Impact of a remote pump head on neonatal priming volumes

ASAIO Journal, 2011

Miniaturized bypass circuits, including the Kids D100 oxygenator and the D130 arterial filter, were specially designed to reduce blood transfusions in small infants undergoing cardiac surgery. This study compared the number of blood product transfusions and short-term outcome between patients younger than 1 year undergoing cardiac surgery with a conventional and a miniaturized bypass circuit, after controlling for baseline characteristics and surgical complexity by 1:1 matching. Adjusted odds ratios (ORs) and 95% confidence intervals for exposure to transfusions and to any additional transfusion were estimated from binary and polytomous regression models. Of the 804 patients enrolled retrospectively, 246 were analyzed after matching. The use of the miniaturized circuit required a lower priming volume, 265.5 vs. 432.4 mL, p < 0.001, fewer packed red blood cell (PRBC) transfusions, 1.4 vs. 2.0 U, p < 0.001, and fewer platelet transfusions on the day of surgery, 57.7% vs. 76.4%, p < 0.001. After adjustment for the use of antifibrinolytics, the ultrafiltration rate, and the year of surgery, the use of the miniaturized circuit was independently related to a reduced risk of additional PRBC transfusions, OR 0.04 (0.01, 0.13), and exposure to platelet transfusions, OR 0.78 (0.63, 0.96). Short-term outcome was similar.

ASAIO Journal, 2005

This article reviews practice patterns of numerous congenital heart surgeons, as collected from surveys (the Congenital Heart Surgeon's Society) and from audience response at the American Association of Thoracic Surgery (May 2003) and the Society of Thoracic Surgeons (January 2004). The information shows that there are numerous practice patterns, with unanimity only in the use of cardioplegia, although the delivery, type, and timing of doses varies. Hypothermic circulatory arrest continues to be used by the majority of congenital heart surgeons, although strategies for delivery have evolved in a way that reflects research contributions over the past decade.

The Annals of Thoracic Surgery, 1996

Background. Progressive metabolic acidosis, hypoxia, and hypercarbia develop rapidly after fetal cardiac bypass mainly as a result of an increase in placental vascular resistance and a decrease in placental blood flow. A number of factors including fetal stress, priming substances, and extracorporeal surfaces have been identified as possible stimuli causing this placental dysfunction. The purpose of this study was to examine the effects of avoiding priming volume and minimizing extracorporeal surface area on placental hemodynamics and function. Methods. Fetal sheep (n = 16) at 118 to 122 days of gestation were subjected to cardiac bypass for 30 minutes using either an in-line axial-flow pump (Hemopump group: n = 8, no prime) or a roller pump with a venous reservoir (control group: n = 8, priming volume = 150 mL). After bypass, the fetuses were observed for 90 minutes. Placental blood flow and combined ventricular output were continuously measured with ultrasonic flow probes, and fetal blood gases were measured at specific intervals. Results. Three fetuses in the control group died during the study, whereas all 8 fetuses in the Hemopump group remained in stable condition throughout the study period. During and after bypass, placental blood flow was significantly higher (p < 0.0001) and placental vascular resistance was significantly lower (p < 0.0001) in the Hemopump group than in the control group. Arterial pH and partial pressure of arterial oxygen declined significantly less (p < 0.0001), and partial pressure of arterial carbon dioxide increased significantly less (p = 0.0002) in the Hemopump group than in the control group. Conclusions. Reducing the extracorporeal surface area and avoiding external priming substances preserves placental hemodynamics after fetal cardiac bypass. An inline axial-flow pump is useful in miniaturizing the bypass circuits for potential use in fetal cardiac surgery.

The Journal of Thoracic and Cardiovascular Surgery, 2011

Objective: Owing to the mismatch between cardiopulomary bypass priming volume and infants' blood volume, pediatric cardiac surgery is often associated with transfusion of homologous blood, which may increase the risk of perioperative complications. Here we report the impact of a very low volume (95-110 mL) cardiopulmonary bypass circuit during arterial switch operations in neonates with transposition of the great arteries on blood requirements, tissue oxygenation, and patient outcome.

The Annals of Thoracic Surgery, 2003

The use of cardiopulmonary bypass is still necessary for the repair of many congenital cardiac defects. However, exposure to cardiopulmonary bypass can still lead to major morbidity and sometimes mortality, especially in neonates and infants, despite a perfect surgical repair. Various research-based strategies have been used to minimize some of the complications related to cardiopulmonary bypass, including the systemic inflammatory response, hemodilution, and transfusion requirement. This overview provides some of the strategies that we use in our practice in applying cardiopulmonary bypass in the repair of congenital cardiac defects in neonates and infants.

Artificial Organs, 2012

New England Journal …, 2004

In an attempt to reduce the coagulopathic and inflammatory responses seen after cardiopulmonary bypass, the use of fresh whole blood during heart operations has become the standard of care for neonates and infants at many institutions. We compared the use of fresh whole blood with the use of a combination of packed red cells and fresh-frozen plasma (reconstituted blood) for priming of the cardiopulmonary bypass circuit. methods We conducted a single-center, randomized, double-blind, controlled trial involving children less than one year of age who underwent open-heart surgery. Patients were assigned to receive either fresh whole blood that had been collected not more than 48 hours previously (96 patients) or reconstituted blood (104 patients) for bypass-circuit priming. Clinical outcomes and serologic measures of systemic inflammation and myocardial injury were compared between the groups. results The group that received reconstituted blood had a shorter stay in the intensive care unit than the group that received fresh whole blood (70.5 hours vs. 97.0 hours, P=0.04). The group that received reconstituted blood also had a smaller cumulative fluid balance at 48 hours (¡6.9 ml per kilogram of body weight vs. 28.8 ml per kilogram, P=0.003). Early postoperative chest-tube output, blood-product transfusion requirements, and levels of serum mediators of inflammation and cardiac troponin I were similar in the two groups. conclusions The use of fresh whole blood for cardiopulmonary bypass priming has no advantage over the use of a combination of packed red cells and fresh-frozen plasma during surgery for congenital heart disease. Moreover, circuit priming with fresh whole blood is associated with an increased length of stay in the intensive care unit and increased perioperative fluid overload.

Perfusion, 1999

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 ...

Translational pediatrics, 2023

Cardiopulmonary bypass is an integral and indispensable part of surgical repair of congenital heart defects. While the complications and morbidity secondary to the use of cardiopulmonary bypass has decreased considerably, there remains a significant incidence of clinically relevant renal and neurological injury. To provide more physiological delivery of oxygenated blood to the end-organs, our center has been successfully using a high-flow, high hematocrit cardiopulmonary bypass strategy since 2006. The essential components of this strategy include maintaining high flows (typically 200 mL/kg/min in neonates, 150-175 mL/kg/min in older infants weighing <10 kg, and 2.6 L/min/m 2 in older children) throughout the duration of cardiopulmonary bypass irrespective of patient temperature, as well as maintaining a hematocrit of at least 32% on cardiopulmonary bypass. The incidence of post-operative acute kidney injury (around 3%) and clinical acute neurological events (<1%) with this strategy is considerably less when compared to other contemporary publications using the conventional cardiopulmonary bypass strategy. In this review, we discuss the rationale behind our approach and present evidence to support the high-flow, high-hematocrit strategy. We also discuss the practical aspects of our strategy and describe the adjuncts we use to derive additional benefits. These adjuncts include the use of a hybrid pH/alpha stat strategy during cooling/rewarming, aggressive use of conventional ultrafiltration during cardiopulmonary bypass, a terminal hematocrit of 40-45%, and avoidance of milrinone and albumin in the early peri-operative period. This results in a very low incidence of post-operative bleeding, facilitates chest closure in the operating room even in most neonates, helps in reducing the need for post-operative blood product transfusion and helps in achieving a favorable post-operative fluid balance early after surgery.