bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Sarns 3M heparin bonded to Duraflo II and control circuits in a porcine model: macro- and microanalysis of thrombi accumulation in circuit arterial filters
Authors: Larson Douglas F , Arzouman David , Kleinert Leigh , Patula Vangie , Williams Stuart
Published: January 2013

Heparin-bonded perfusion circuits have been reported to reduce the thrombus formation during various levels of systemic heparinization. The goal of this study was to compare the efficacy of thrombo-resistance of the Sarns 3M heparin-bonded circuit to Baxter Duraflo II and untreated control in a porcine model. Fifteen Yorkshire pigs (60-65 kg) were anesthetized, heparinized with 3000 IU, intravenously (i.v.) and surgically cannulated with an internal jugular outflow and a femoral vein inflow. All circuits consisted of a 22-Fr venous cannula, centrifugal pump, arterial filter, an 18-Fr cannula for return and connected with equal lengths of 3/8″ polyvinyl chloride tubing. The flows were maintained at 2.0 l/min for 4 h. Thrombus formation in filter samples were morphometrically analyzed through macro-densitometry, light microscopy, and scanning electron microscopy (SEM). Our findings revealed that the 3M circuit had significantly less gross thrombus ( p < 0.001), 66% and 84% less microscopic thrombi and fivefold less SEM-measured aggregates ( p = 0.03) compared to the Duraflo II and uncoated groups. This study demonstrated that the 3M heparin-bonded circuit had significantly reduced the formation of micro- and macro-thrombi in the minimally heparinized pig model compared to the Duraflo II and untreated control circuits.
A retrospective study on perfusion incidents and safety devices
Authors: Mejak Brian L , Stammers Alfred , Rauch Eric , Vang See , Viessman Tom
Published: January 2013

Despite the acceptance of extracorporeal circulation as an effective modality to facilitate cardiac surgery, patient outcomes can be negatively influenced by the occurrence of perfusion incidents. A perfusion survey was conducted to identify safety techniques and incidents related to cardiopulmonary bypass (CPB).

An 80-question survey was mailed to chief perfusionists of all 1030 USA cardiac surgical centers using CPB. The survey was designed to examine practices and incidents that occurred during a 2-year period (July 1996 to July 1998). Five-hundred-and-fifty-two (54% response rate) surveys were returned, which accounted for 797 hospitals (79% of all cardiac centers) and 653 621 surgical procedures. Of the 27 identified CPB safety devices, the highest utilization was arterial line filters (98.5%) and the lowest arterial line bubble traps (3.4%). Of the reported cases, a CPB incident occurred once every 138 cases. The most common occurring incidents were protamine reactions (1:783), coagulation problems (1:771), and heater/cooler failures (1:1809). The rate of occurrence of an incident resulting in a serious injury or death was one for every 1453 procedures.

Although techniques and safety devices create a relatively secure environment for CPB, lower incident rates may be achieved with further improvements in coagulation monitoring and incident reporting.
Anticoagulation in extracorporeal circulation using recombinant hirudin: a case report
Authors: Beholz Sven , Grubitzsch Herko , Bergmann Britta , Wollert Hans-Georg , Eckel Lothar
Published: January 2013

Heparin-induced thrombocytopenia (HIT) is a severe complication following the application of heparin; antibodies against complexes of heparin and PDF4 initiate activation of platelets. This may lead to massive thrombembolism, which is associated with a slight and transient drop of platelets in HIT I or a drop below 50% after approximately 5 days in HIT II. Further administration of heparin has to be strictly avoided in these patients. Immunologic evidence for HIT can easily be obtained by the heparin-induced platelet aggregation assay. If anticoagulation is necessary, different, alternative drugs are available. Recombinant hirudin (r-hirudin) is a well-established drug for safe anticoagulation. Monitoring is possible by estimating the plasma level of r-hirudin from the ecarin-clotting time. We report a case of a patient with prosthetic aortic valve endocarditis and HIT II who suffered from massive postoperative bleeding requiring massive substitution of blood components and coagulants caused by free circulating r-hirudin due to the use of a hemofilter.
Endotoxin in pooled pericardial blood contributes to the systemic inflammatory response during cardiac surgery
Authors: Spanier Talia , Tector Kelly , Schwartz Graham , Chen Jonathan , Oz Mehmet , Beck James , Mongero Linda
Published: January 2013

Although endotoxin has been implicated as an important contributor to the systemic inflammatory response (SIR) during cardiopulmonary bypass (CPB), its source remains unclear. While gut translocation has traditionally been perceived as the primary source of endotoxemia, accumulation of endotoxin in pooled pericardial blood may represent an additional source of endotoxin that is continually reinfused into the CPB circuit.

Eighteen patients undergoing primary coronary revascularization procedures were prospectively evaluated. Shed blood pooled in the pericardial space was returned to the CPB circuit through cardiotomy suction catheters at 45 min after placement of the aortic crossclamp. Simultaneous samples of pooled pericardial and peripheral arterial blood were obtained and analyzed by a limulus amebocyte lysate assay for the determination of endotoxin concentration, and an enzyme-linked immonosorbert assay for tumor necrosis factor (TNF-α) levels.

Significant elevations in endotoxin were demonstrated in pooled pericardial blood samples compared with arterial blood (3.5 ± 0.5 vs 0.8 ± 0.2 pg/ml; p < 0.05). TNF-α levels were below the limits of detection in both samples.

These data implicate pooled pericardial blood as an important primary source of endotoxin that, when continually reinfused throughout CPB, may contribute to the overall SIR. Because endotoxemia has been identified as an important predictor of adverse outcomes following cardiac surgery, removal of endotoxin antigen in shed pericardial blood, prior to its reinfusion into the CPB circuit, may provide a directed means to improve perioperative outcome without compromising established blood conservation techniques.
Inhibition of neutrophil L-selectin shedding: a potential anti-inflammatory effect of aprotinin
Authors: Asimakopoulos George , Taylor Kenneth M , Haskard Dorian O , Landis R Clive
Published: January 2013

The cardiopulmonary bypass (CPB)-related inflammatory response involves leucocyte activation and increased leucocyte-endothelial cell interaction. L-selectin is an adhesion molecule expressed on the surface of leucocytes which participates in the initial rolling step of the leucocyte-endothelial cell adhesion cascade. L-selectin is proteolytically cleaved off the surface of leucocytes when they become activated, an event that is regarded as a marker of leucocyte activation. Aprotinin is a protease inhibitor that has been used in cardiac surgery as a haemostatic agent and also exhibits certain anti-inflammatory properties. In this study, peripheral venous blood from volunteers was pre-incubated with aprotinin at 200, 800 and 1600 kallikrein inhibiting units (kiu)/ml and stimulated with the chemoattractants N-formyl-methyl-leucyl-phenylalanine (fMLP) or platelet activating factor (PAF). Surface expression of L-selectin on neutrophils was measured using a monoclonal antibody and flow cytometry. The results demonstrate that aprotinin inhibits shedding of L-selectin in a dose-dependent fashion ( p=0.0278 and 0.0005, respectively, at 800 and 1600 kiu/ml for fMLP-stimulated shedding; p=0.0017 and 0.0010, respectively, at 200 and 800 kiu/ml for PAF-stimulated shedding). This effect may be of significance with respect to the anti-inflammatory action of aprotinin in patients undergoing CPB.
The impact of normothermia on the outcome of aortic valve surgery
Authors: Tosson R , Buchwald D , Klak K , Laczkovics A
Published: January 2013

The purpose of this study was to examine the effects of systemic perfusion temperature on the clinical outcome after aortic valve surgery.

In this study, we examined 323 patients who underwent aortic valve surgery between January 1994 and April 1996. Forty-six patients were perfused in moderate hypothermia (28°C) and 277 patients in normothermia.

Age and sex distribution of the patients were similar. There were no statistically significant differences between the groups regarding neurological, renal or cardiac complications. Patients in hypothermia required less catecholamine at the end of the operation ( p 0.00001), but there was no significant difference in the length of the stay in the intensive care unit between the groups.

Cardiopulmonary bypass temperature did not influence early outcome after aortic valve surgery.
Autotransfusion in cardiac surgery
Authors: Cross M H
Published: January 2013

There are a number of problems with allogeneic blood transfusion. Some of these problems are defined and can be quantified, such as the problem of rising cost or the risk of viral infection, but some of the problems are not well defined and it is only outcome data that point to allogeneic blood transfusion contributing to patient mortality and morbidity. Autotransfusion includes any technique in which the patient’s own blood is collected, processed and stored, followed by reinfusion when circumstances dictate. In the perioperative period of cardiac surgery, a number of techniques are recognized as useful in this context. Preoperative autologous donation, with or without erythropoietin supplementation, intraoperative acute normovolaemic haemodilution, intraoperative cell salvage, postoperative cell salvage (reinfusion of shed mediastinal blood) and platelet rich plasmapheresis are all techniques which are used with more or less enthusiasm to reduce the need for an allogeneic blood transfusion. Modification of the priming technique of the cardiopulmonary bypass circuit using an autologous blood prime is included in this review even though it does not fall strictly within the definition of autotransfusion.

Although autotransfusion is not the answer to every problem, there is no doubt that it should play a significant part in the strategy of blood conservation.
Low-dose versus high-dose heparinization during arteriovenous carbon dioxide removal
Authors: Murphy J A , Savage C M , Alpard S K , Deyo D J , Jayroe J B , Zwischenberger J B
Published: January 2013

The purpose of this study was to compare low-dose (LD) and high-dose (HD) systemic heparinization in a prospective randomized study of arteriovenous carbon dioxide removal (AVCO2R) during acute respiratory distress syndrome, using a commercially available heparin-coated oxygenator. Adult sheep ( n = 13) received an LD50 smoke inhalation and 40% TBSA third degree cutaneous flame burn injury. At 40-48 h post-injury, animals underwent cannulation of the carotid artery and jugular vein and were then randomized to HD heparin (activated clotting time, ACT > 300 s, n = 6) and LD heparin (ACT > 200 s, n = 7) and placed on AVCO2R for approximately 72 h using an oxygenator with the Trillium Bio-Passive Surface™. Mean ACTs were significantly different, as expected (HD: 446 ± 26 s, LD: 213 ± 12 s, p < 0.05). AVCO2R shunt flow averaged approximately 13% of cardiac output with mean CO2 removal similar in HD and LD, p = NS. The hematocrit, platelet count, and fibrin degradation products for the two groups were not different. No differences in thrombosis or bleeding were noted. In conclusion, LD systemic heparin (ACT < 200 s) with a heparin-coated oxygenator does not increase thrombogenicity during AVCO2R for smoke/burn-induced severe lung injury in sheep.
Respiratory failure caused by tuberculous pneumonia requiring extracorporeal membrane oxygenation
Authors: Petrillo Toni M , Heard Micheal L , Fortenberry James D , Stockwell Jana A , Leonard Michael K
Published: January 2013

While a common pathogen, Mycobacterium tuberculosis (TB) pneumonitis is only rarely reported as a cause for respiratory failure in developed countries. We report an adolescent with TB pneumonitis and respiratory failure requiring extracorporeal membrane oxygenation (ECMO) with eventual survival. With the incidence of TB rising globally, TB should be suspected and treated as early as possible. ECMO should be considered as a treatment option if conventional ventilatory support is inadequate. ECMO survival with TB pneumonia and anti-TB antimicrobial therapy is possible.
Preoperative versus postoperative extracorporeal life support in neonatal cardiac patients
Authors: McKay Victor J , Stewart Dan L , Robinson Tonya W , Cook Larry N , Austin Erle H
Published: January 2013

The aim of this study is to document our experience with the use of extracorporeal life support (ECLS) in the neonatal cardiac patient, to detect differences in the morbidity and mortality between patients who required ECLS preoperatively and those who required ECLS postoperatively, and to determine the long-term effects of these morbidities.

A chart review was undertaken of all neonatal cardiac patients who required ECLS between May 1985 and July 1994 at Kosair Children’s Hospital, Louisville, Kentucky.

Twenty-three neonatal cardiac patients had received preoperative or postoperative ECLS with an overall survival rate of 35%. Our preoperative and postoperative patients had similar demographics, diagnoses, decannulation rates and survival rates. However, patients receiving postoperative ECLS more frequently required more than two inotropes ( p < 0.001), had an increased incidence of renal failure ( p < 0.02), had more central nervous system abnormalities on brain imaging studies ( p < 0.004), and had a longer hospital stay ( p < 0.05). Follow-up testing of survivors yielded normal Bayley Scale of Infant Development (BSID) scores in half of the patients.

Survival in the two groups was similar, but a significant difference in morbidity was found. Except for severe intracranial abnormalities, the morbidity was shown to be reversible on follow-up examination. We recommend the continued use of ECLS for neonatal cardiac patients who require preoperative or postoperative support even when severe renal failure ensues or minor abnormalities are detected on brain imaging studies.
Extracorporeal circuit design considerations for giant intracranial aneurysm repair
Authors: MacDonald James L , Cleland Andrew G , Mayer Richard L , Henderson Mark J
Published: January 2013

Clinical perfusionists must be able to modify the existing extracorporeal circuit in order to accommodate a specific surgical pathology. The clipping of a giant intracranial middle cerebral artery aneurysm, unapproachable with conventional neurosurgical techniques, required the use of a modified closed cardiopulmonary bypass circuit combined with deep hypothermia and total circulatory arrest. In-hospital discussions with anaesthesia, cardiac surgery, neurosurgery, and cardiology enabled an informed team approach directed towards the successful treatment of this complex neurosurgical lesion.
Cardiopulmonary bypass venous cannulation challenges in a paediatric patient with complex congenital heart disease: a case report
Authors: Manzer Rich , Sutton Robin G , Ploessl James , Niles Scott , Behrendt Douglas
Published: January 2013

When choosing cannulae for cardiac surgery the two most important factors to be considered are the proposed procedure and the patient anatomy. These factors are especially crucial in paediatric patients with congenital heart disease. A 3-year-old, 14-kg male presented to the University of Iowa Hospitals and Clinics with dextro-transposition of the great arteries, atrioventricular canal, left pulmonary stenosis, azygous continuation, bilateral superior vena cavae, partial anomalous pulmonary venous return, left aortic arch and status post-right Blalock-Taussig shunt. The complex anatomy presented a surgical dilemma. The course of surgical intervention was determined, a variation of the modified Fontan procedure, and the anatomy of the patient was directly viewed. The surgeon concluded that four venous cannulae were required to provide adequate venous return for the cardiopulmonary bypass (CPB) circuit and a bloodless surgical field. The operation was successfully performed under mild hypothermia with no complications. The patient fully recovered with only mild restrictions on his activity level. This case acutely illustrates the importance of anatomical and procedural awareness when choosing cannulae and cannulation sites for CPB in paediatric patients with congenital heart disease.
Clinical evaluation of the new Pall leucocyte-depleting blood cardioplegia filter (BC1)
Authors: Heggie A J , Corder J S , Crichton P R , Hesford J W , Bingham H , Jeffries S , Hooper T L
Published: January 2013

It is now widely acknowledged that autologous leucocytes are inappropriately activated during cardiopulmonary bypass (CPB). Removal of these activated leucocytes has been proposed as a clinical intervention. Several papers have recently reported benefits of systemic leucocyte depletion during CPB. There is also evidence that leucocyte-depleted blood cardioplegia is advantageous in the globally ischaemic human heart transplant setting. Recently, a new leucocyte-depleting filter for blood cardioplegia has been developed (Pall, BC1). In this paper, we report on the safety and efficiency of this device in the clinical situation.

Fourteen patients undergoing routine cardiac surgery were recruited into this study. The BC1 blood cardioplegia filter was found to be an efficient leucocyte-depleting device, removing in excess of 70% ( p = 0.001) of white blood cells, on average, from up to 5.3 litres of blood cardioplegia. The filter removed a small proportion of platelets (typically 11.3%), however, this was not statistically significant and no bleeding problems were encountered. Red cell removal was negligible and was not statistically significant, and no evidence of haemolysis was noted. The filter offered a very low resistance to flow with a mean pressure drop (Δ P) of 10.8 mmHg at a mean flow rate of 315 ml/min. We conclude that the Pall BC1 filter is a safe and efficient device for use with blood cardioplegia.
Comparison of three plasma expanders used as priming fluids in cardiopulmonary bypass patients
Authors: Tigchelaar Izaak , Huet Rolf CG Gallandat , Boonstra Piet W , van Oeveren Willem
Published: January 2013

Ten per cent low molecular weight hydroxyethyl starch is a plasma substitute only recently used as priming solution in an extracorporeal circuit, in contrast to human albumin and gelatin. To evaluate the effect of priming solutions on haemodynamics and colloid osmotic pressure, we studied 36 patients elected for cardiopulmonary bypass (CPB). They were randomly assigned to 2.5% hydroxyethyl starch, 3% gelatin or 4% human albumin priming solution.

Total blood loss (perioperative + intensive care unit period) was higher in the gelatin group than in the albumin and hydroxyethyl starch groups. During CPB, the colloid osmotic pressure was best preserved in the gelatin group, although no excessively low colloid osmotic pressures were measured in the other two groups. Due to the extended half-life and the additional postoperative colloid administration, the hydroxyethyl starch group had a higher colloid osmotic pressure in the postoperative phase.

We conclude that, next to human albumin, 2.5% hydroxyethyl starch is a safe CPB priming solution additive and is effective as plasma substitute. Its somewhat longer half-life requires adaptation of the routine protocol for transfusion of colloids and blood products.
Expression of soluble endothelial adhesion molecules in clinical cardiopulmonary bypass
Authors: Galea Joseph , Rebuck Naomi , Finn Adam , Manché Alex , Moat Neil
Published: January 2013

Soluble endothelial adhesion molecule expression in clinical cardiopulmonary bypass (CPB) was investigated. Neutrophil-mediated endothelial injury plays an important role in CPB-induced organ dysfunction. The adhesion of neutrophil to the endothelium is central to this process. It has been well documented that CPB induces neutrophil activation and changes in neutrophil adhesion molecule expression, but the effect of CPB on endothelial cell activation is not known. This study was designed to measure soluble endothelial adhesion molecules during CPB.

We made serial measurements (by specific enzyme-linked immunoabsorbent assay) of plasma levels of the soluble endothelial adhesion molecules, ICAM-1 and E-selectin in patients undergoing routine CPB ( n =7) and in a control group (thoracotomy, n = 3).

The results show an initial significant decrease during CPB followed by an increase in plasma E-selectin from 29.3 ± 5.1 ng/ml (mean ± SEM) prebypass to 34.0 ± 5.4 ng/ml at 48 h postbypass. Likewise, plasma ICAM-1 significantly decreased during CPB and then increased from 246.3 ± 38.0 ng/ml before bypass to 324.8 ± 25.0 ng/ml and 355.0 ± 23.0 ng/ml at 24 and 48 h after bypass, respectively. The rise in levels is statistically significant ( p < 0.05).

This study shows a decrease in circulating ICAM-1 and soluble E-selectin during CPB and an increase in their levels at 48 h after CPB.
Inflammatory response to cardiopulmonary bypass using two different types of heparin-coated extracorporeal circuits
Authors: Baufreton Christophe , Moczar Madeleine , Intrator Liliane , Jansen Piet GM , te Velthuis Henk , Le Besnerais Paul , Farcet Jean Pierre , Wildevuur Charles RH , Loisance Daniel Y
Published: January 2013

Previous reports have highlighted the disparity in biocompatibility of two differently engineered heparin coatings during the cardiopulmonary bypass (CPB) procedure. The aim of this prospective study was to evaluate the impact of the difference in haemocompatibility provided by either the Duraflo II equipment or the Carmeda equipment in the terminal inflammatory response observed after coronary artery surgery.

Thirty patients were randomly allocated to two groups to be operated on using either Duraflo II equipment (group I) or Carmeda equipment (group 2) for extracorporeal circulation (ECC). Initial inflammatory response was assessed by terminal complement complex activation (SC5b-9). The late inflammatory response observed in the postoperative period was assessed by measuring cytokine production (tumour factor necrosis (TNFα), interleukin IL-6, interleukin IL-8) and circulating concentrations of adhesion molecules (ELAM-1, ICAM-1).

The release of SC5b-9 after CPB and after protamine administration was lower in group 2 than in group 1 ( p = 0.0002 and p = 0.006, respectively). A significant production of cytokines was detected in both groups with peak values observed within the time range of 4-6 h after the start of CPB.

However, no difference was observed between the groups except for the IL-8 level in group 2, which was lower 2 h after the start of CPB ( p = 0.01). Plasma levels of adhesion molecules were similar in both groups within the investigation period.

Although the Carmeda equipment was more effective in reducing complement activation, the late inflammatory response was similar using either the Duraflo II or Carmeda equipment for extracorporeal circulation as reflected by the changes of cytokine and circulating adhesion molecule levels.
Haemocompatibility of paediatric membrane oxygenators with heparin-coated surfaces
Authors: Wendel Hans P , Scheule Albertus M , Eckstein Friedrich S , Ziemer Gerhard
Published: January 2013

Extracorporeal circulation (ECC) in paediatric patients with heparin-coated oxygenation systems is rarely investigated. The objective of this study was to evaluate, preclinically, the haemocompatibility of paediatric membrane oxygenators with heparin-coated surfaces. We compared 16 paediatric membrane oxygenators (Minimax, Medtronic) in an in vitro heart-lung machine model with fresh human blood. Eight of these oxygenation systems had a covalent heparin coating (Carmeda bioactive surface). After 90 min simulated ECC, the heparin-coated systems showed significantly higher platelet count, lower platelet-factor 4 release, reduced contact activation (factor XIIa and kallikrein), and lower neutrophil elastase levels ( p < 0.05), compared to the noncoated oxygenator group. More biocompatible materials for paediatric operations may ameliorate the various postperfusion syndromes arising from ECC procedures, particularly unspecific inflammation, hyperfibrinolysis and blood loss.
Clinical experience with the Sorin Monolyth Oxygenator at high altitude
Authors: Steinberg Carl , Dragan Robert
Published: January 2013

High altitude combined with low barometric pressure can present unique challenges during cardiopulmonary bypass (CPB), not only for the perfusionist, but also for the oxygenator. Manufacturers of cardiopulmonary devices have responded to the requests from the perfusion community with a variety of oxygenators which balance low priming volumes and low pressure drops against high gas transfer. This paper will feature the first author’s clinical studies using the Sorin Monolyth Oxygenator in a selected group of patients at an altitude of approximately 5200 feet and an average barometric pressure of 634 mmHg (sea level is 760 mmHg).

A review of the 47 charts on patients requiring CPB and who met the selection criteria was performed retrospectively. To qualify for this study, the patient needed to weigh more than 91 kg. The data reviewed included type of surgery, age, weight, bypass time, crossclamp time, pump flows (l/min/m2), hematocrits pre- and post-CPB, and pressure drop across the membrane. The PaO2, PaCO2, FiO2 and sweep gas flow at hypothermia and normothermia were recorded. Data concerning oxygen transfer were obtained from the manufacturer’s report to the Food and Drug Administration.

All patients had adequate blood gases while on CPB. We feel that the design of the Sorin Monolyth Oxygenator met our criteria for an oxygenator: low priming volume, low pressure drop, and sufficient gas transfer to provide safe oxygenation of all patients at high altitude.
Treatment of primary peritoneal mesothelioma by hyperthemic intraperitoneal chemotherapy
Authors: Mongero L B , Beck J R , Kroslowitz R M , Argenziano M , Chabot J A
Published: January 2013

Perfusion of the peritoneal cavity with chemotherapy agents under hyperthermic conditions has been utilized by several investigators in the treatment of intra-abdominal malignancies. Based on the concept that hyperthermia may potentiate the cytotoxic effects of chemotherapeutic agents, we embarked on a clinical trial of two-stage peritoneal chemotherapy for patients with primary peritoneal mesothelioma, a neoplasm unresponsive to traditional systemic chemotherapeutic regimens. In stage I, patients underwent surgical debulking of gross disease and placement of an intraperitoneal infusion catheter, through which intraperitoneal chemotherapy was administered for four months. Stage II consisted of debulking of residual tumor, placement of two transabdominal perfusion cannulae and administration of high-dose intraperitoneal chemotherapy at 40°C using a simple, disposable perfusion circuit. Flow rates were maintained at 1 l/min, and inflow and outflow temperatures maintained at 42 and 40°C, respectively. To date, three patients have undergone both phases of the protocol, with no perioperative complications related to either hyperthermia or end-organ toxicity. One patient died of progressive disease after three months, and two patients are alive and well. One patient developed a small bowel anastomotic leak three weeks after operation. In summary, intraoperative hyperthermic peritoneal chemotherapy may play a role in novel approaches to the treatment of peritoneal malignancies previously unresponsive to traditional chemotherapeutic regimens.
The incidence and cause of emergency oxygenator changeovers
Authors: Fisher A R
Published: January 2013

Emergency oxygenator changeover presents as an important potential hazard during cardiopulmonary bypass. In order to assess the frequency and possible causes of this event a retrospective survey was conducted of cardiothoracic units in the UK and Ireland. The survey was sent to these units in 1993 to cover the period from 1990 to 1992 inclusive and again in 1997 to cover the period from 1994 to 1996 inclusive. The total number of procedures reported in 1993 was 68 937 (response of 63%), among which there were 17 emergency oxygenator changeovers representing an incidence of one for every 4055 cases. The use of aprotinin was associated with nine of these incidents. Two other incidents occurred due to leaking oxygenators. The total number of procedures reported in 1997 was 97 313 (response of 70%), among which there were 21 emergency oxygenator changeovers, representing an incidence of one for every 4634 cases. The use of aprotinin was only associated with two of these incidents while seven were due to the development of a high trans-oxygenator pressure gradient and six occurred due to leaking oxygenators.
Patient outcome as a selection criterion in determining treatment mode
Authors: Ninni Kimberly M , Brownstein Louis
Published: January 2013

The climate of health care reform encourages scrutiny of traditional and new forms of medical and surgical therapy. With the emergence of technologically innovative cardiac procedures, therapy advocates must weigh cost versus patient outcomes. Therapies range from purely medical management, through staged interventions, to median sternotomy and cardiopulmonary bypass. Outcomes will necessarily be related to quality of life. A literature search was performed to determine types of medical and surgical therapies associated with patient outcomes as they define quality of life. Medical treatment may include the use of anti-platelet therapy, beta-blockers and diuretics to treat the cardiac patient at low risk who can maintain an acceptable quality of life. Improvements in medical therapies may extend the life of the low-risk patient, eliminating the need to consider bypass surgery. Some patients at high risk, or with left ventricular hypertrophy combined with an impaired ejection fraction, may require coronary artery bypass surgery. Studies indicate that patients undergoing open heart surgery demonstrate significant improvement in functional classification, increased activity and reduction in anti-anginal medications. Proponents of minimally invasive surgery claim potential benefits of lower surgical trauma, shorter hospital stays and shorter recovery times. Quality of life is defined by outcomes. Only by comparing outcomes of all available therapies can a physician or patient make an informed decision regarding treatment.
Mini-circuit cardiopulmonary bypass with vacuum assisted venous drainage: feasibility of an asanguineous prime in the neonate
Authors: Lau Christine L , Posther Katherine E , Stephenson G Robert , Lodge Andrew , Lawson Jeffrey H , Darling Edward M , Davis R Duane , Ungerleider Ross M , Jaggers James
Published: January 2013

Conventional cardiopulmonary bypass (CPB) in neonates results in increased transfusion requirements and hemodilution. There has been little advancement in CPB for the neonatal population. There is evidence that increased priming volumes and blood product transfusion enhances inflammatory response to CPB and increases myocardial and pulmonary dysfunction. We have devised a miniaturized CPB circuit that utilizes vacuum-assisted venous drainage (VAVD) in an effort to decrease priming volume and avoid transfusion requirements. The purpose of this study was to evaluate the safety and efficacy of this miniaturized CPB system and determine the feasibility of an asanguineous prime. Ten 1-week-old piglets were randomized to five mini- and five conventional CPB pump circuits. Subjects were supported with CPB at 100 ml/kg/min, cooled to 28°C, exposed to 10 min aortic crossclamp with cardioplegic arrest, rewarmed to 37°C, weaned from bypass, and subjected to modified-ultrafiltration (MUF) for approximately 10 min. This method was chosen to simulate a situation with all the elements of clinical CPB. Blood transfusion trigger was a hematocrit <15 on CPB. Serum samples were obtained pre-CPB, at 15 min of CPB onset, immediately post-CPB completion, and immediately post-MUF. Indices of hemolysis (SGOT, LDH), production of inflammatory mediators (interleukin (IL)-8, tumor necrosis factor-alpha (TNFα)), and physiologic parameters of inflammation were measured. The overall blood requirement was significantly less in the mini-circuit compared to conventional CPB (47.0 ± 5.8 ml vs 314.2 ± 31.6 ml; p < 0.0001). The only significant blood requirement in the mini-circuit was to replace the volume removed for samples. During the study, mean arterial pressure (MAP) ( p = 0.004), static pulmonary compliance ( p = 0.04), platelets ( p = 0.0003), and white blood cells ( p = 0.003) significantly decreased across the groups. Lung water content ( p = 0.02), TNFα levels ( p = 0.05), and SGOT ( p = 0.009) increased significantly during the study, across the groups. Among all parameters tested, except for blood requirement and hematocrit post-CPB, there were no significant differences between the two circuits. VAVD makes asanguineous prime in neonates feasible. When used in this study to miniaturize a conventional-CPB circuit, VAVD with a reconfigured neonatal CPB console and circuit resulted in no detrimental effects, and allowed for markedly decreased priming volumes and blood transfusion requirements.
Vacuum assisted venous drainage (VAVD)
Authors: Münster Karin , Andersen Ulrich , Mikkelsen Jens , Pettersson Gösta
Published: January 2013

Poor venous drainage is a common problem in cardiac surgery, causing trouble for the surgeon and adverse effects to the patient. Smaller incisions for minimally invasive cardiac surgery require smaller venous catheters. In this study the function, safety and possible benefits of a system for vacuum assisted venous drainage has been tested experimentally and applied clinically. A vacuum regulator (‘The Hamlet box’) and safety procedures were developed. The system was characterized in vitro in regard to the relationship between vacuum, catheter size, and blood temperature and flow. The clinical study included 54 adult patients, coronary artery bypass graft surgery and valve operations. Venous cannulation was bi-caval with two 24 Fr catheters. All the perfusions were essentially event free, and the system was easy to manage and regulate. Venous drainage was totally adequate, irrespective of the position of the heart, and less fluid was added during the perfusions (a median of 250 ml/patient compared to a median of 1000 ml/patient in the control group). There has been no evidence of increased haemolysis or other adverse effects. All patients were hospital survivors and had uneventful postoperative courses. Vacuum assisted venous drainage is now used routinely, and further studies are under way to develop the system and clarify the physiological effects.
Oxygenator thrombosis: an international phenomenon
Authors: Schaadt Jennifer
Published: January 2013

Oxygenator thrombosis, despite adequate anticoagulation, has become a recent concern amongst perfusionists worldwide. The phenomenon is characterized by a transient increase in oxygenator inlet pressure of up to 900 mmHg about 10-15 min after the institution of cardiopulmonary bypass (CPB). Depending on the size and location of the thrombus, shunting may occur that compromises gas transfer to the extent where oxygenator change-out is necessary. This article presents various case reports and publications, both domestic and international, detailing this phenomenon. Research hypothesizes that it is the activation of platelets that subsequently may cause the deposition of fibrin, yielding thrombus formation; however, the primary etiology of this phenomenon remains unknown. Possible catalysts include bypass techniques, equipment selection, pharmacological agents, prime and the patient. This paper will review all of the above with an emphasis on the often overlooked factor - the patient, as there are certain variables in patient hematology that provoke a hypercoagulable state leading to thrombosis, including blood type, genetics, age, disease state, gender and heparin.
Assessing Student Pharmacist Impact on Patient Over-the-Counter Medication Selection
Authors: McConaha Jamie L. , Finoli Lauren M. , Heasley Jennifer E. , Lunney Philip D.
Published: January 2013

Objective:

To evaluate the financial and clinical outcomes of an over-the-counter (OTC) medication consultation performed by doctorate of pharmacy student pharmacists in a community pharmacy.

Design:

Cross-sectional survey.

Setting:

Independent and chain community pharmacy locations in Pittsburgh, Pennsylvania.

Participants:

Fourth professional year (PY4) advanced experiential student pharmacists on community rotations at the designated settings who performed OTC consultations and the participants of these encounters.

Main Outcome Measured:

Financial and clinical impact of an OTC consultation performed by student pharmacists on rotation.

Results:

A total of 559 OTC consultations were offered in 5 participating community pharmacy settings over a period of 1 year. Student pharmacists initiated 62.4% of all documented interactions and 60.5% of all participants accepted the consultation offer. The student pharmacists’ OTC recommendations resulted in significant cost savings to the participant. Those participants accepting consultation reported being more likely to consult with a pharmacist in the future. PY4 students were also able to demonstrate capability in impacting clinical outcomes on several occasions by implementing OTC medication changes due to patient safety concerns.

Conclusion:

Student pharmacist OTC consultations have the potential to positively impact both financial and clinical outcomes associated with the use of OTC medications.
Awareness and Knowledge of Micro Health Insurance: A Case Study of Sampoorna Suraksha Programme in Karnataka, India
Authors: Savitha  , K.B. Kiran
Published: January 2013

Micro health insurance (MHI) is an innovative health financing mechanism that caters to the insurance need of the bottom of the pyramid in India to tackle the impoverishing effects of huge medical bills and mitigate iatrogenic poverty. This study was conducted to ascertain the knowledge and awareness on the scheme features of Sampoorna Suraksha Programme (SSP), a micro insurance programme initiated by SKDRDP (Sri Kshetra Dharmasthala Rural Development Project) in Karnataka, India. A descriptive study was conducted in three randomly selected districts namely Dakshina Kananda, Uttara Kannada and Gadag, in Karnataka. Primary data was collected using a questionnaire from the insured members of SSP adopting survey methodology. Our study affirms that insured members of SSP have different levels of knowledge and awareness on the various features of SSP. The results indicate that the degree of knowledge and awareness of the main features of SSP (benefits of package, excluded diseases and network hospitals) were more prevalent amongst members who have been renewing rather than the newly insured SSP members. We reiterate that such positive trends on knowledge and awareness were attributable to high income, educational level, and members living in more developed districts of Karnataka.
Analyzing Accessibility of Health Care for HIV Positive Women in Karnataka and West Bengal
Authors: Sahu Skylab
Published: January 2013

Right to health ensures health care to all irrespective of any socio-economic and cultural differences. Since the late 1980s, HIV/AIDS has emerged as an epidemic in India and it has put forth several challenges like medical, socio-economic isssues. The health problem has more adverse effects on vulnerable sections of the society like the poor and women. In such a context, there is a need for the state to address the issue in a way that the health rights of women could be ensured effectively. In this article, we explore the role of the state in ensuring health rights of HIV positive women. Two states are selected, i.e., Karnataka (one of the high prevalence states) and West Bengal (one of the low prevalence states) to examine the difference of performance of state towards assurance of health rights of women. One of the vital parameters of health rights, i.e., accessibility of health care and treatment is considered. We found that despite initiatives taken by the states, accessibility of health care has remained an oasis for many HIV positive people. More importantly, state governments fail in ensuring accessibility of health care facilities due to widespread instances of treatment denial, discrimination and absence of counselling.
Detection of Heavy Metals Concentration Due to Leather Tanning Industry and Prevalent Disease Pattern in Kasur, Pakistan
Authors: Abbas Moneeza , Rahman M. Atiq ur , Safdar Asma
Published: January 2013

Leather tanning industry is the third largest export earning industry of Pakistan. Kasur is second largest leather producing city in Punjab. It is among Pakistan’s most contaminated cities due to discharge of highly toxic industrial effluent into open fields. This study aims to identify the level of toxicity of the soil in terms of heavy metals in different parts of Kasur city. Seventy (70) soil samples were collected from seven different locations including city centre, evacuated ponds and agriculture fields being fed with the recycled water from the wastewater treatment plant.

In this study, the presence of three heavy metals, that is, Chromium (Cr), Manganese (Mn) and Nickel (Ni) were measured by using Atomic Absorption Spectrophotometer. The overall mean value of these metals (Cr 3.859 ± 0.510 mg/Kg, Mn 0.5243 ± 0.0691 mg/Kg and Ni 0.4759 ± 0.0318 mg/Kg, respectively) in Kasur was found higher as compared to control samples (Cr 0.2622 ± 0.033 mg/Kg, Mn 0.1701 ± 0.016 mg/Kg and Ni 0.1817 ± 0.021 mg/Kg, respectively). The results reflect that the areas which are in contact with tannery effluents have high levels of Cr, Mn and Ni as compared to other sites and control samples. It was seen that majority of the city population is facing diseases associated with drinking water, soil and air pollution caused by tanning industry.
Cerebrospinal fluid eosinophilia is a sensitive and specific test for the diagnosis of Parelaphostrongylus tenuis in camelids in the northeastern United States
Authors: Pinn Toby L. , Bender Hannah S. , Stokol Tracy , Erb Hollis N. , Schlafer Donald H. , Perkins Gillian A.
Published: January 2013

Aberrant migration of Parelaphostrongylus tenuis in camelids results in neurologic deficits, recumbency, and sometimes death. An antemortem diagnosis of P. tenuis in camelids is typically based upon the presence of characteristic asymmetric neurologic deficits, known exposure to white-tailed deer, cerebrospinal fluid (CSF) eosinophilia, and response to treatment. The diagnostic accuracy of CSF eosinophil percentage for the diagnosis of P. tenuis in camelids has not been critically examined. The objective of the current study was to determine the sensitivity (Se) and specificity (Sp) of CSF eosinophil percentage, CSF eosinophil concentration, total nucleated cell concentration, and protein concentration for the antemortem diagnosis of P. tenuis. Medical records of camelids admitted to Cornell University with clinical signs of neurologic disease, CSF analysis, and necropsy were examined from January 2000 through December 2009. Se and Sp were determined by receiver operating characteristic curves in camelids diagnosed with P. tenuis ( n = 13) or other conditions ( n = 24) based on postmortem examination. More than 17% of eosinophils in CSF had a Se of 85% and Sp of 92% for P. tenuis diagnosis (area under the curve [AUC]: 0.87; SE AUC: 0.07; P < 0.0001; 95% confidence interval [CI] AUC: 0.72–0.96), and >1.4 eosinophils/µl of CSF had a Se of 85% and Sp of 96% (AUC: 0.9; SE AUC: 0.06; P < 0.0001; 95% CI AUC: 0.76–0.97). Cerebrospinal fluid eosinophil percentage and concentration are sensitive and specific methods for diagnosing P. tenuis antemortem in camelids residing in regions endemic to white-tailed deer.
The Cultural Meaning of Children Sleeping Outdoors in Finnish Winter
Authors: Tourula Marjo , Pölkki Tarja , Isola Arja
Published: January 2013

Purpose: Little is known about children sleeping outdoors in a northern winter climate, although it is a common practice in northern countries. The article describes the cultural meaning of this child care practice from the viewpoint of mothers. Design: Explorative descriptive study design was adopted and unstructured interviews were processed by qualitative content analysis. Participants: Twenty-one mothers of families in northern Finland participated. Results: Family, cultural outdoor sleeping practice and northern winter environment constituted compatibility, which consisted of four generic categories: strengthening family well-being through outdoor sleeping, taking notice of security perspectives, adaptation to the northern winter environment, and cultural knowledge-building processes. Conclusions: Family well-being was strengthened through outdoor sleeping of children when all security perspectives were first taken into account. Families were adapted to the northern winter environment and cultural knowledge was built. A fit was found between families, cultural child care practice, and northern winter environment constituting a coherent whole.
Computed Tomography Analysis of Third Webspace Injections for Interdigital Neuroma
Authors: Hembree W. Chad , Groth Adam T. , Schon Lew C. , Guyton Gregory P.
Published: January 2013

Background:

Injection for interdigital neuroma (IDN) may not selectively target the common digital nerve. We investigated the anatomical localization and extent of extravasation with injection for IDN.

Methods:

Two fellowship-trained foot and ankle surgeons injected radiopaque contrast into the third webspace of 49 cadaveric specimens (29 with 2 mL and 20 with 1 mL). Computed tomography scan of each specimen was obtained. An independent blinded foot and ankle surgeon analyzed the scans.

Results:

All injections were accurate. Contrast was found in the second (greater than 70%) and fourth (greater than 30%) webspaces in both injection volume groups. No contrast was found within the third metatarsophalangeal joint. Extravasation extent was significantly greater with 2 mL versus 1 mL of solution in the medial to lateral (27.9 [7.8] mm vs 23.7 [6.0] mm; P = .05) and distal to proximal (52.1 [13.7] mm vs 40.4 [16.1] mm; P = .01) planes. No differences were observed in extravasation extent between surgeons.

Conclusion:

Injection for IDN was accurate, and extravasation extended into adjacent webspaces in a large percentage of specimens with both solution volumes. Lower extent of extravasation with 1 mL of solution did not indicate better selectivity of injection.

Clinical Relevance:

Steroid injections for interdigital neuroma were accurate for therapeutic purposes but not diagnostic, except potentially for distinguishing webspace pain from joint pain.