) leukofiltration; Group 2 (N = 10): ECC + single leukocyte filter with the method of continuous leukofiltration; Group 3 (N = 10): ECC + single leukocyte filter with the method of strategic leukofiltration; Group 4 (N = 10) Control: ECC without leukocyte filtration. Blood samples were collected at T1: Baseline, T2: On CPB, T3: X-Clamp, T4: Off CPB, T5: ICU24 and T6: ICU48. Perioperative follow-up was thoroughly monitored. Leukocyte counts in double filter and strategic filtration groups demonstrated significant differences at T4 (p < .05 vs. control). TNF-alpha levels were significantly lower in Group 1 at T4 and procalcitonin levels at T5 and T6 (p < .05 vs. control). CKMB levels demonstrated well preserved myocardium in double filter group (p < .05 vs. control). Brain natriuretic peptide levels in double filter group were significantly lower at T5 and T6 with respect to Group 2 (p < .05) and control (p < .001). Matrixmetallopeptidase 9 and D-Dimer levels in double filter group were significantly lower at T5 and T6 (p < .05 vs. control). Two-phase leukofiltration is associated with some compound benefit over continuous deployment in high-risk patients. A larger more powerful study than this pilot one is warranted for further evaluation.
Management and Monitoring of Anticoagulation for Children Undergoing Cardiopulmonary Bypass in Cardiac Surgery
Authors: Gruenwald Colleen E. , Manlhiot Cedric , Crawford-Lean Lynn , Foreman Celeste , Brandão Leonardo R. , McCrindle Brian W. , Holtby Helen , Richards Ross , Moriarty Helen , Van Arsdell Glen , Chan Anthony K.
Published: July 2023

Cardiopulmonary bypass (CPB) creates a pro-coagulant state by causing platelet activation and inflammation leading to thrombin generation and platelet dysfunction. It is associated with severe derangements in normal homeostasis resulting in both thrombotic and hemorrhagic complications. This derangement is greater in children with congenital heart disease than in adults because of the immaturity of the coagulation system, hemodilution of coagulation factors, hyperreactive platelets, and in some patients, physiologic changes associated with cyanosis. During CPB, an appropriate amount of heparin is given with the goal of minimizing the risk of thrombosis and platelet activation and at the same time reducing the risk of bleeding from over anticoagulation. In young children, this balance is more difficult to achieve because of inherent characteristics of the hemostatic system in these patients. Historically, protocols for heparin dosing and monitoring in children have been adapted from adult protocols without re-validation for children. Extreme hemodilution of coagulation factors and platelets in young children affects the accuracy of anticoagulation monitoring in children. The activated clotting time does not correlate with plasma levels of heparin. In addition, recent studies suggest that children need larger doses of heparin than adults, because they have lower antithrombin levels, and they metabolize heparin more rapidly. Preliminary studies demonstrated that the use of individualized heparin and protamine monitoring and management in children is associated with reduced platelet activation and dysfunction and improved clinical outcomes. However, this review article clearly establishes that further studies are necessary to obtain evidence-based protocols for the proper management of anticoagulation of children undergoing cardiopulmonary bypass.
In Vitro Comparison of the New In-Line Monitor BMU 40 versus a Conventional Laboratory Analyzer
Authors: Grosse F. Oliver , Holzhey David , Falk Volkmar , Schaarschmidt Jan , Kraemer Klaus , Mohr Friedrich W.
Published: July 2023

Reliable information about different blood parameters is essential in maintaining hemodynamics, perfusion, and gas exchange during cardiopulmonary bypass (CPB). For this purpose, a precise and continuous monitoring is needed. The objective of this in vitro study was to compare a novel continuous in-line blood parameter monitoring system versus a reference laboratory analyzer. The study was conducted as an in vitro prospective experimental study during a CPB simulation. The reliability of BMU 40 was tested in monitoring the pO2, oxygen saturation (SO2), and hematocrit (Hct) under physiological and extreme conditions with regards to temperature, oxygenation, and blood concentration. Four different tests were performed and conducted with five sensors each. Correlation analyses and Bland-Altman analyses were performed. A total of 350 measurement points were compared. All monitored values of blood parameters correlated highly with laboratory values (all r values >.90). Test 1: Biases of pO2(act) varied from −3.24 mmHg (±6.86 mmHg) up to 6.0 mmHg (±17.89 mmHg). The biases of pO2(37°C) ranged from −3.52 mmHg (±6.01 mmHg) up to 68.8 mmHg (±67.82 mmHg). Test 2: The biases standard deviations (SD) for Hct ranged from −0.35% (±.79%) up to 2.35% (±.91%). The biases (SD) for SO2varied from −.45% (±.86%) up to .85% (±1.01%). Test 3: The biases (SD) of Hct ranged from −1.00% (±1.84%) up to −.67% (±1.49%). Test 4: The biases (SD) for SO2varied from −.36% (±1.60%) up to.48% (±.90%). The BMU 40 is a reliable device in measuring the partial oxygen pressure (pO2), SO2, and Hct under normal physiological and extreme conditions with regards to temperature, oxygenation, and blood concentration in simulation of CPB. The algorithm to calculate pO2(37°C) under hypothermic conditions needs to be adjusted. (Before the official market launch a new software version of the BMU 40 has been developed. The algorithm to calculate pO2(37°C) under hypothermic conditions has been improved and the miscalculation eliminated.)
Blood Temperature Management and Gaseous Microemboli Creation: An In-Vitro Analysis
Authors: Sleep Joseph , Syhre Ingrid , Evans Ed
Published: July 2023

Gaseous microemboli have been associated with post operative neurological deficits in patients undergoing cardiopulmonary bypass. Creating an optimal perfusion system that minimizes microemboli production and has enhanced abilities to sequester entrained air during the bypass procedure has been an important focus. This study examines the air-handling capabilities of a cardiopulmonary bypass circuit and correlates blood temperatures with microemboli loads proximal and distal to the arterial line filter within the circuit. Utilizing a Capiox RX25R oxygenator, Capiox 37 micron arterial filter, vacuum assisted venous return, and emboli detectors, 30 mL of air were injected into the venous line of a bypass circuit at eight different temperatures. Emboli were counted distal to the arterial line filter by the EDAQ® Quantifier (Emboli Detection and Classification). The average number of emboli detected distal to the arterial filter progressively increased as the perfusate temperature was dropped. At 37.0°C an average of 1.4 emboli was observed distal to the arterial filter within 90 seconds of the air injection. At 23.0°C an average of 49.8 emboli was detected. Air introduced into the venous side of the bypass circuit resulted in showers of microemboli being sent past the arterial line filter. In addition, as the bovine blood was cooled, the air handling capability of the circuit was diminished.
Vicarious Audiovisual Learning in Perfusion Education
Authors: Rath Thomas E. , Holt David W.
Published: July 2023

Perfusion technology is a mechanical and visual science traditionally taught with didactic instruction combined with clinical experience. It is difficult to provide perfusion students the opportunity to experience difficult clinical situations, set up complex perfusion equipment, or observe corrective measures taken during catastrophic events because of patient safety concerns. Although high fidelity simulators offer exciting opportunities for future perfusion training, we explore the use of a less costly low fidelity form of simulation instruction, vicarious audiovisual learning. Two low fidelity modes of instruction; description with text and a vicarious, first person audiovisual production depicting the same content were compared. Students (n = 37) sampled from five North American perfusion schools were prospectively randomized to one of two online learning modules, text or video. These modules described the setup and operation of the MAQUET ROTAFLOW standalone centrifugal console and pump. Using a 10 question multiple-choice test, students were assessed immediately after viewing the module (test #1) and then again 2 weeks later (test #2) to determine cognition and recall of the module content. In addition, students completed a questionnaire assessing the learning preferences of today’s perfusion student. Mean test scores from test #1 for video learners (n = 18) were significantly higher (88.89%) than for text learners (n = 19) (74.74%), (p < .05). The same was true for test #2 where video learners (n = 10) had an average score of 77% while text learners (n = 9) scored 60% (p < .05). Survey results indicated video learners were more satisfied with their learning module than text learners. Vicarious audiovisual learning modules may be an efficacious, low cost means of delivering perfusion training on subjects such as equipment setup and operation. Video learning appears to improve cognition and retention of learned content and may play an important role in how we teach perfusion in the future, as simulation technology becomes more prevalent.
Injuries and Overuse Syndromes in Rink Hockey Players
Authors: Husen Martin , Burgsmüller Lars , Burggraf Manuel , Jaeger Marcus , Dudda Marcel , Kauther Max
Published: July 2023

Rink Hockey is a high-speed low-contact sport with a widely recognized injury potential.
Played with a hard ball by players wearing little or no protective gear, the rates of
concussions and head injuries are of high interest. In this study, we reviewed and
investigated injuries sustained by 108 German National League rink hockey players. We
conducted an epidemiological cross-sectional study to determine sport-specific injuries and
injury patterns in female and male rink hockey players. Data were collected by a standardized
questionnaire. A total of 108 players participated in the study. The combined rate of injuries
were 9.4/1000 athlete exposures. There was no significant difference between injury rates
during games and practice. A sexspecific difference was not detected. Head injuries were the
most frequent type (20.8 % of all injuries). Concussions made up 7 % of all head injuries with
a rate of 0.76/1000 athlete exposure. Ball contact was the cause for 31 % of injuries, while
player contact generated 26.2 % of all injuries. High rates of ball-contact-related injuries
resulted in time loss and medical consultations. Head injuries were frequent, however did not
result in significant time loss as compared to other injuries. The use of protective gear
should be recommended.
Copper-Catalyzed Construction of Amide Linkages via Coupling between Unactivated Acids and Amines
Authors: Bhadra Sukalyan , Rahaman Ajijur
Published: July 2023

Traditional amide linkage forming reactions by the coupling between an acid and an amine rely primarily on triggering the carboxylic acid counterpart with (over)stoichiometric activating agent(s) and generate unacceptable quantity of nondisposable waste, leading to poor atom economy. Herein, we report an efficient catalytic amide synthesis that proceeds through the in situ activation of the amine counterpart in the form of a reactive N-formyl amine species. The strategy gives an expedient access to an array of structurally varied amides, including dipeptides, from numerous genre of acids and amines without producing stoichiometric solid wastes.
Risco de lesão neurovascular durante a fixação com parafuso de fraturas da tuberosidade da tíbia em pacientes pediátricos e adolescentes
Authors: Biolatto Paula , Kothari Alpesh , Masquijo Javier
Published: July 2023

Objetivo Revisar estudos de ressonância magnética (RM) do joelho para análise da localização das estruturas neurovasculares (ENVs) e definição do risco de fixação bicortical.

Métodos As distâncias entre o córtex posterior e as ENVs poplíteas foram medidas nas RMs de 45 adolescentes (50 joelhos) em 3 níveis (C1: centro da epífise proximal da tíbia; C2: 10 mm distalmente à fise e C3: 20 mm distalmente à fise). Considerou-se que as ENVs entre 5 mm e 10 mm da incisão estavam na zona de risco moderado de lesão, as ENVs a menos de 5 mm da incisão, na zona de alto risco de lesão, e as ENVs a mais de 10 mm da incisão, na zona de baixo risco de lesão. O teste t de Student independente foi usado para comparar a distância até as ENVs com o gênero, a maturidade esquelética e a distância entre a tuberosidade tibial e a garganta (fundo) da tróclea (TT-GT). Valores de p < 0,05 foram considerados estatisticamente significativos.

Resultados A trajetória do parafuso em C1 apresentou maior risco de lesão à artéria e à veia poplítea em comparação com outras trajetórias (p < 0,001). A artéria poplítea apresenta risco de lesão alto em C1 (4,2 ± 2,2 mm) e moderado em C2 (9,6 ± 2,4 mm), e a veia poplítea tem risco moderado em C1 (6,0 ± 2,7 mm) e baixo em C2 e C3 (10,8 ± 3,1 mm e 12,05 ± 3,1 mm, respectivamente). A posição C3 apresentou o menor risco de lesão dessas estruturas (p < 0,001). A distância entre o córtex tibial posterior e o nervo tibial posterior foi inferior a 15 mm nos 3 níveis analisados (C1: 11,0 ± 3,7 mm; C2: 13,1 ± 3,8 mm; e C3: 13 ± 3,9 mm).

Conclusões Este estudo esclarece que os vasos poplíteos correm risco de lesão durante a fixação do parafuso na tuberosidade tibial, principalmente durante a perfuração da epífise proximal da tíbia. A perfuração monocortical e a fixação com parafusos são recomendadas para o tratamento cirúrgico das fraturas da tuberosidade tibial.

Nível de Evidência III Estudo diagnóstico.
Displasia do desenvolvimento do quadril – Parte 1
Authors: Braga Susana Reis , Júnior Amâncio Ramalho , Akkari Miguel , Figueiredo Marina Juliana Pita Sassioto Silveira , Waisberg Gilberto , Santili Claudio
Published: July 2023

O termo displasia do desenvolvimento quadril (DDQ) refere-se à condição na qual a articulação sofre alterações na sua formação durante os últimos meses da vida intrauterina ou nos primeiros meses após o nascimento. No espectro de apresentação, varia desde a instabilidade femuroacetabular, passando por estádios de displasia até a completa luxação. O diagnóstico precoce é fundamental para o sucesso do tratamento. A triagem através do exame clínico incluindo manobras apropriadas é imprescindível nos recém-nascidos e nas avaliações subsequentes durante o crescimento da criança.

O rastreamento ultrassonográfico é indicado nos bebês sob suspeita clínica e muito mais recomendável naqueles que tiveram apresentação pélvica para o parto ou que tenham antecedentes familiares. A ultrassonografia do quadril nos primeiros meses seguida da radiografia da bacia após o 4° ou 6° mês de vida são os exames que determinam o diagnóstico e auxiliam o seguimento.

O tratamento está baseado na obtenção de uma redução concêntrica e na manutenção e estabilização do quadril, propiciando a remodelação articular. Inicialmente, as órteses de flexão/abdução são a escolha; em crianças maiores pode ser necessário o uso de gesso após redução incruenta com ou sem tenotomia; redução aberta pode ser indicada e após os 18 meses as osteotomias pélvicas associadas a capsuloplastia e eventuais osteotomias acetabular e femoral.

Crianças tratadas devem ser acompanhadas durante todo o seu crescimento pelo eventual risco de displasias tardias.
Transadaptation and Validation of the Telugu Version of the Dysphagia Handicap Index
Authors: Dasari Philemon Benison , Verma Himanshu , Madishetty Harisha , Pagidimarri Jothirmai , Balaji Janaki
Published: July 2023

Dysphagia Handicap Index (DHI) is a clinically effective, concise, and user-friendly tool for assessing the functional impact of dysphagia in clinical populations. The present study aims to trans-adapt the DHI in the Telugu language and assesses its psychometric properties. The present study was conducted in two phases. The first phase includes translating and adapting the DHI tool into Telugu (T-DHI). The second phase includes an analysis of the psychometric properties of the trans-adapted Telugu version of the DHI. The DHI was translated into the Telugu language using the forward–backward translation method. The psychometric analysis was done on 100 participants. All the participants underwent a detailed clinical swallow examination after filling the T-DHI. The overall internal consistency and Guttmann split-half reliability for the Telugu version of the DHI were good. The correlation between the T-DHI subscales and the self-perceived severity of dysphagia was found to be high. The comparison of the T-DHI scores of the control and experimental groups revealed a significant difference. The T-DHI is a reliable and valid tool to assess the quality of life of the Telugu-speaking dysphagia population.
Improving the efficiency of wind energy through early damage detection
Authors: Green Leigh Ann
Published: July 2023

Drones and AI partner to detect damage to wind turbines.
Hierarchical energy optimization of flywheel energy storage array systems for wind farms based on deep reinforcement learning
Authors: Zhang Zhanqiang , Meng Keqilao , Li Yu , Liu Qing , Wu Huijuan
Published: July 2023

Due to the volatility and intermittency of renewable energy, injecting large amounts of renewable energy into the grid will have a tremendous impact on the stability and security of the network. In this paper, we propose the hierarchical energy optimization of flywheel energy storage array system (FESAS) applied to smooth the power output of wind farms to realize source-grid-storage intelligent dispatching. The energy dispatching problem of the FESAS is described as a Markov decision process by the actor-critic (AC) algorithm. In order to solve the problems of stability and low sampling efficiency of the AC algorithm, the soft actor-critic (SAC) algorithm, a deep reinforcement learning (DRL) algorithm based on the model-free off-policy method of the maximum entropy framework, is adopted. Furthermore, SAC and prioritized experience replay (PER) are utilized to greatly improve learning efficiency and sample utilization. The experimental results show that SAC-PER has better performance and stability in energy optimization of the FESAS.
Elevating zero dimensional global scaling predictions to self-consistent theory-based simulations
Authors: Slendebroek T. , McClenaghan J. , Meneghini O. M. , Lyons B. C. , Smith S. P. , Neiser T. F. , Shi N. , Candy J.
Published: July 2023

We have developed an innovative workflow, Stability, Transport, Equilibrium, and Pedestal (STEP)-zero-dimensional (0D), within the OMFIT integrated modeling framework. Through systematic validation against the International Tokamak Physics Activity global H-mode confinement database, we demonstrated that STEP-0D, on average, predicts the energy confinement time with a mean relative error of less than 19%. Moreover, this workflow showed promising potential in predicting plasmas for proposed fusion reactors such as the affordable, robust, compact (ARC) reactor, the European demonstration power plant (EU-DEMO), and the China fusion engineering test reactor (CFETR) indicating moderate H-factors between 0.9 and 1.2. STEP-0D allows theory-based prediction of tokamak scenarios, beginning with 0D quantities. The workflow initiates with the PRO-create module, generating physically consistent plasma profiles and equilibrium using the same 0D quantities as the IPB98(y,2) confinement scaling. This sets the starting point for the STEP module, which further iterates between theory-based physics models of equilibrium, core transport, and pedestal to yield a self-consistent solution. Given these attributes, STEP-0D not only improves the accuracy of predicting plasma performance but also provides a path toward a novel fusion power plant design workflow. When integrated with engineering and costing models within an optimization, this new approach could eliminate the iterative reconciliation between plasma models of varying fidelity. This potential for a more efficient design process underpins STEP-0D's significant contribution to future fusion power plant development.