Issue 12

TM

For the use of a registered medical practitioner or a hospital or a laboratory only

Perfusion-Related Insights – Management and Evidence

Date of preparation: January 2019

Review Articles
Expert Experiences
TIPL-014-10-PRI

Guidelines
Latest News
Self-Assessment
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 Scientific Committee Editorial Letter
Dear Readers,
We are glad to present to you yet another engaging issue of PRIME newsletter.
Name Designation
“Perfusion-Related Insights - Management and Evidence” or "PRIME" is a scientific
Dr. Kamla Rana HOD of Perfusion Department at newsletter, which is published every quarter with the help of our editorial board
members. It includes latest reviews, guidelines, and expert experiences associated
Medanta - The Medicity, Gurgaon with perfusion strategies.

P. V. S. Prakash Consultant Chief Perfusionist at Narayana In this twelfth issue of PRIME newsletter, we have focused on five interesting articles
Hrudayalaya, Bengaluru under the section “Review Articles.” The first article evaluates the benefits of using
conventional versus minimized cardiopulmonary bypass support during coronary
Bhaskaran Vishwanathan Chief Perfusionist at Madras Medical Mission artery bypass grafting. The second article gives an overview of the efficacy of
normothermic versus hypothermic cardiopulmonary bypass method in low-risk
Hospital, Chennai
pediatric heart surgery. The third article determines the effectiveness of zero-balance
ultrafiltration of priming blood on the procalcitonin level and respiratory function in
Manoj M. C. Perfusionist at Kokilaben Dhirubhai Ambani Hospital,
infants after cardiopulmonary bypass. The benefits of direct innominate artery
Mumbai cannulation as a systemic and cerebral perfusion technique in aortic surgery are
highlighted in the fourth article. The final article evaluates the impact of lung
G. Naveen Kumar Chief Perfusionist at Care Hospital, Hyderabad protection strategies during cardiopulmonary bypass on the composition of the
bronchoalveolar fluid and lung tissue in patients undergoing cardiac surgery.
Atul Solanki Chief Perfusionist at U. N. Mehta Hospital,
Ahmedabad The section "Expert Experiences" presents two articles; the first article deals with
blood conservation management in cardiac surgery, and another article talks about
R. Nair Sir Ganga Ram Hospital, Delhi perfusion strategies for aortic arch surgeries.
The "Guidelines" section offers recommendations made by the American Society of
ExtraCorporeal Technology regarding the management of blood flow and blood
pressure during cardiopulmonary bypass.
The section "Latest News" shares recent insights on two articles, which include the
PRIME Newsletter invites new authors for their contribution to the perfusion community. If you are interested in effect of vasogenic shock or cardiogenic shock following cardiac surgery on gait speed
volunteering your time writing an article or a topic of your expertise and willing to share your knowledge with and length of stay in a hospital, and the association between perioperative point-of-
care platelet function testing and postoperative blood loss in patients undergoing
our readers, we certainly encourage you to do so. We invite everyone interested in joining our team, and you can
high-risk cardiac surgery.
contact us at the email given below. Any amount of time that you can volunteer in adding to our quality of
publication will be greatly appreciated. Thank you for your interest in PRIME Newsletter. What are you waiting The final section "Self-assessment" is a fun section, which will allow you to evaluate
for? your knowledge of cardiology.
We hope that perfusionists will find these articles interesting and helpful. We look
E-mail: rahul_sharma@terumo.co.jp forward to receiving your valuable feedback, comments, and suggestions to help us
work better on future issues.

Dr. Sandeep Arora Mr. Rahul Sharma

Regional Medical Director Sr. Manager - Medical Affairs
Terumo Intervention Systems, Terumo India Pvt. Ltd.
Terumo Asia Pacific, Director - Medical & rahul_sharma@terumo.co.jp
Clinical Affairs
Terumo India Private Limited
 Scientific Committee Editorial Letter
Dear Readers,
We are glad to present to you yet another engaging issue of PRIME newsletter.
Name Designation
“Perfusion-Related Insights - Management and Evidence” or "PRIME" is a scientific
Dr. Kamla Rana HOD of Perfusion Department at newsletter, which is published every quarter with the help of our editorial board
members. It includes latest reviews, guidelines, and expert experiences associated
Medanta - The Medicity, Gurgaon with perfusion strategies.

P. V. S. Prakash Consultant Chief Perfusionist at Narayana In this twelfth issue of PRIME newsletter, we have focused on five interesting articles
Hrudayalaya, Bengaluru under the section “Review Articles.” The first article evaluates the benefits of using
conventional versus minimized cardiopulmonary bypass support during coronary
Bhaskaran Vishwanathan Chief Perfusionist at Madras Medical Mission artery bypass grafting. The second article gives an overview of the efficacy of
normothermic versus hypothermic cardiopulmonary bypass method in low-risk
Hospital, Chennai
pediatric heart surgery. The third article determines the effectiveness of zero-balance
ultrafiltration of priming blood on the procalcitonin level and respiratory function in
Manoj M. C. Perfusionist at Kokilaben Dhirubhai Ambani Hospital,
infants after cardiopulmonary bypass. The benefits of direct innominate artery
Mumbai cannulation as a systemic and cerebral perfusion technique in aortic surgery are
highlighted in the fourth article. The final article evaluates the impact of lung
G. Naveen Kumar Chief Perfusionist at Care Hospital, Hyderabad protection strategies during cardiopulmonary bypass on the composition of the
bronchoalveolar fluid and lung tissue in patients undergoing cardiac surgery.
Atul Solanki Chief Perfusionist at U. N. Mehta Hospital,
Ahmedabad The section "Expert Experiences" presents two articles; the first article deals with
blood conservation management in cardiac surgery, and another article talks about
R. Nair Sir Ganga Ram Hospital, Delhi perfusion strategies for aortic arch surgeries.
The "Guidelines" section offers recommendations made by the American Society of
ExtraCorporeal Technology regarding the management of blood flow and blood
pressure during cardiopulmonary bypass.
The section "Latest News" shares recent insights on two articles, which include the
PRIME Newsletter invites new authors for their contribution to the perfusion community. If you are interested in effect of vasogenic shock or cardiogenic shock following cardiac surgery on gait speed
volunteering your time writing an article or a topic of your expertise and willing to share your knowledge with and length of stay in a hospital, and the association between perioperative point-of-
care platelet function testing and postoperative blood loss in patients undergoing
our readers, we certainly encourage you to do so. We invite everyone interested in joining our team, and you can
high-risk cardiac surgery.
contact us at the email given below. Any amount of time that you can volunteer in adding to our quality of
publication will be greatly appreciated. Thank you for your interest in PRIME Newsletter. What are you waiting The final section "Self-assessment" is a fun section, which will allow you to evaluate
for? your knowledge of cardiology.
We hope that perfusionists will find these articles interesting and helpful. We look
E-mail: rahul_sharma@terumo.co.jp forward to receiving your valuable feedback, comments, and suggestions to help us
work better on future issues.

Dr. Sandeep Arora Mr. Rahul Sharma

Regional Medical Director Sr. Manager - Medical Affairs
Terumo Intervention Systems, Terumo India Pvt. Ltd.
Terumo Asia Pacific, Director - Medical & rahul_sharma@terumo.co.jp
Clinical Affairs
Terumo India Private Limited
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

SECTION 1
Table of Contents Conventional versus Minimized Cardiopulmonary Bypass Support
during Coronary Artery Bypass Grafting
Section 1: Review Articles 5

Conventional versus minimized cardiopulmonary bypass support during coronary artery bypass grafting 5 Introduction Minimized bypass systems can be
There exists a lack of clarity on the use of minimized considered as a favorable alternative to reduce
Efficacy of normothermic versus hypothermic cardiopulmonary bypass in low-risk pediatric heart surgery 6 cardiopulmonary bypass (MCPB) support in reducing the side adverse effects associated with cardiopulmonary
effects associated with extracorporeal circulation. Several
Effect of zero-balance ultrafiltration of priming blood on the procalcitonin level and respiratory
bypass support.
studies that compared conventional and minimized bypass
function in infants after cardiopulmonary bypass 7 circuits for coronary artery bypass grafting (CABG) focused on w The mean BP was lower in the CCPB group than in the
factors, such as stroke, mortality, myocardial damage, need MCPB group during aortic clamping (53 ± 10 vs. 56 ±
Role of direct innominate artery cannulation as a systemic and cerebral perfusion technique in aortic surgery 8 for perioperative blood component transfusion, atrial 13 mmHg, p < 0.0001), at 34 °C (57 ± 9 vs. 61 ± 12 mmHg,
fibrillation, renal failure, and inflammatory response p < 0.0001), and during aortic clamp removal (55 ± 9 vs.
Section 2: Expert Experiences 9 activated by the extracorporeal circuit. The following study 59 ± 11 mmHg, p < 0.0001) at all time points.
aimed to evaluate differences between conventional
w Both CCPB and MCPB groups demonstrated comparable
Blood conservation management in cardiac surgery patients undergoing cardiopulmonary bypass 9 cardiopulmonary bypass (CCPB) and MCPB systems with the
levels of venous oxygen saturation, which were greater
help of perfusion parameters and their course during CABG.
than 70% (Figure 1).
Perfusion strategies for aortic arch surgeries 10 Methods w The increase in serum lactate was more prominent in the
CCPB group (8.98 ± 1.28 mg/dL, p = 0.0079) than in the
Section 3: Guidelines 12 The study conducted by Provaznik Z et al. included the data of
MCPB group (3.66 ± 1.25 mg/dL, p = 0.0079).
5,164 patients who had undergone stand-alone CABG.
w The serum pH level decreased to the acidotic range
The American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice (2017) The following factors were used to assess tissue perfusion
during support with CCPB (7.33 ± 0.06, p < 0.0001),
Recommendations on the Management of Blood Flow and Blood Pressure during Cardiopulmonary Bypass Surgery 12 during cardiopulmonary bypass support and cardiac arrest:
whereas it was maintained at the physiological level
w Body mass index (BMI) during support with MCPB (7.35 ± 0.06, p < 0.0001).
Section 4: Latest News 13 w Hemodilution All BMI ranges showed evidence of the above-mentioned
w Blood pressure with corresponding pump flow and results.
Effect of vasogenic shock or cardiogenic shock following cardiac surgery on gait speed and length of venous oxygen saturation
stay in hospital 13 Figure 1: Venous oxygen saturation during support with MCPB and
w Serum lactate
CCPB across BMI subgroups
Association between perioperative point-of-care platelet function testing and postoperative blood loss in w Serum pH
patients undergoing high-risk cardiac surgery 14 85 MCPB CCPB

Venous oxygen saturation (%)

Results
80
The study elicited the following results:
Section 5: Self-Assessment 15 75
w The BMI, which was comparable between the two 70
cohorts, was 29 ± 4.7 kg/m² for the CCPB group and
65
28 ± 3.9 kg/m² for the MCPB group.
60 *p < 0.001
w Hemodilution was more prominent after CCPB compared
0
with MCPB. The hemoglobin level had dropped to < 25 25–29.9 30–34.9 35–39.9 > 40
4.47 ± 0.142 g/dL and 2.77 ± 0.148 g/dL (p = 0.0022) after BMI (kg/m2)
CCPB and MCPB, respectively.
CONCLUSION

Minimized cardiopulmonary bypass support is equivalent to CCPB, because MCPB provides efficient
perfusion in all BMI ranges.

Reference: Provaznik Z, Unterbuchner C, Philipp A, Foltan M, Creutzenberg M, Schopka S, et al. Conventional or minimized cardiopulmonary bypass support
during coronary artery bypass grafting? - An analysis by means of perfusion and body mass index. Artif Organs. 2018 Nov 9.

5
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

SECTION 1
Table of Contents Conventional versus Minimized Cardiopulmonary Bypass Support
during Coronary Artery Bypass Grafting
Section 1: Review Articles 5

Conventional versus minimized cardiopulmonary bypass support during coronary artery bypass grafting 5 Introduction Minimized bypass systems can be
There exists a lack of clarity on the use of minimized considered as a favorable alternative to reduce
Efficacy of normothermic versus hypothermic cardiopulmonary bypass in low-risk pediatric heart surgery 6 cardiopulmonary bypass (MCPB) support in reducing the side adverse effects associated with cardiopulmonary
effects associated with extracorporeal circulation. Several
Effect of zero-balance ultrafiltration of priming blood on the procalcitonin level and respiratory
bypass support.
studies that compared conventional and minimized bypass
function in infants after cardiopulmonary bypass 7 circuits for coronary artery bypass grafting (CABG) focused on w The mean BP was lower in the CCPB group than in the
factors, such as stroke, mortality, myocardial damage, need MCPB group during aortic clamping (53 ± 10 vs. 56 ±
Role of direct innominate artery cannulation as a systemic and cerebral perfusion technique in aortic surgery 8 for perioperative blood component transfusion, atrial 13 mmHg, p < 0.0001), at 34 °C (57 ± 9 vs. 61 ± 12 mmHg,
fibrillation, renal failure, and inflammatory response p < 0.0001), and during aortic clamp removal (55 ± 9 vs.
Section 2: Expert Experiences 9 activated by the extracorporeal circuit. The following study 59 ± 11 mmHg, p < 0.0001) at all time points.
aimed to evaluate differences between conventional
w Both CCPB and MCPB groups demonstrated comparable
Blood conservation management in cardiac surgery patients undergoing cardiopulmonary bypass 9 cardiopulmonary bypass (CCPB) and MCPB systems with the
levels of venous oxygen saturation, which were greater
help of perfusion parameters and their course during CABG.
than 70% (Figure 1).
Perfusion strategies for aortic arch surgeries 10 Methods w The increase in serum lactate was more prominent in the
CCPB group (8.98 ± 1.28 mg/dL, p = 0.0079) than in the
Section 3: Guidelines 12 The study conducted by Provaznik Z et al. included the data of
MCPB group (3.66 ± 1.25 mg/dL, p = 0.0079).
5,164 patients who had undergone stand-alone CABG.
w The serum pH level decreased to the acidotic range
The American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice (2017) The following factors were used to assess tissue perfusion
during support with CCPB (7.33 ± 0.06, p < 0.0001),
Recommendations on the Management of Blood Flow and Blood Pressure during Cardiopulmonary Bypass Surgery 12 during cardiopulmonary bypass support and cardiac arrest:
whereas it was maintained at the physiological level
w Body mass index (BMI) during support with MCPB (7.35 ± 0.06, p < 0.0001).
Section 4: Latest News 13 w Hemodilution All BMI ranges showed evidence of the above-mentioned
w Blood pressure with corresponding pump flow and results.
Effect of vasogenic shock or cardiogenic shock following cardiac surgery on gait speed and length of venous oxygen saturation
stay in hospital 13 Figure 1: Venous oxygen saturation during support with MCPB and
w Serum lactate
CCPB across BMI subgroups
Association between perioperative point-of-care platelet function testing and postoperative blood loss in w Serum pH
patients undergoing high-risk cardiac surgery 14 85 MCPB CCPB

Venous oxygen saturation (%)

Results
80
The study elicited the following results:
Section 5: Self-Assessment 15 75
w The BMI, which was comparable between the two 70
cohorts, was 29 ± 4.7 kg/m² for the CCPB group and
65
28 ± 3.9 kg/m² for the MCPB group.
60 *p < 0.001
w Hemodilution was more prominent after CCPB compared
0
with MCPB. The hemoglobin level had dropped to < 25 25–29.9 30–34.9 35–39.9 > 40
4.47 ± 0.142 g/dL and 2.77 ± 0.148 g/dL (p = 0.0022) after BMI (kg/m2)
CCPB and MCPB, respectively.
CONCLUSION

Minimized cardiopulmonary bypass support is equivalent to CCPB, because MCPB provides efficient
perfusion in all BMI ranges.

Reference: Provaznik Z, Unterbuchner C, Philipp A, Foltan M, Creutzenberg M, Schopka S, et al. Conventional or minimized cardiopulmonary bypass support
during coronary artery bypass grafting? - An analysis by means of perfusion and body mass index. Artif Organs. 2018 Nov 9.

5
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Efficacy of Normothermic versus Hypothermic Cardiopulmonary Effect of Zero-Balance Ultrafiltration of Priming Blood on the Procalcitonin Level
Bypass in Low-Risk Pediatric Heart Surgery and Respiratory Function in Infants after Cardiopulmonary Bypass

Introduction Significant differences in renal function, Introduction demonstrated a smaller rise in the peak procalcitonin
concentration than that seen in the non−Z-BUF group at
An absence of shivering, hemodynamic stability, minimal which were in favor of normothermic CPB, were Blood priming is essential for cardiopulmonary bypass (CPB)
need for use of inotropes, and early extubation were in neonates and infants to avoid excessive hemodilution; 24 h after the operation, and the difference between the
seen across several markers of renal damage.
observed when patients underwent normothermic systemic however, transfusion-related inflammation has been shown two groups constituted a statistical significance (P = 0.05)
perfusion. A study was conducted to evaluate normothermic support, intubation time, and postoperative hospital stay, as to affect post-CPB outcomes in open heart surgery of infants. [Table 1].
(35 °C−36 °C) versus hypothermic (28 °C) cardiopulmonary the coprimary clinical outcomes in both trials. Procalcitonin, which is a newly identified inflammatory w A positive correlation was seen between the peak
bypass (CPB) in pediatric patients undergoing open heart moderator and a sensitive parameter for forecasting procalcitonin concentration and the time to extubation
surgery and to test the hypothesis that normothermic CPB Results pulmonary dysfunction secondary to CPB, rises after CPB. directly (P = 0.001). A positive correlation was witnessed
perfusion preserves the functional integrity of the major The researchers found no significant difference between the Dehaki MG et al. conducted a randomized trial to assess the between the peak procalcitonin concentration and PC
organ systems leading to rapid recovery. treatment groups for any of the co-primary outcomes: effects of hemofiltration of priming blood before CPB on the reversely (P = 0.003) [Table 2].
Duration of inotropic support (hazard ratio [HR] = 1.01, 95% CI procalcitonin concentration and postoperative pulmonary w The Z-BUF group demonstrated a significantly lower
Methods = 0.72–1.41), intubation time (HR = 1.14, 95% CI = 0.86–1.51), function among infants following CPB. postoperative mechanical ventilation time than the
Caputo M et al. conducted two single-center, randomized or postoperative hospital stay (HR = 1.06, 95% CI = 0.80–1.40) non−Z-BUF group did (P = 0.03).
controlled trials (also known as Thermic-1 and Thermic-2 [Figure 1]. Methods
studies, respectively) to evaluate the effectiveness and Differences that favored normothermia were found in the Table 1: Mean serum procalcitonin level (ng/mL) in the study
The researchers chose 60 infants with weight < 10 kg and
acceptability of normothermic CPB versus hypothermic CPB in groups at various time points
following parameters at the specified time points: divided them randomly into two equal groups; one group
children with congenital heart disease undergoing open heart Baseline At ICU admission 24 h postoperatively
w Neutrophil gelatinase-associated lipocalin at 4 hours: undergoing CPB with the zero-balance ultrafiltration (Z-BUF)
surgery. Z-BUF 0.2 ± 0.26 1.2 ± 1.4 2.1 ± 1.6
Geometric mean ratio (GMR) = 0.47 (95% CI = 0.22–1.02) of priming blood and another group undergoing CPB without
A total of 200 patients (aged £ 18 years) participated in the Z-BUF. The researchers measured the procalcitonin level
Non–Z-BUF 0.3 ± 0.37 1.9 ± 1.3 3.3 ± 2.7

study. Of them, 59 were recruited to the Thermic-1 study and w Urinary albumin at 48 hours: GMR = 0.32 (95% CI = P 0.2 0.8 0.05*
0.14–0.74) before anesthesia, after admission to the intensive care unit
141 patients were recruited to the Thermic-2 study. Of the 200 Data are reported as mean ± SD.
(ICU), and 24 h later. They also measured the respiratory index *P < 0.05 compared with the non−Z-BUF group; P for the main effect of time = 0.001; P for interaction = 0.12.
patients, normothermic CPB was induced in 98 patients and w Urea nitrogen at 2 days: GMR = 0.86 (95% CI = 0.77–0.97)
and pulmonary compliance (PC) after anesthesia, after CPB,
hypothermic CPB was induced in 102 patients. The w Serum creatinine at 3 days: GMR = 0.89 (95% CI =
and 2 h after admission to the ICU. Moreover, they recorded
researchers selected factors, such as duration of inotropic 0.81–0.98) Table 2: Correlations between the peak procalcitonin
the time to extubation.
concentration and time to extubation as well as PC
Peak procalcitonin level
Figure 1: Primary outcomes associated with the normothermic and hypothermic CPB groups Results
Correlation coefficient P
Primary outcomes The researchers observed the following results: Time to extubation 0.44 0.001
HR = 1.01 (0.72, 1.41) Hypothermic median = 21
Inotrope duration (hours)
p = 0.96 Normothermic median = 23
w The procalcitonin concentration in the Z-BUF group and PC (mL/cmH2O) at ICU -0.38 0.003
non−Z-BUF group demonstrated a postoperative P < 0.05 indicates a positive correlation between the peak procalcitonin level and the time to extubation directly
HR = 1.14 (0.86, 1.51) Hypothermic median = 16.4 increase compared with baseline. The Z-BUF group and PC reversely.
Intubation time (hours)
p = 0.36 Normothermic median = 10.6

HR = 1.06 (0.80, 1.40) Hypothermic median = 6

Length of stay (days)
p = 0.70 Normothermic median = 6

0.3 0.5 0.75 1.0 1.5 2.0 2.5 3.0

Favors normothermic group Favors hypothermic group
Estimate (95% CI)
CONCLUSION

The Z-BUF of priming blood may lead to favorable clinical effects in the form of improved respiratory function
CONCLUSION

The safety and efficacy of normothermic CPB are comparable to the findings seen with hypothermic CPB. Thus, and attenuated procalcitonin.
normothermic CPB can be accepted as a perfusion strategy in low-risk infants and children undergoing open
heart surgery.
Reference: Gholampour Dehaki M, Niknam S, Azarfarin R, Bakhshandeh H, Mahdavi M. Zero-balance ultrafiltration of priming blood attenuates procalcitonin and
Reference: Caputo M, Pike K, Baos S, Sheehan K, Selway K, Ellis L, et al. Normothermic versus hypothermic cardiopulmonary bypass in low-risk paediatric heart improves the respiratory function in infants after cardiopulmonary bypass: A randomized controlled trial. Artif Organs. 2018 Oct 5.
surgery: A randomised controlled trial. Heart. 2018 Oct 15.

6 7
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Efficacy of Normothermic versus Hypothermic Cardiopulmonary Effect of Zero-Balance Ultrafiltration of Priming Blood on the Procalcitonin Level
Bypass in Low-Risk Pediatric Heart Surgery and Respiratory Function in Infants after Cardiopulmonary Bypass

Introduction Significant differences in renal function, Introduction demonstrated a smaller rise in the peak procalcitonin
concentration than that seen in the non−Z-BUF group at
An absence of shivering, hemodynamic stability, minimal which were in favor of normothermic CPB, were Blood priming is essential for cardiopulmonary bypass (CPB)
need for use of inotropes, and early extubation were in neonates and infants to avoid excessive hemodilution; 24 h after the operation, and the difference between the
seen across several markers of renal damage.
observed when patients underwent normothermic systemic however, transfusion-related inflammation has been shown two groups constituted a statistical significance (P = 0.05)
perfusion. A study was conducted to evaluate normothermic support, intubation time, and postoperative hospital stay, as to affect post-CPB outcomes in open heart surgery of infants. [Table 1].
(35 °C−36 °C) versus hypothermic (28 °C) cardiopulmonary the coprimary clinical outcomes in both trials. Procalcitonin, which is a newly identified inflammatory w A positive correlation was seen between the peak
bypass (CPB) in pediatric patients undergoing open heart moderator and a sensitive parameter for forecasting procalcitonin concentration and the time to extubation
surgery and to test the hypothesis that normothermic CPB Results pulmonary dysfunction secondary to CPB, rises after CPB. directly (P = 0.001). A positive correlation was witnessed
perfusion preserves the functional integrity of the major The researchers found no significant difference between the Dehaki MG et al. conducted a randomized trial to assess the between the peak procalcitonin concentration and PC
organ systems leading to rapid recovery. treatment groups for any of the co-primary outcomes: effects of hemofiltration of priming blood before CPB on the reversely (P = 0.003) [Table 2].
Duration of inotropic support (hazard ratio [HR] = 1.01, 95% CI procalcitonin concentration and postoperative pulmonary w The Z-BUF group demonstrated a significantly lower
Methods = 0.72–1.41), intubation time (HR = 1.14, 95% CI = 0.86–1.51), function among infants following CPB. postoperative mechanical ventilation time than the
Caputo M et al. conducted two single-center, randomized or postoperative hospital stay (HR = 1.06, 95% CI = 0.80–1.40) non−Z-BUF group did (P = 0.03).
controlled trials (also known as Thermic-1 and Thermic-2 [Figure 1]. Methods
studies, respectively) to evaluate the effectiveness and Differences that favored normothermia were found in the Table 1: Mean serum procalcitonin level (ng/mL) in the study
The researchers chose 60 infants with weight < 10 kg and
acceptability of normothermic CPB versus hypothermic CPB in groups at various time points
following parameters at the specified time points: divided them randomly into two equal groups; one group
children with congenital heart disease undergoing open heart Baseline At ICU admission 24 h postoperatively
w Neutrophil gelatinase-associated lipocalin at 4 hours: undergoing CPB with the zero-balance ultrafiltration (Z-BUF)
surgery. Z-BUF 0.2 ± 0.26 1.2 ± 1.4 2.1 ± 1.6
Geometric mean ratio (GMR) = 0.47 (95% CI = 0.22–1.02) of priming blood and another group undergoing CPB without
A total of 200 patients (aged £ 18 years) participated in the Z-BUF. The researchers measured the procalcitonin level
Non–Z-BUF 0.3 ± 0.37 1.9 ± 1.3 3.3 ± 2.7

study. Of them, 59 were recruited to the Thermic-1 study and w Urinary albumin at 48 hours: GMR = 0.32 (95% CI = P 0.2 0.8 0.05*
0.14–0.74) before anesthesia, after admission to the intensive care unit
141 patients were recruited to the Thermic-2 study. Of the 200 Data are reported as mean ± SD.
(ICU), and 24 h later. They also measured the respiratory index *P < 0.05 compared with the non−Z-BUF group; P for the main effect of time = 0.001; P for interaction = 0.12.
patients, normothermic CPB was induced in 98 patients and w Urea nitrogen at 2 days: GMR = 0.86 (95% CI = 0.77–0.97)
and pulmonary compliance (PC) after anesthesia, after CPB,
hypothermic CPB was induced in 102 patients. The w Serum creatinine at 3 days: GMR = 0.89 (95% CI =
and 2 h after admission to the ICU. Moreover, they recorded
researchers selected factors, such as duration of inotropic 0.81–0.98) Table 2: Correlations between the peak procalcitonin
the time to extubation.
concentration and time to extubation as well as PC
Peak procalcitonin level
Figure 1: Primary outcomes associated with the normothermic and hypothermic CPB groups Results
Correlation coefficient P
Primary outcomes The researchers observed the following results: Time to extubation 0.44 0.001
HR = 1.01 (0.72, 1.41) Hypothermic median = 21
Inotrope duration (hours)
p = 0.96 Normothermic median = 23
w The procalcitonin concentration in the Z-BUF group and PC (mL/cmH2O) at ICU -0.38 0.003
non−Z-BUF group demonstrated a postoperative P < 0.05 indicates a positive correlation between the peak procalcitonin level and the time to extubation directly
HR = 1.14 (0.86, 1.51) Hypothermic median = 16.4 increase compared with baseline. The Z-BUF group and PC reversely.
Intubation time (hours)
p = 0.36 Normothermic median = 10.6

HR = 1.06 (0.80, 1.40) Hypothermic median = 6

Length of stay (days)
p = 0.70 Normothermic median = 6

0.3 0.5 0.75 1.0 1.5 2.0 2.5 3.0

Favors normothermic group Favors hypothermic group
Estimate (95% CI)
CONCLUSION

The Z-BUF of priming blood may lead to favorable clinical effects in the form of improved respiratory function
CONCLUSION

The safety and efficacy of normothermic CPB are comparable to the findings seen with hypothermic CPB. Thus, and attenuated procalcitonin.
normothermic CPB can be accepted as a perfusion strategy in low-risk infants and children undergoing open
heart surgery.
Reference: Gholampour Dehaki M, Niknam S, Azarfarin R, Bakhshandeh H, Mahdavi M. Zero-balance ultrafiltration of priming blood attenuates procalcitonin and
Reference: Caputo M, Pike K, Baos S, Sheehan K, Selway K, Ellis L, et al. Normothermic versus hypothermic cardiopulmonary bypass in low-risk paediatric heart improves the respiratory function in infants after cardiopulmonary bypass: A randomized controlled trial. Artif Organs. 2018 Oct 5.
surgery: A randomised controlled trial. Heart. 2018 Oct 15.

6 7
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Role of Direct Innominate Artery Cannulation as a Systemic and SECTION 2

Cerebral Perfusion Technique in Aortic Surgery
Blood Conservation Management in Cardiac Surgery Patients
Introduction w Replacement of the ascending aorta and hemiarch was Undergoing Cardiopulmonary Bypass
performed in one patient.
Surgeons often find the arterial cannulation procedure used
Contributed by: Alok Kumar, Perfusionist, All India Institute of Medical Sciences, New Delhi
in thoracic aortic surgery very challenging due to the site of w Replacement of the concurrent mitral valve was
the surgery and need for cerebral protection during periods performed in one patient.
of circulatory arrest. The use of cannulation sites that Blood conservation and importance of blood w Plasmapheresis and plateletpheresis
comprise the ascending and descending aorta along with the Results Plasmapheresis and plateletpheresis are terms used to
Cardiac surgery is associated with excessive bleeding when
axillary, carotid, and femoral arteries has limitations and is The postoperative outcomes of the new innominate artery compared with noncardiovascular surgery. Regional blood describe the removal of fresh plasma and platelets from
associated with complications due to their closeness to cannulation technique in aortic surgery are mentioned in centers find it increasingly difficult to collect sufficient blood whole blood, respectively, while separating the red blood
surrounding structures. Therefore, surgeons use the Table 1. to meet patient needs in many areas of the country. In the cells and giving them back to the patient after bypass
innominate artery by either direct cannulation or indirect next 15–20 years, the number of patients > 65 years will be surgery.
cannulation through a graft as an alternative site. The more than double, but the number of blood donors will only w Hemoconcentrators
following article presents a retrospective review of the Table 1: Postoperative outcomes of the new innominate artery increase marginally. Excess fluid can be removed from patients' vascular system
cannulation technique in aortic surgery
outcomes obtained when the artery cannulation technique Improved with a hemoconcentrator. The hematocrit of the patient
Parameters Values patient increases as the fluid is removed. During cardiopulmonary
which involved the sole direct innominate artery was used to outcomes
perform aortic surgery. Survival 14 (100%) bypass (CPB), these devices may be connected to the
Neurological deficit pump circuit and are a great asset for fluid management.
Patient The residual blood left in the pump circuit can be salvaged
Methods CVA 1 (7%)
Blood
centered
Prolonged delirium 1 (7%) conservation
Appropriate and concentrated with the hemoconcentrator after CPB is
The new innominate artery cannulation technique was used transfusion
completed.
ICU LOS (days)* 4.62 ± 3.77 (2–13) practices
to perform surgery that involved the ascending aorta in 14
Hospital LOS (days)** 13.07 ± 6.61 (5–26) w Isovolemic hemodilution
patients between 2011 and 2015. Acute renal failure 3 (21%)
Blood management During this technique, one to two units of the patients'
From the group of 14 patients: Creatinine 101.69 ± 38.74 (50–191)§ blood are withdrawn at the beginning of a procedure, and
w Replacement of the aortic valve, aortic root, and Atrial fibrillation 8 (57%) Methods to reduce blood use in surgery the blood volume is restored with the crystalloid/colloid
ascending aorta with a valved conduit was performed in New 6 (43%)
Preoperative solution. The surgical procedure is accomplished with
six patients. Pre-existing 2 (14%) patients' blood (thin blood) during the procedure, and
CHB 1 (7%)
Preoperative conservation of blood is accomplished by patients get blood back at the end of the surgery.
w Replacement of the aortic valve and ascending aorta was hemoglobin optimization; correction of nutritional anemia
Permanent pacemaker 1 (7%) w Cardiopulmonary bypass circuit modifications
performed in four patients. with iron therapy via dietary advice, supplementation with
Reoperation for bleeding 1 (7%) An open reservoir membrane oxygenator system during
w Replacement of only the ascending aorta was performed vitamin B12, as well as folate and erythropoietin therapies; and
Deep sternal infection 0 (0%)
by stopping drugs that interfere with hemostasis. CPB may reduce blood utilization and improve safety.
in two patients. DVT 1 (7%) Similarly, activated clotting time (ACT)-guided heparin
HIT 1 (7%) Intraoperative dosing during prolonged CPB reduces blood transfusion,
Innominate artery dissection or Abbreviations: CVA, cerebrovascular accident; *ICU LOS, intensive care length of stay (days); **Hospital LOS, Meticulous hemostasis and operative techniques can play an hemostatic system activation, platelets, and protein
hospital length of stay (days); CHB, complete heart block; DVT, deep vein thrombosis; HIT, heparin-induced
thrombocytopenia. essential role in reducing blood loss. consumption compared with fixed-dose heparin
damage during the procedure was not §
Absolute creatinine value (mg/L)
supplements.
seen even in a single patient. Postoperative
w Autologous blood transfusion
Blood can be salvaged from drains into collection devices that
permit reinfusion through cell salvage techniques and the use It involves collection and reinfusion (transfusion) of the
of blood substitutes, such as volume expanders, human patients' blood or blood components after completion of
albumin, and perfluorocarbon emulsions. surgery. This procedure is beneficial as the blood is fully
compatible and there is no risk of transfusion - transmitted
CONCLUSION

diseases.
Innominate artery cannulation technique is safe, convenient, and able to provide both systemic and selective
CONCLUSION

cerebral perfusion promptly during aortic surgery. The use of management options, such as controlled hypotensive anesthesia, regional anesthesia and
tranexamic acid, autologous hemotransfusion, normovolemic hemodilution, modification in the CPB circuit,
cell-savaging procedures, plasmapheresis, and ultrafiltration, offers multidimensional alternatives for blood
Reference: Kashani A, Doyle M, Horton M. Direct innominate artery cannulation as a sole systemic and cerebral perfusion technique in aortic surgery. conservation in cardiac surgery patients undergoing CPB.
Heart Lung Circ. 2018 Aug 28.

8 9
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Role of Direct Innominate Artery Cannulation as a Systemic and SECTION 2

Cerebral Perfusion Technique in Aortic Surgery
Blood Conservation Management in Cardiac Surgery Patients
Introduction w Replacement of the ascending aorta and hemiarch was Undergoing Cardiopulmonary Bypass
performed in one patient.
Surgeons often find the arterial cannulation procedure used
Contributed by: Alok Kumar, Perfusionist, All India Institute of Medical Sciences, New Delhi
in thoracic aortic surgery very challenging due to the site of w Replacement of the concurrent mitral valve was
the surgery and need for cerebral protection during periods performed in one patient.
of circulatory arrest. The use of cannulation sites that Blood conservation and importance of blood w Plasmapheresis and plateletpheresis
comprise the ascending and descending aorta along with the Results Plasmapheresis and plateletpheresis are terms used to
Cardiac surgery is associated with excessive bleeding when
axillary, carotid, and femoral arteries has limitations and is The postoperative outcomes of the new innominate artery compared with noncardiovascular surgery. Regional blood describe the removal of fresh plasma and platelets from
associated with complications due to their closeness to cannulation technique in aortic surgery are mentioned in centers find it increasingly difficult to collect sufficient blood whole blood, respectively, while separating the red blood
surrounding structures. Therefore, surgeons use the Table 1. to meet patient needs in many areas of the country. In the cells and giving them back to the patient after bypass
innominate artery by either direct cannulation or indirect next 15–20 years, the number of patients > 65 years will be surgery.
cannulation through a graft as an alternative site. The more than double, but the number of blood donors will only w Hemoconcentrators
following article presents a retrospective review of the Table 1: Postoperative outcomes of the new innominate artery increase marginally. Excess fluid can be removed from patients' vascular system
cannulation technique in aortic surgery
outcomes obtained when the artery cannulation technique Improved with a hemoconcentrator. The hematocrit of the patient
Parameters Values patient increases as the fluid is removed. During cardiopulmonary
which involved the sole direct innominate artery was used to outcomes
perform aortic surgery. Survival 14 (100%) bypass (CPB), these devices may be connected to the
Neurological deficit pump circuit and are a great asset for fluid management.
Patient The residual blood left in the pump circuit can be salvaged
Methods CVA 1 (7%)
Blood
centered
Prolonged delirium 1 (7%) conservation
Appropriate and concentrated with the hemoconcentrator after CPB is
The new innominate artery cannulation technique was used transfusion
completed.
ICU LOS (days)* 4.62 ± 3.77 (2–13) practices
to perform surgery that involved the ascending aorta in 14
Hospital LOS (days)** 13.07 ± 6.61 (5–26) w Isovolemic hemodilution
patients between 2011 and 2015. Acute renal failure 3 (21%)
Blood management During this technique, one to two units of the patients'
From the group of 14 patients: Creatinine 101.69 ± 38.74 (50–191)§ blood are withdrawn at the beginning of a procedure, and
w Replacement of the aortic valve, aortic root, and Atrial fibrillation 8 (57%) Methods to reduce blood use in surgery the blood volume is restored with the crystalloid/colloid
ascending aorta with a valved conduit was performed in New 6 (43%)
Preoperative solution. The surgical procedure is accomplished with
six patients. Pre-existing 2 (14%) patients' blood (thin blood) during the procedure, and
CHB 1 (7%)
Preoperative conservation of blood is accomplished by patients get blood back at the end of the surgery.
w Replacement of the aortic valve and ascending aorta was hemoglobin optimization; correction of nutritional anemia
Permanent pacemaker 1 (7%) w Cardiopulmonary bypass circuit modifications
performed in four patients. with iron therapy via dietary advice, supplementation with
Reoperation for bleeding 1 (7%) An open reservoir membrane oxygenator system during
w Replacement of only the ascending aorta was performed vitamin B12, as well as folate and erythropoietin therapies; and
Deep sternal infection 0 (0%)
by stopping drugs that interfere with hemostasis. CPB may reduce blood utilization and improve safety.
in two patients. DVT 1 (7%) Similarly, activated clotting time (ACT)-guided heparin
HIT 1 (7%) Intraoperative dosing during prolonged CPB reduces blood transfusion,
Innominate artery dissection or Abbreviations: CVA, cerebrovascular accident; *ICU LOS, intensive care length of stay (days); **Hospital LOS, Meticulous hemostasis and operative techniques can play an hemostatic system activation, platelets, and protein
hospital length of stay (days); CHB, complete heart block; DVT, deep vein thrombosis; HIT, heparin-induced
thrombocytopenia. essential role in reducing blood loss. consumption compared with fixed-dose heparin
damage during the procedure was not §
Absolute creatinine value (mg/L)
supplements.
seen even in a single patient. Postoperative
w Autologous blood transfusion
Blood can be salvaged from drains into collection devices that
permit reinfusion through cell salvage techniques and the use It involves collection and reinfusion (transfusion) of the
of blood substitutes, such as volume expanders, human patients' blood or blood components after completion of
albumin, and perfluorocarbon emulsions. surgery. This procedure is beneficial as the blood is fully
compatible and there is no risk of transfusion - transmitted
CONCLUSION

diseases.
Innominate artery cannulation technique is safe, convenient, and able to provide both systemic and selective
CONCLUSION

cerebral perfusion promptly during aortic surgery. The use of management options, such as controlled hypotensive anesthesia, regional anesthesia and
tranexamic acid, autologous hemotransfusion, normovolemic hemodilution, modification in the CPB circuit,
cell-savaging procedures, plasmapheresis, and ultrafiltration, offers multidimensional alternatives for blood
Reference: Kashani A, Doyle M, Horton M. Direct innominate artery cannulation as a sole systemic and cerebral perfusion technique in aortic surgery. conservation in cardiac surgery patients undergoing CPB.
Heart Lung Circ. 2018 Aug 28.

8 9
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Perfusion Strategies for Aortic Arch Surgeries 5. All neuroprotective agents are administered 5 min before 8. The left common carotid artery requires additional
DHCA/ACP. cannulation if left NIRS is less than the baseline during
Contributed by: Sam Immanuel, P. V. S. Prakash, Selva Kumar Rajamani, and Dr. Devi Shetty, Narayana Health, Bengaluru 6. During hypothermia, FiO2 levels are titrated with ACP.
response to SvO2. 9. The recommended ACP duration should not exceed
7. Activated clotting time is maintained in the range of 90 min with the temperature difference of the nasal
Cerebral protection cardioplegia is preferred.
480–600 sec. (18 ˚C) and rectal (22 ˚C).
1. Cerebral protection remains crucial. Current trends are 4. At lower temperature (< 20 ˚C), STS cardioplegia is
8. Arterial blood gas is monitored every half hourly. 10. Myocardial protection with STS cardioplegia is repeated
hinting toward selective antegrade cerebral perfusion repeated once in 30–40 min, even during the ACP period.
at 25–40 min with respect to the patient's core
(ACP) at moderate temperature (24 ˚C nasal and 26 ˚C 5. After implantation/repair of the aortic valve with the 9. Fresh frozen plasma is given as an infusion 50 mL/h in the
temperature.
rectal). coronary buttons, antegrade cardioplegia is performed CPB circuit.
11. Once the ACP time exceeds 40 min, femoral arterial flow
2. Cerebral metabolism can be estimated and monitored using a modified Foley's catheter in the neo-root (graft). 10. During profound hypothermia, accept hematocrit up to
is re-established after introducing an endoaortic clamp
indirectly by the oxygen metabolic rate equation 20%, and come off bypass at a hematocrit percentage
just distal to the left subclavian artery.
(cerebral metabolic rate of oxygen = cerebral blood flow × Visceral organ protection that is not less than 28%.
12. During ACP, SVC saturation is measured and kept in a
cerebral arteriovenous oxygen content difference/100). 1. Once ACP time exceeds 40 min, re-establish the femoral 11. Serum lactate is maintained at 4–6 mmol/L and serum
range of 70%–80% with FiO2 adjustment in the perfusate.
3. Total circulatory arrest is established at a core flow to the visceral organs. This is performed when an glucose level has to be maintained at 150–200 mg/dL
endoclamp catheter is deployed just after the left during the CPB run. 13. Employ mild hypercapnia (pH-stat) during the cooling
temperature of less than 20 ˚C.
subclavian artery. phase for DHCA and normocapnia (alpha-stat) during the
4. Near‐infrared spectroscopy (NIRS), bispectral index, rewarming phase.
2. Monitor the difference between the upper and lower Strategies for ascending and arch aortic aneurysm
electroencephalogram, and mixed venous oxygen
body perfusions by incorporating a noninvasive 1. Initiate CPB with bicaval venous and double arterial 14. Sodium thiopental (stat 10–15 mg/kg) and propofol
saturation (SvO2) tests are routinely conducted and
ultrasonic flow sensor. cannulation (axillary and femoral arteries with an 8-mm infusion (7–10 mg/kg/h) are routinely used for aortic
monitored for aortic arch reconstructive procedures.
graft). arch reconstructive procedures.
5. Cerebrospinal fluid is drained, and somatosensory 3. Aim to achieve urine output 0.5–1 mL/kg/h during the
cardiopulmonary bypass (CPB) run. 2. Invasive ambulatory blood pressure monitoring is 15. Cerebrospinal fluid is drained to decrease the intracranial
evoked potentials are stimulated periodically. These
conducted via right radial access and left femoral access. pressure which helps avoid cerebral hypoperfusion.
measures help keep the intracranial pressure within the 4. Frusemide 20 mg stat is administered during the
desirable range and avoid paraplegia. rewarming phase. 3. Near‐infrared spectroscopy monitoring is mandatory for 16. Tranexamic acid (stat 10 mg/kg) is administered, and an
all cases of aneurysmal dissection involving the aortic infusion of tranexamic acid at 1 mg/kg/h is kept on flow.
6. Monitor the differential flow of blood between the upper 5. Conventional ultrafiltration is performed during the
and lower body by incorporating a noninvasive ultrasonic rewarming phase, and modified ultrafiltration is done for arch. 17. Effective deairing is accomplished by placing the patient
flow sensor. 10–15 minutes. 4. Safer DHCA lasts for less than 30 min at 18 ˚C core in the Trendelenburg position and compressing the
temperature. bilateral carotid arteries under transesophageal
7. The pH-stat is used during the cooling phase, and the 6. Cerebrospinal fluid pressure increases during clamping,
5. During DHCA, cerebral reperfusion is re-established once echocardiography guidance.
alpha-stat is used during the rewarming phase. Employ further decreasing the perfusion pressure of the spinal
mild hypercapnia during the cooling phase for deep cord. the NIRS value reaches 20% less than the baseline index. 18. Serum lactate is maintained at 4–6 mmol/L and serum
hypothermic circulatory arrest (DHCA) and alpha-stat 6. The neurological outcome is better in DHCA with ACP glucose level has to be maintained at 150–200 mg/dL
normocapnia during the rewarming phase. Perfusion strategies versus DHCA without ACP. during the CPB run.

8. Steroids are routinely administered as per the protocol. 1. Double arterial cannulation is performed with the right 7. Antegrade cerebral perfusion flows 10%–20% of total
9. Hypoperfusion may result in central nervous system axillary/innominate and femoral arteries using an 8-mm cardiac output which varies with NIRS and right radial
ischemia, whereas hyperperfusion leads to cerebral graft with an elongated one-piece arterial cannula. pressure 40–50 mmHg.
edema. Venous circulation is accessed with regular bicaval
cannulation.
Myocardial protection 2. Plasmalyte A solution is the most preferred prime with
1. Venting of the right superior pulmonary vein and left additives of mannitol 50 mL and sodium bicarbonate
ventricular apex is routinely performed to avoid 25 mL.
myocardial rewarming and distension. 3. Cooling is commenced soon after ongoing bypass
2. During profound hypothermia (< 18 ˚C), cardioplegia is maintaining the difference between nasal and rectal
administered just before DHCA. temperatures around 3–4 ˚C.
3. STS solution (4 ˚C) is administered through both coronary 4. If DHCA is indicated, the patient is cooled to 18 ˚C core
ostia. If coronary ostia are small and calcified, retrograde temperature, and if ACP is indicated, the patient is cooled
to 24 ˚C.

10 11
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Perfusion Strategies for Aortic Arch Surgeries 5. All neuroprotective agents are administered 5 min before 8. The left common carotid artery requires additional
DHCA/ACP. cannulation if left NIRS is less than the baseline during
Contributed by: Sam Immanuel, P. V. S. Prakash, Selva Kumar Rajamani, and Dr. Devi Shetty, Narayana Health, Bengaluru 6. During hypothermia, FiO2 levels are titrated with ACP.
response to SvO2. 9. The recommended ACP duration should not exceed
7. Activated clotting time is maintained in the range of 90 min with the temperature difference of the nasal
Cerebral protection cardioplegia is preferred.
480–600 sec. (18 ˚C) and rectal (22 ˚C).
1. Cerebral protection remains crucial. Current trends are 4. At lower temperature (< 20 ˚C), STS cardioplegia is
8. Arterial blood gas is monitored every half hourly. 10. Myocardial protection with STS cardioplegia is repeated
hinting toward selective antegrade cerebral perfusion repeated once in 30–40 min, even during the ACP period.
at 25–40 min with respect to the patient's core
(ACP) at moderate temperature (24 ˚C nasal and 26 ˚C 5. After implantation/repair of the aortic valve with the 9. Fresh frozen plasma is given as an infusion 50 mL/h in the
temperature.
rectal). coronary buttons, antegrade cardioplegia is performed CPB circuit.
11. Once the ACP time exceeds 40 min, femoral arterial flow
2. Cerebral metabolism can be estimated and monitored using a modified Foley's catheter in the neo-root (graft). 10. During profound hypothermia, accept hematocrit up to
is re-established after introducing an endoaortic clamp
indirectly by the oxygen metabolic rate equation 20%, and come off bypass at a hematocrit percentage
just distal to the left subclavian artery.
(cerebral metabolic rate of oxygen = cerebral blood flow × Visceral organ protection that is not less than 28%.
12. During ACP, SVC saturation is measured and kept in a
cerebral arteriovenous oxygen content difference/100). 1. Once ACP time exceeds 40 min, re-establish the femoral 11. Serum lactate is maintained at 4–6 mmol/L and serum
range of 70%–80% with FiO2 adjustment in the perfusate.
3. Total circulatory arrest is established at a core flow to the visceral organs. This is performed when an glucose level has to be maintained at 150–200 mg/dL
endoclamp catheter is deployed just after the left during the CPB run. 13. Employ mild hypercapnia (pH-stat) during the cooling
temperature of less than 20 ˚C.
subclavian artery. phase for DHCA and normocapnia (alpha-stat) during the
4. Near‐infrared spectroscopy (NIRS), bispectral index, rewarming phase.
2. Monitor the difference between the upper and lower Strategies for ascending and arch aortic aneurysm
electroencephalogram, and mixed venous oxygen
body perfusions by incorporating a noninvasive 1. Initiate CPB with bicaval venous and double arterial 14. Sodium thiopental (stat 10–15 mg/kg) and propofol
saturation (SvO2) tests are routinely conducted and
ultrasonic flow sensor. cannulation (axillary and femoral arteries with an 8-mm infusion (7–10 mg/kg/h) are routinely used for aortic
monitored for aortic arch reconstructive procedures.
graft). arch reconstructive procedures.
5. Cerebrospinal fluid is drained, and somatosensory 3. Aim to achieve urine output 0.5–1 mL/kg/h during the
cardiopulmonary bypass (CPB) run. 2. Invasive ambulatory blood pressure monitoring is 15. Cerebrospinal fluid is drained to decrease the intracranial
evoked potentials are stimulated periodically. These
conducted via right radial access and left femoral access. pressure which helps avoid cerebral hypoperfusion.
measures help keep the intracranial pressure within the 4. Frusemide 20 mg stat is administered during the
desirable range and avoid paraplegia. rewarming phase. 3. Near‐infrared spectroscopy monitoring is mandatory for 16. Tranexamic acid (stat 10 mg/kg) is administered, and an
all cases of aneurysmal dissection involving the aortic infusion of tranexamic acid at 1 mg/kg/h is kept on flow.
6. Monitor the differential flow of blood between the upper 5. Conventional ultrafiltration is performed during the
and lower body by incorporating a noninvasive ultrasonic rewarming phase, and modified ultrafiltration is done for arch. 17. Effective deairing is accomplished by placing the patient
flow sensor. 10–15 minutes. 4. Safer DHCA lasts for less than 30 min at 18 ˚C core in the Trendelenburg position and compressing the
temperature. bilateral carotid arteries under transesophageal
7. The pH-stat is used during the cooling phase, and the 6. Cerebrospinal fluid pressure increases during clamping,
5. During DHCA, cerebral reperfusion is re-established once echocardiography guidance.
alpha-stat is used during the rewarming phase. Employ further decreasing the perfusion pressure of the spinal
mild hypercapnia during the cooling phase for deep cord. the NIRS value reaches 20% less than the baseline index. 18. Serum lactate is maintained at 4–6 mmol/L and serum
hypothermic circulatory arrest (DHCA) and alpha-stat 6. The neurological outcome is better in DHCA with ACP glucose level has to be maintained at 150–200 mg/dL
normocapnia during the rewarming phase. Perfusion strategies versus DHCA without ACP. during the CPB run.

8. Steroids are routinely administered as per the protocol. 1. Double arterial cannulation is performed with the right 7. Antegrade cerebral perfusion flows 10%–20% of total
9. Hypoperfusion may result in central nervous system axillary/innominate and femoral arteries using an 8-mm cardiac output which varies with NIRS and right radial
ischemia, whereas hyperperfusion leads to cerebral graft with an elongated one-piece arterial cannula. pressure 40–50 mmHg.
edema. Venous circulation is accessed with regular bicaval
cannulation.
Myocardial protection 2. Plasmalyte A solution is the most preferred prime with
1. Venting of the right superior pulmonary vein and left additives of mannitol 50 mL and sodium bicarbonate
ventricular apex is routinely performed to avoid 25 mL.
myocardial rewarming and distension. 3. Cooling is commenced soon after ongoing bypass
2. During profound hypothermia (< 18 ˚C), cardioplegia is maintaining the difference between nasal and rectal
administered just before DHCA. temperatures around 3–4 ˚C.
3. STS solution (4 ˚C) is administered through both coronary 4. If DHCA is indicated, the patient is cooled to 18 ˚C core
ostia. If coronary ostia are small and calcified, retrograde temperature, and if ACP is indicated, the patient is cooled
to 24 ˚C.

10 11
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

SECTION 3 SECTION 4

Effect of Vasogenic Shock or Cardiogenic Shock following Cardiac Surgery on Gait

The American Society of ExtraCorporeal Technology Standards and Guidelines Speed and Length of Stay in Hospital
for Perfusion Practice (2017) Recommendations on the Management of Blood
Flow and Blood Pressure during Cardiopulmonary Bypass Surgery Introduction w No difference was seen in the incidence of cardiogenic or
vasogenic shock on a comparison of the gait speed
Frailty is a syndrome characterized by increased vulnerability
groups.
to stressors owing to multiple impairments in the functioning
Blood flow w Postoperative vasogenic shock was seen in 183 (55%)
of organs and diminishment of physiological reserves. Frailty
has been demonstrated as a prognostic indicator of poor patients, cardiogenic shock was seen in 99 (29.7%)
The perfusionist should: outcomes after cardiac surgery. One crucial factor that has patients, and both shocks were seen in 71 (21.3%)
been validated as a reliable marker of frailty is gait speed. patients.
w Determine the target blood flow rates prior to cardiopulmonary bypass (CPB) according to the protocol Slow gait speed has been linked to mortality after cardiac w The percentage of patients with vasogenic, cardiogenic,
surgery. Clark et al. conducted a retrospective analysis to and both shocks within each gait speed tertile is
w Work in tandem with the surgical care team to maintain the targeted blood flow rate during CPB investigate the etiology of poor outcomes after cardiac
represented in Figure 1.
surgery with regards to gait speed.
w Report and communicate about the variance between the intended and targeted blood flow to the w The researchers also found that the total length of stay in
physician-in-charge Methods the hospital was significantly different among the gait
speed groups (p = 0.005).
The study analyzed patients who were about to undergo
w Determine the appropriate blood flow rate by evaluation of factors, such as acid–base balance, anesthetic level, cardiac surgery and who had a 5-meter walk test performed w The patients in the slowest gait speed tertile
arterial blood pressure, cerebral oximetry, lactate burden, oxygen delivery and consumption, systemic vascular preoperatively (n = 333). demonstrated a significant association with the need for
resistance, temperature, and venous oxygen saturation a postoperative permanent pacemaker (p = 0.0298)
Results compared with those present in the other gait speed
tertiles.
w The tertiles that were used to stratify gait speeds were
Blood pressure categorized as < 0.83 m/s, 0.83–1 m/s, and > 1 m/s.

The perfusionist should: Figure 1: Percentage of patients with vasogenic, cardiogenic, or both shocks

w Work in close collaboration with the physician-in-charge to define and communicate the intended treatment 40
36.5 Cardiogenic shock
algorithm for the management of blood pressure before CPB Vasogenic shock
30 Both shocks

Frequency (%)
24.2
w Work in tandem with the surgical team to maintain blood pressure according to protocol during CPB
20
14.2
w Report and communicate about the variance between the intended and targeted blood pressure to the
10
physician-in-charge so that requisite changes can be made in the blood pressure management plan 2.4 3.8
6.6 4.7 5.7
1.9
0
Slow gait speed ( < 0.83 m/s) Medium gait speed (0.83–1 m/s) Fast gait speed ( > 1 m/s)
CONCLUSION Gait speed tertile

No significant association exists between gait speed and the incidence of cardiogenic or vasogenic shock
after cardiac surgery. Gait speed is related to an increased length of stay in the hospital and a need for a
permanent pacemaker after cardiac surgery.

Reference: American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice [Internet]. Available at: http://www.amsect.org/p/ Reference: Clark K, Leathers T, Rotich D, He J, Wirtz K, Daon E, et al. Gait speed is not associated with vasogenic shock or cardiogenic shock following cardiac
cm/ld/fid=1617. Accessed on Jan 3, 2018. surgery, but is associated with increased hospital length of stay. Crit Care Res Pract. 2018 Oct 23;2018:1538587.

12 13
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

SECTION 3 SECTION 4

Effect of Vasogenic Shock or Cardiogenic Shock following Cardiac Surgery on Gait

The American Society of ExtraCorporeal Technology Standards and Guidelines Speed and Length of Stay in Hospital
for Perfusion Practice (2017) Recommendations on the Management of Blood
Flow and Blood Pressure during Cardiopulmonary Bypass Surgery Introduction w No difference was seen in the incidence of cardiogenic or
vasogenic shock on a comparison of the gait speed
Frailty is a syndrome characterized by increased vulnerability
groups.
to stressors owing to multiple impairments in the functioning
Blood flow w Postoperative vasogenic shock was seen in 183 (55%)
of organs and diminishment of physiological reserves. Frailty
has been demonstrated as a prognostic indicator of poor patients, cardiogenic shock was seen in 99 (29.7%)
The perfusionist should: outcomes after cardiac surgery. One crucial factor that has patients, and both shocks were seen in 71 (21.3%)
been validated as a reliable marker of frailty is gait speed. patients.
w Determine the target blood flow rates prior to cardiopulmonary bypass (CPB) according to the protocol Slow gait speed has been linked to mortality after cardiac w The percentage of patients with vasogenic, cardiogenic,
surgery. Clark et al. conducted a retrospective analysis to and both shocks within each gait speed tertile is
w Work in tandem with the surgical care team to maintain the targeted blood flow rate during CPB investigate the etiology of poor outcomes after cardiac
represented in Figure 1.
surgery with regards to gait speed.
w Report and communicate about the variance between the intended and targeted blood flow to the w The researchers also found that the total length of stay in
physician-in-charge Methods the hospital was significantly different among the gait
speed groups (p = 0.005).
The study analyzed patients who were about to undergo
w Determine the appropriate blood flow rate by evaluation of factors, such as acid–base balance, anesthetic level, cardiac surgery and who had a 5-meter walk test performed w The patients in the slowest gait speed tertile
arterial blood pressure, cerebral oximetry, lactate burden, oxygen delivery and consumption, systemic vascular preoperatively (n = 333). demonstrated a significant association with the need for
resistance, temperature, and venous oxygen saturation a postoperative permanent pacemaker (p = 0.0298)
Results compared with those present in the other gait speed
tertiles.
w The tertiles that were used to stratify gait speeds were
Blood pressure categorized as < 0.83 m/s, 0.83–1 m/s, and > 1 m/s.

The perfusionist should: Figure 1: Percentage of patients with vasogenic, cardiogenic, or both shocks

w Work in close collaboration with the physician-in-charge to define and communicate the intended treatment 40
36.5 Cardiogenic shock
algorithm for the management of blood pressure before CPB Vasogenic shock
30 Both shocks

Frequency (%)
24.2
w Work in tandem with the surgical team to maintain blood pressure according to protocol during CPB
20
14.2
w Report and communicate about the variance between the intended and targeted blood pressure to the
10
physician-in-charge so that requisite changes can be made in the blood pressure management plan 2.4 3.8
6.6 4.7 5.7
1.9
0
Slow gait speed ( < 0.83 m/s) Medium gait speed (0.83–1 m/s) Fast gait speed ( > 1 m/s)
CONCLUSION Gait speed tertile

No significant association exists between gait speed and the incidence of cardiogenic or vasogenic shock
after cardiac surgery. Gait speed is related to an increased length of stay in the hospital and a need for a
permanent pacemaker after cardiac surgery.

Reference: American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice [Internet]. Available at: http://www.amsect.org/p/ Reference: Clark K, Leathers T, Rotich D, He J, Wirtz K, Daon E, et al. Gait speed is not associated with vasogenic shock or cardiogenic shock following cardiac
cm/ld/fid=1617. Accessed on Jan 3, 2018. surgery, but is associated with increased hospital length of stay. Crit Care Res Pract. 2018 Oct 23;2018:1538587.

12 13
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Association between Perioperative Point-of-Care Platelet Function Testing and SECTION 5

Postoperative Blood Loss in Patients Undergoing High-Risk Cardiac Surgery
1. Which of the following statements is true in case of cardiopulmonary bypass?
a. Venous cannulation is normally into the inferior vena cava for closed procedures.
Introduction Results
b. The optimal perfusion pressure is 120 mmHg.
Hemostatic impairment is very common after cardiac surgery w Platelet aggregation induced by ADP and AA declined
c. The femoral artery is a recognized site for inserting the arterial cannula.
and is associated with increased morbidity and mortality. during cardiopulmonary bypass (CPB) and after
During cardiac surgery, function of platelets is influenced by d. The arterial cannula is usually inserted in the descending aorta.
decannulation from CPB. The ADP test showed a
several factors that include patient and procedural maximum decrease of 55% (35 vs. 77 AU at baseline; e. The patient is cooled to 25 0C if circulatory arrest is necessary.
characteristics. Platelet dysfunction can be rapidly detected P < 0.001), and the ASPI test showed a maximum
and quantified by point-of-care (POC) platelet function decrease of 78% (14 vs. 64 AU at baseline; P < 0.001) 2. Which of the following outcomes is commonly seen after coronary artery bypass grafting?
testing with whole blood multiple electrode aggregometry [Figure 1]. a. Basal lung collapse
(MEA). This test can contribute to optimal patient blood
w The ADP-induced platelet aggregometry at baseline and b. Atrial arrhythmia
management. Vlot EA et al. conducted a study to explore the
postoperative blood loss (r = -0.249; P = 0.015) c. Diffuse cerebral injury resulting in an alteration in short-term memory
possible association between the POC platelet function
testing during the perioperative period and postoperative demonstrated a linear relationship between them. d. New Q waves on electrocardiogram
blood loss occurring in patients undergoing high-risk cardiac w The maximum decrease in platelet function between e. Blood loss of approximately 250 mL in the first hour after surgery
surgery. baseline and CPB decannulation was associated with
postoperative blood loss (r = 0.308; P = 0.037) in aspirin 3. Which of the following options is an indicator of poor peripheral perfusion?
users.
Neonatal and infant cardiac a. Oliguria
w The multivariate analysis elicited a finding that a reduced
surgery has been catapulted into b. Hyperthermia
ADP platelet function before cardiac surgery was linked
the mainstream standard of care c. Confusion
to postoperative blood loss (r = -0.239; P = 0.012).
through the development of CPB d. Central cyanosis
and perfusion techniques. Figure 1: Perioperative platelet function e. Metabolic alkalosis

200
4. Which of the following statements is true for the transfusion process?
Methods ii
iii
#
a. Transfusion-related acute lung injury manifests itself classically by severe dyspnea.
The study included 99 patients undergoing CABG and heart 150 iv b. Graft versus host disease usually occurs within 24 hours.
Aggregation units (AU)

valve surgery, of which 59 (60%) patients were on antiplatelet #

therapy at the time of surgery. The platelet function was c. Management of WBC-mediated transfusion reactions includes immediate cessation of transfusion.
#
evaluated using POC MEA at four different perioperative time 100
#
d. Leukodepletion reduces the risk of febrile reactions.
points in response to stimulation with four specific receptor #
e. Massive transfusion is defined as the transfusion of more than half of the blood volume in 24 hours.
agonist reagents, namely adenosine diphosphate (ADP) [ADP #
50
test], arachidonic acid (AA) [ASPI test], collagen (COL) [COL 5. Which of the following factors is associated with monitoring of the central venous pressure (CVP)?
test], and thrombin receptor activating peptide-6 (TRAP)
a. It allows assessment of preload/filling pressure of the left heart.
[TRAP test]. The recording of postoperative bleeding was 0
done 24 h after the surgery. The researchers used regression ADP ASPI COL TRAP b. It carries a higher risk of pneumothorax by the subclavian approach compared with the internal
analyses to establish associations between platelet function (*) Significant change compared with previous time point (P < 0.05). (#) Significant change compared with baseline (P < 0.05). jugular approach.
Baseline (i), during CPB (ii), after CPB decannulation and protamine (iii), and arrival at the ICU (iv). Values are median
during the perioperative period and postoperative blood loss. [interquartile range]. c. It carries a higher risk of hemothorax by the subclavian approach compared with the internal
jugular approach.
d. It indicates hypovolemia when the CVP is low.
e. It may not reflect the left heart filling pressure in patients with chronic obstructive pulmonary disease.
CONCLUSION

Reduced platelet aggregation induced by the ADP reagent at baseline is related to increased postoperative
blood loss in patients undergoing high-risk cardiac surgery. Reference: Ashford RU, Evans TN, Archbold RA. Key questions in surgical critical care. London, United Kingdom: Cambridge University Press; 2003. Section 1: MCQs.
Cardiovascular system - Questions; p.3–11.

Reference: Vlot EA, Willemsen LM, Van Dongen EPA, Janssen PW, Hackeng CM, Kloppenburg GTL, et al. Perioperative point of care platelet function testing and Issue 11 Answered: 1 - c, 2 - d, 3 - b, 4 - b, 5 - a, 6 - a
postoperative blood loss in high-risk cardiac surgery patients. Platelets. 2018 Nov 9:1–7.

14 15
 Perfusion-Related Insights – Management and Evidence Perfusion-Related Insights – Management and Evidence

Association between Perioperative Point-of-Care Platelet Function Testing and SECTION 5

Postoperative Blood Loss in Patients Undergoing High-Risk Cardiac Surgery
1. Which of the following statements is true in case of cardiopulmonary bypass?
a. Venous cannulation is normally into the inferior vena cava for closed procedures.
Introduction Results
b. The optimal perfusion pressure is 120 mmHg.
Hemostatic impairment is very common after cardiac surgery w Platelet aggregation induced by ADP and AA declined
c. The femoral artery is a recognized site for inserting the arterial cannula.
and is associated with increased morbidity and mortality. during cardiopulmonary bypass (CPB) and after
During cardiac surgery, function of platelets is influenced by d. The arterial cannula is usually inserted in the descending aorta.
decannulation from CPB. The ADP test showed a
several factors that include patient and procedural maximum decrease of 55% (35 vs. 77 AU at baseline; e. The patient is cooled to 25 0C if circulatory arrest is necessary.
characteristics. Platelet dysfunction can be rapidly detected P < 0.001), and the ASPI test showed a maximum
and quantified by point-of-care (POC) platelet function decrease of 78% (14 vs. 64 AU at baseline; P < 0.001) 2. Which of the following outcomes is commonly seen after coronary artery bypass grafting?
testing with whole blood multiple electrode aggregometry [Figure 1]. a. Basal lung collapse
(MEA). This test can contribute to optimal patient blood
w The ADP-induced platelet aggregometry at baseline and b. Atrial arrhythmia
management. Vlot EA et al. conducted a study to explore the
postoperative blood loss (r = -0.249; P = 0.015) c. Diffuse cerebral injury resulting in an alteration in short-term memory
possible association between the POC platelet function
testing during the perioperative period and postoperative demonstrated a linear relationship between them. d. New Q waves on electrocardiogram
blood loss occurring in patients undergoing high-risk cardiac w The maximum decrease in platelet function between e. Blood loss of approximately 250 mL in the first hour after surgery
surgery. baseline and CPB decannulation was associated with
postoperative blood loss (r = 0.308; P = 0.037) in aspirin 3. Which of the following options is an indicator of poor peripheral perfusion?
users.
Neonatal and infant cardiac a. Oliguria
w The multivariate analysis elicited a finding that a reduced
surgery has been catapulted into b. Hyperthermia
ADP platelet function before cardiac surgery was linked
the mainstream standard of care c. Confusion
to postoperative blood loss (r = -0.239; P = 0.012).
through the development of CPB d. Central cyanosis
and perfusion techniques. Figure 1: Perioperative platelet function e. Metabolic alkalosis

200
4. Which of the following statements is true for the transfusion process?
Methods ii
iii
#
a. Transfusion-related acute lung injury manifests itself classically by severe dyspnea.
The study included 99 patients undergoing CABG and heart 150 iv b. Graft versus host disease usually occurs within 24 hours.
Aggregation units (AU)

valve surgery, of which 59 (60%) patients were on antiplatelet #

therapy at the time of surgery. The platelet function was c. Management of WBC-mediated transfusion reactions includes immediate cessation of transfusion.
#
evaluated using POC MEA at four different perioperative time 100
#
d. Leukodepletion reduces the risk of febrile reactions.
points in response to stimulation with four specific receptor #
e. Massive transfusion is defined as the transfusion of more than half of the blood volume in 24 hours.
agonist reagents, namely adenosine diphosphate (ADP) [ADP #
50
test], arachidonic acid (AA) [ASPI test], collagen (COL) [COL 5. Which of the following factors is associated with monitoring of the central venous pressure (CVP)?
test], and thrombin receptor activating peptide-6 (TRAP)
a. It allows assessment of preload/filling pressure of the left heart.
[TRAP test]. The recording of postoperative bleeding was 0
done 24 h after the surgery. The researchers used regression ADP ASPI COL TRAP b. It carries a higher risk of pneumothorax by the subclavian approach compared with the internal
analyses to establish associations between platelet function (*) Significant change compared with previous time point (P < 0.05). (#) Significant change compared with baseline (P < 0.05). jugular approach.
Baseline (i), during CPB (ii), after CPB decannulation and protamine (iii), and arrival at the ICU (iv). Values are median
during the perioperative period and postoperative blood loss. [interquartile range]. c. It carries a higher risk of hemothorax by the subclavian approach compared with the internal
jugular approach.
d. It indicates hypovolemia when the CVP is low.
e. It may not reflect the left heart filling pressure in patients with chronic obstructive pulmonary disease.
CONCLUSION

Reduced platelet aggregation induced by the ADP reagent at baseline is related to increased postoperative
blood loss in patients undergoing high-risk cardiac surgery. Reference: Ashford RU, Evans TN, Archbold RA. Key questions in surgical critical care. London, United Kingdom: Cambridge University Press; 2003. Section 1: MCQs.
Cardiovascular system - Questions; p.3–11.

Reference: Vlot EA, Willemsen LM, Van Dongen EPA, Janssen PW, Hackeng CM, Kloppenburg GTL, et al. Perioperative point of care platelet function testing and Issue 11 Answered: 1 - c, 2 - d, 3 - b, 4 - b, 5 - a, 6 - a
postoperative blood loss in high-risk cardiac surgery patients. Platelets. 2018 Nov 9:1–7.

14 15
 Issue 12

TM

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Perfusion-Related Insights – Management and Evidence

Date of preparation: January 2019

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