INDIAN JOURNAL OF

Extra-CorporealTechnology

Official JournalIndian Society of Extra-Corporeal Technology (Regd.)

EditorMr. Albert Jayakumar Davis, Chennai

Editorial Correspondence toTHE EDITOR

INDIAN JOURNAL OF EXTRA-CORPOREAL TECHNOLOGYNew no.:38, old no,: 42, P.E. Koil West Mada Street

(Near Don Bosco Church), Ayanavaram,Chennai- 600 023, Tamil Nadu, INDIA

Contact: +919952447068, +918939299019Email id: catchalbert@yahoomail.co.in & capturealbert@gmail.com

Views expressed by the authors do not reflect those of the Indian Society of Extra-corporeal Technology. All statements,ideas expressed in the manuscripts are purely those of the authors and not of the editor(s), publisher(s). The editor(s)and publisher(s) disclaim any responsibility for such contents. Moreover, the editor(s) and publisher(s) neitherguarantee/warrant/endorse any product or service advertised in the journal, nor do they guarantee any claim madeby the manufacturer or such products or services.

Associate EditorsMr. Bhaskaran V., ChennaiMrs. Jayanthi, Chennai

Editorial Review Board MembersMr. Rajendar Raina, ChandigarhMrs. Meeta Mathur, JaipurMr. Kevin Menezes, MumbaiMr. Prakash, BangaloreMr. Loknath Tiwari, Kolkata

Assistant EditorsMr. L. John Peter, ChennaiMr. S. Sundar Rajan, Chennai

Editorial Advisory BoardDr. T. Sunder, ChennaiDr. B. Shashidhar Rao, ChennaiDr. Akil Govil, KOTADr. A.K. Bisoi, New Delhi

Overseas Review Board MembersMr. Ranil Fernando, Colombo, Sri LankaMr. Ajith Kumar, Colombo, Sri Lanka

Indian Society ofExtra-Corporeal

Technology

PresidentDr. Kamala Rana- New Delhi

Vice-PresidentsMr. Sanjeev Wadhera- New Delhi

Mr. Ravindra Pal Singh- New Delhi

Gen. SecretaryMr. Ravinath Swami- Mumbai

Joint SecretariesMr. Naveen Kumar G. HydrabadMr. Debasis Ray- Kolkata

Moderator WebsiteMr. Suresh C. Yadav- New Delhi

LIST OF OFFICE BEARERS

TreasurerMr. Nilesh Mcwan- Nadiad

AdvisorsMr. S. Anandhan- VelloreMr. K.M. Rao- Hyderabad

Editor, IJECTMr.Albert J. Davis- Chennai

Executive Committee Members

Mr. Rajender RainaMr. Kalaprasad SharmaMr. Bhaskar Chandra PantMr. Yogendra Singh ChauhanMr. Venkata Krishna MohanMr. Jaswindar SinghMr. Patel VishalMr. Loknath TiwariMs. M.S. Maya L. GopalMrs. Mukta Tiwari

Mr. Emmanuel ManoharMr. Yogesh SolankiMr. Alok KumarMr. Saurav Sen GuptaMr. Shailendhra K. SinghMs. Kinnari ChudasamaMr. Sheikh Jubair AhmedMr. Angel JonesMr. Srinivasulu ReddyMr. Vijaya L. Nakade

From the Editor's DeskMy dear friends, first and foremost, my sincere gratitude goes to you for electing me as

the Editor of IJECT. I also owe you my earnest apologies for not bringing out the journal in time.It's a kind of schism within the society regarding the release of funds for the immediateexpenditures that retarded the initiation of this work. Deo volente! (God willing!), I will executemy duties to the best of my ability in bringing forth good journals during my tenure. I am verymuch grateful to the former Editors for the valuable advice and encouragement that they haverendered to me.

On behalf of ISECT, I also convey my best wishes to the organising committee of ISECTCON2014 in Thiruvananthapuram, the capital of Kerala for all its success. I feel that everyone attendingthe conference would surely feel the elegant and serene atmosphere of the city and witness theheritage of its past glory.

Thanks and Regards,Editor

MESSAGEDear Friends

On behalf of the Indian Society of Extra Corporeal Technology and ISECTCON 2014 TRIVENDRUM, it is a great pleasure and honour to welcome youto the 14th National Conference of the Indian Society of Extra CorporealTechnology on 21st -22nd February, 2014 Trivendrum.

The main goal of the Conference thanks to its Scientifific Programme is toenable Perfusionists to communicate with one another. This Conference willprovide an excellent platform for exchanging views and encouraging theevolution of new research in regards to the future of Extra Corporeal Technologyin the coming years.

Friends for the formation of Perfusion Council we five members of our Association appeared beforethe Department related Parliamentary Standing Committee on Heath and Family Welfare and madepresentation. A short film presentation and necessary support material was also place before the saidCommittee showing them the status of Perfusion around the Globe.Recently we met Directorate GeneralHealth and Family Welfare with supporting documents for getting the Perfusion Profession recognisein the Government of India.In short as per Director of Medical Council, Paramedical Council and AlliedHealth Services and Directorate General Health and Family Welfare Perfusion Profession will be soonregistered under Allied Health Services. I am continous in touch with Director of Medical Council andother Authorities in this regard and try my best for Registration of Perfusion Profession in Governamentof India.

The ultimate success of the Conference depends on you and your active participation in discussion.I hope many delegates from all over the world will come to Trivendrum to participate in 14th NationalConference to make it a successful and memorable view.

I look forward to see you all in ISECT CON 2014 TRIVANDRUM.

DR KAMLA RANAPRESIDENT - ISECT

Message from the General Secretary, ISECT

Dear Colleagues,

I am happy to present yet another issue of our Journal, this time under thestewardship of Mr. Albert J. Davis.

Great care has been taken in preparing this issue, and I am sure that it willbe interesting and informative. Perfusionists are constantly innovating andadapting newer techniques. We request you to come forward and share theresults of such modifications as also your research / study.

Let me also take this opportunity to welcome all the delegates to the 14thAnnual Conference of ISECT to be held in Trivandrum on 21st and 22nd February, 2014. Our conferenceshave been organized very well and we have national and international delegates and faculty. Thisconference too promises to be educative and innovative.

Finally a big "Thank U" to all of you members who have participated in the activities of our societyand made it grow from strength to strength.

With best wishes for the New Year,

RAVINATH SWAMIGeneral Secretary, ISECT

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology6

ContentsVolume 23 2014

INDIAN SOCIETY OFEXTRA-CORPOREAL TECHNOLOGY

Role of Ultrafiltration in Paediatric Cardiopulmonary Bypass 7Alok Kumar*, S.C. Yadav**, Yogender S Chauhan** Lokendra Kumar**,A.K. Bisoi***, Sandeep Chauhan@, Balram Airan@@.

A comparative study of Albumin versus 6 % Hydroxyethyl starch used as 13priming solution for Cardiopulmonary Bypass in adults undergoing Coronary Artery Bypass Grafting

Namita Mishra*, Alok Kumar* S.C.Yadav**, Lokendra Kumar**, Minati Choudhury@, Milind Hote***,Sandeep Chauhan@, Balram Airan****

Case Report 20Senthil Kumaran.D**, P.V.S.Prakash***, Sunil Mekala***, Sunil.L.G*, Dr.Binoy***,Dr.Devi Prasad Shetty****

REVIEW ARTICLE:

Perspectives in Vascular Surgery and other Non-cpb Protocols a perfusionist can involve 22Hareendran A

FOR YOUR KIND ATTENTION! 30Editor IJECT

Blood Conservation During CPB - Role Of Perfusionist without ↑Cost 32Saurav Sengupta

Modified Cardioplegia for Neonates and Infants' Cardiac Surgery 35Mr. Sunderrajan, Mr. Senthil.Dr. Neville Solomon, Dr. Swapna

7

Role of Ultrafiltration inPaediatric Cardiopulmonary BypassAuthor:Alok Kumar*, S.C. Yadav**, Yogender S Chauhan** Lokendra Kumar**,A.K. Bisoi***, Sandeep Chauhan@, Balram Airan@@.*Clinical Perfusionist, Department of Cardio-Thoracic and Vascular Surgery**Senior Perfusionist, Department of Cardio-Thoracic and Vascular Surgery***Professor, Department of Cardio-Thoracic and Vascular Surgery@@Professor & Head, Department of Cardio-Thoracic and Vascular Surgery@Professor, Department of Cardio-Thoracic and Vascular AnaesthesiaAll India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi

Corresponding Author:Alok KumarClinical Perfusionist, Department of Cardio-Thoracic and Vascular Surgery.

Abstract

Background: Cardiopulmonary bypass (CPB) is associated with a “whole body inflammatory response”characterized by capillary leak and increased total body water (1). The development of tissue edema maycause dysfunction of vital organ systems leading to significant morbidity and mortality (2,3).

Aim: This prospective, randomized study was designed to investigate the effects of conventionalultrafiltration in paediatric patients undergoing corrective surgery for congenital heart disease using CPB.

Material & Method: One fifty children aged between 2-14 years with Tetralogy of Fallot (TOF) undergoingintra cardiac repair on CPB were divided into two groups. Group-I comprised of 75 children in whomconventional ultrafiltration (CUF) was performed intraoperatively and during rewarming period ofcardiopulmonary bypass. Group-II comprised of 75 children in whom no ultrafiltration was performed.

Intraoperative urine production, fluid overload (net pump balance after CPB), electrolyte disbalance, andpostoperative chest tube drainage, ventilation time, blood and blood component transfusion requirementfrom the end of bypass procedure until 24 hours in intensive care unit were studied in both groups.

Results were analysed by students paired ‘t’ test, Mann- Whitney test and Wilcoxon Signed Ranks.To maintain haematocrit level 30% during CPB, in group-I (n=74) conventional ultrafiltration was

performed and in group-II (n=73) packed red blood cells were added.In group-I: Urine output (159.77ml ± 69.3ml) during CPB was not significantly different from group-II

where urine output was (243.2ml ± 85ml). The mean total haemofiltrate (444.19 ml ± 169.17 ml) volume wereremoved only in group-I during intraoperative period of cardiopulmonary bypass.

Result: There were significant (p

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology8

Introduction

Paediatric cardiopulmonary bypass (CPB) isassociated with an increase risk of complications. The“Capillary leak syndrome” occurs because of increasedcapillary permeability as an inflammatory responses toCPB leading to sequestration of excess fluid in tissueinterstitial space causing increase in total body water.The resultant multiorgan dysfunction remains the singlemost important post CPB complication in paediatriccardiac surgery (4,5). Lower body weight, low bodytemperature, long duration of bypass and haemodilutionare few of the recognized factors implicated for thecapillary leak syndrome.

Pre bypass use of intravenous crystalloid andColloidal solutions CPB cicuit prime, and use ofcardioplegic solution put cardiac surgery patients at riskof fluid overload. Ultrafiltration is a useful method toreduce the risk of fluid overload after CPB.

The concept of removal of this excess body water byultrafiltration during CPB was introduced by Ramegnoliet al (8,9) and popularized by Magilligan (10), in orderto protect the patient from fluid overload and electrolyticimbalance. Ultrafiltration also helps to reduce variousinflammatory and complimentary activators resulting inearly and better postoperative recovery.

Unlike the popular upsurge of ‘no pump’ techniquesin adult cardiac surgery, CPB remains necessary for mostcongenital heart defect repairs and these difficultsurgeries are being accomplished with significantlyreduced mortality and morbidity (2,3).

The systemic inflammatory response evoked by CPBare the ultimate pathophysiological mechanismresponsible for immunological disorder. There can be asmuch as more than 20% increase in body weight, whichis well evident in children because of loose aereolartissue and is described as ‘Michline baby’ effect (6,7). Itis the clinically significant multiorgan dysfunction as aresult of the capillary leak, which is responsible for themost of the CPB related morbidity and mortality (2,3).

There are various methods to treat established fluidoverload during and in the early post bypass period.These include, administering diuretics and steroid forcapillary leak. However use of diuretics is not reliable,

is not consistent, and may be ineffective during CPB.

We decided to study the beneficial aspects ofhaemofilteration during CPB to minimize capillary leaksyndrome in paediatric surgery by reducinghaemodilution and fluid overload.

MATERIAL AND METHODS

After approval from the institute’s ethics committeeand informed parental consent, this prospectiverandomized and controlled clinical study was plannedat All India Institute of Medical Sciences, New Delhi inthe department of Cardiothoracic Vascular Surgery.

Inclusion Criteria

This study included 150 children aged between 2- 14years with Tetralogy of Fallot (TOF) undergoing intracardiac repair on CPB. The patients were randomlydivided into two equal groups.

Group-I comprised of 75 children in whomconventional ultrafiltration (CUF) was performed duringthe rewarming period of CPB.

Group-II comprised of 75 children in whom noultrafiltration was performed.

Exclusion Criteria

Patients with a preoperative renal dysfunction, orwho were preoperatively on inotropic and ventilatorysupport or who had neurological dysfunction andemergency surgery were excluded from the study.

Conduct of Anesthesia and Surgery:

Patients in both group received same premedicationand anesthetic management. Both group hadstandardized and surgical management by the sameteam.

Perfusion techniques performed duringcardiopulmonary bypass

Conduct of CPB was also standardized and similarin the both groups, The pump was primed withCrystalloid (Ringer’s solution) 20 ml/kg, Starch (HES)10 ml/kg, Mannitol 5 ml/kg, Heparin 50 mg/l of prime,NaHCO3 1 ml/kg, and Packed Red Blood Cell wereadded, whenever the estimated HCT came down to lessthan 30% during CPB in the both group. A non pulsatileflow (150-250ml/min/m2) was maintained during CPBusing a twin roller pump (Sarns, 9000, USA) and ahollow membrane oxygenator (Capiox SX 10, Terumocorporation, Japan) with a 40 micron arterial line filter.

Address for correspondence:

Alok Kumar1st Floor, C.N. Centre,All India Institute of Medical Sciences (AIIMS),Ansari Nagar, New Delhi,Email: aiims.alok@gmail.com

9

Myocardial preservation protocol included moderatesystemic hypothermia (Nasopharyngeal temperature,32°C-33°C), intermittent cold (4°C) antegrade St. Thomascrystalloid blood cardioplegia solution dose was 20 ml/kg followed by half of the initial dose every 20 minuteand topical cooling of the myocardium was done withice slush in the pericardial sac.

Arterial blood gas analysis was done every 15 to 30minutes to maintain pO2, pCO2, pH, BE to normal value.Urine output and electrolyte composition was noted inperioperative period.

The only difference in management of CPB betweenthe two group was use of ultrafiltration in group-I.

After completion of surgery, patients were rewarmedto 37°C. During rewarming phase of cardiopulmonarybypass Conventional Ultrafiltration (CUF), (circuitdiagram shown in fig.-1) was performed in group I usinga paediatric haemofilter (Terumo corporation). Themean haemofiltration rate of 10 ml//min wasmaintained. The venous reservoir level was keptadequately by the addition of replacement volume asrequired. CUF was not performed in group II.

At the termination of CPB in both groups, 1.3mg ofprotamine sulfate for every 100 IU of total heparin dosewas administered and confirmed by the return ofactivated clotting time to baseline values.

In both the groups, patients received Epsilon aminocaproic acid (EACA) 100 mg/kg during pre CPB, CPBand post CPB period.

Patients were weaned off from bypass with inotropicsupport of injection Dopamine (5-l0 µg/kg/min) andNitroglycerin (0.5-l µg/kg/min) which were started oninitiation of rewarming.

After surgery patients were transferred to intensivecare unit (ICU). In the ICU, postoperative ventilationtime, urine output, blood and blood productrequirement and chest tube drainage at intervals of 6 hrwas recorded for first 24 hr.

Statistical analysis:

Statistical comparison of results was made usinganalysis of variance for non-parametric data. The resultswere expressed as mean ± standard deviation. Thechanges in variables within a group were evaluated withpaired ‘t’ test, Mann- Whitney test and Wilcoxon SignedRanks. Inter group comparison between variables wasmade by the unpaired ‘t’ test, Mann-Whitney test and

Wilcoxon Signed Ranks test. A probability value of lessthan 0.05 was regarded as statistically significant.

Results

Out of 150 patients one patient in group I and twopatients in group-II were excluded from our studybecause they were found to have developed low cardiacoutput syndrome due to right ventricular failure.

Both groups were similar in term of age, weight andsex. Demographic data is shown in table-l and graph-I.Extra corporeal circuit (ECC) priming and preoperativebase line values. were also similar. No significantdifference was found in CPB time (90±15 min in group-I & 96±18.1 min in group II) and aortic cross clamp time(40±10 min in group-I and 48±12 min in group-II).

Perioperative data presented in table-2 and graph-2shows that there was statistically significant (p

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology10

slightly lower values during the intraoperative periodbut failed to reach statistical significance. Nocomplication related to the practice of CUF wasencountered in any of the patients.

Postoperative data is shown in table-3 and graph-3shows that HCT, (39.03% ± 11.1% in group-I increasedsignificantly (p

11

Discussion

The principle finding of this study was animprovement in postoperative clinical state associatedwith a reduction in postoperative bleeding, postoperativeblood transfusion, ventilation time, anticoagulating timeand lower incidence of marked rise in body temperatureafter ultrafiltration in children undergoing CPB. Severalstudies have already reported improvement in biologicend-points that are believed to reflect beneficial clinicaleffects. These improvements have been achieved bydifferent techniques such as haemofiltration (12,13),administration of anti-inflammatory agents (14) or useof heparin-coated CPB circuits (15).

We found that there was an increase in HCT levelpostoperatively in group-I in which ultrafiltration wasperformed during rewarming phase of CPB as comparedto Hct values in group-II where no ultrafiltration wasperformed. Our results are similar to the work done byFrisen RH, Cambell DN, Clark DR, et al (19) whoconducted an experiment by prophylactic haemofiltrationduring CPB and concluded that haemofiltration increasethe HCT, reduce some inflammatory markers and mayincrease the variability of heparin levels. It may alsoreduce postoperative blood transfusion and possiblyincrease blood pressure and cardiac index immediatelyafter haemofiltration, although no difference in morbidityand mortality has ever been shown.

Our findings were also confirmed by the study ofHuang H et al.(11). They took 30 patients with congenitalheart defects who were divided into two groups. In thestudy group I conventional ultrafiltration, balancedultrafiltration plus modified ultrafiltration was usedthroughout CPB. Pulmonary function, serum albumin,some inflammatory mediators where measured. Theyfound that after ten to fifteen minute MUF the HCT, andserum albumin increased by 40% and 48% and concedethat the combined use of balanced ultrafiltration andmodified ultrafiltaration can effectively concentrate theblood.

The decrease in postoperative blood loss in our studyin ultrafilterate group-I may be due to thehypercoagulable state at the microvascular circulationlevel produced by haemodilution. Ramegboli A, HackerJ, Keats AS et al (9) in his report on effect of haemodilutionon coagulation demonstrated that a hypercoagulable stateat the microvascular circulation level is produced byhaemodilution. They attributed this hypercoagulablestate to a decrease in concentration of the coagulationinhibitors and lowering of threshold for positive feedbackoccurring in the coagulation pathway.

Although our findings were similar Didier J et al (11);who concluded that haemofiltration can reducepostoperative blood loss in the absence of major changesin coagulation factor concentrations (11). They postulatedthat this effect is not due to haemoconcentration alone.Cytokines have been implicated in altered coagulationand fibrinolysis, and a reduction in their production maybe the mechanism involved in reducing blood loss.

Postoperative high body temperature was more oftenpresent during ICU stay even in the absence of infectionin group-II (38°C, 23/73) as compared to group-I (35°C,5/74 because some pyrogenic substance eg.Cytolucine,interleukins may have been filtered outduring haemofiltration on CPB in group-I. Casey LC: (16)In his study showed the role of cytokines in thepathogenesis of CPB-induced multisystem organ failure.They concluded that this phenomenon is attributed tothe effects of various endogenous pyrogens, includingIL-l beta IL-6 & IL-8 (17,18). The lower peaks and meanpostoperative temperature observed in the-ZBUF groupmay reflect a globally reduced inflammatory response.

Our study, shows that the value of electrolytes didnot show significant changes postoperatively and it wassimilar to the baseline value in both groups due to theslow rate of haemofiltration in which electrolytes arefiltered out and this findings is similar to that reportedby Magilligan DJ et al (10), who conducted the study in10 patients with clinical evidence of fluid over-load.Ultrafiltration was employed during CPB, and theyobserved a decrease in extra vascular lung water from1,132 ± 183 m1 to 919 ± 267 ml (p>0.209). It was concludedthat the value of electrolytes and urea nitrogen did notshow significant changes postoperatively.

The principal findings of our study was the reductionin the ventilation time seen in group-I due to increasedhaematocrit along with a reduction in lung water whichcan significantly (p

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology12

as compared to children where ultrafiltration was notperformed, and we conclude that ultrafiltration providesvaluable benefits where used in this situation.

Acknowledgement

I would like to thank Dr.Guresh, SeniorScientist,Department of Biostatistics, AIIMS New Delhifor his valuable cooperation in data analysis.

References

1. Yamaguehi H, Yarnauchi II, IIa/ma S, et al: Evaluation of body tluids alter cardiac surgeryusing bioelectrical impedance analysis.J Curdiovase Surg (Torino) 2000; 41 (4): 559-566.

2. Wan S, LeClerc J-L: Cytokine responses tocardiopulmonary bypass: lessons learned fromcardiac transplantation. Ann Thorac Surg 1997;63:269-276.

3. Lidmunds IJ I: Why cardiopulmonary bypassmakes patients sick: Strategies to control the bloodsynthetic surface interface. Adv Cardiac Surg 1998;6:131-133.

4. Naik S. Elliott M: Ultrafication: In Jonas RA, ElliottMJ eds Cardiopulmonary bypass in neonates.Infants and Young children. Oxford, ButterworthHeinmann 1994; 158-172.

5. Kirklin J. Blackstone F and Kirkline J:Cardiopulmonary bypass Studies on its damagingeffects. Blood Purif 1987; 5: 168-78.

6. Maehara T, Novak I, Eliot M: Peri-operativechanges in total body water in Childrenundergoing open heart surgery. Eur J CardiothoracSurg 1991; 5: 258-65.

7. Eliott MJ: Modified ultrafiltration and open-heartsurgery ill children Paediatr Anaesth 1999; 9: 1-5.

8. William Gavnor: Use of ultrafiltration during andafter cardiopulmonary bypass in children. J ThoracCardiovasc Surg 2001; 122: 209-211.

9. Ramegboli A, Hacker J, Keats AS et al: Externalhaemoconcentration after deliberatehaemodilution. Annual Meeting of the AmericanSociety of Anesthesiologist Extracts of ScientificPapers. Park Ridege 1976; 269.

10. Magilligan DJ, Oyama C: Ultrafiltration duringcardiopulmonary bypass laboratory evaluation

and initioa clinical experience Ann Thorac Surg1984; 37: 33-39.

11. Journois, Didier, et al: High volume, Zero-balanced Haemofiltration to Reduced DelayedInflammatory Response to CardiopulmonaryBypass in Children. The Journal of the Americansociety of Anesthesiologist, 1996; 85(5): 965-976.

12. Andreasson S, Gothberg S, Berggren H, BengtssonA, Eriksson E, Risberg B: Haemofiltration modifiescomplement activation after extracorporealcirculation in infants. The Ann Thorac S urg 1993;56: 1515 - 7.

13. Millar AB, Armstrong L, van der Linden J, MoatN, Ekroth R, Westwick J, Scallan M, Lincoln C:Cyto1cine production and haemofiltration inchildren undergoing cardiopulmonary bypass.Ann Thorac Surg 1993; 56: 1499- 1502.

14. Casey LC: Role of cytokines in pathogenesis ofcardiopulmonary- induced multisystem organfailure. Ann Thorac Surg 1993; 56: 92-96.

15. Stein B, Pfenninger E, Grunert A, Schmitz JE,Deller A, Kocher F: The consequences ofcontinuous haemofiltration on lung mechanicsand extra vascular lung water in a porcineendotoxic shock model. Intensive Care Med 1991;17: 293-8.

16. Markewitz A, Faist E, Lang S, Endres S, Fuchs D,Reichart B: Successful restoration of cell mediatedimmune response after cardiopulmonary bypassby immunomodulation. J Thorac Cardiovasc Surg1993; 105: 15-24.

17. Fosse E, Moen 0, Johnson E, Semb G, BrockmeirV, Mollness TE, Fagerhol MK, Venge P: Reducedcomplement and granulocyte activation withheparin-coated cardiopulmonary bypass. AnnThorac Surg 1994; 58: 472-7.

18. Dinarello CA: Interleukin -1 and tumor necrosisfactor and their naturally occurring antagonistsduring haemodialysis. Kidney Int Suppl 1992; 38:S68-77.

19. Frisen RH, Cambell DN, Clark DR, et al: Modifiedultrafiltration attenuates dilution coagulopathy inpaediatric open heart surgery. Ann Thorac Surg1997; 64: 1787-1789.

13

A comparative study of Albumin versus 6 %Hydroxyethyl starch used as priming solution forCardiopulmonary Bypass in adults undergoingCoronary Artery Bypass Grafting

Author:Namita Mishra*, Alok Kumar* S.C.Yadav**, Lokendra Kumar**, Minati Choudhury@, MilindHote***, Sandeep Chauhan@, Balram Airan****

*Clinical Perfusionist , Department of Cardio-Thoracic and Vascular Surgery**Senior Perfusionist , Department of Cardio-Thoracic and Vascular Surgery@ Additional Professor, Cardiac Anesthesia***Additional Professor, Cardio-Thoracic and Vascular surgery@ Professor Cardiac Anesthesia****Professor and Head

All India Institute of Medical Sciences (AIIMS)Ansari Nagar, New Delhi

Abstract

Background: The issue of optimal priming solution for cardiopulmonary bypass is unclear. Colloids have theadvantages of maintaining the colloid oncotic pressure and reducing tissue edema. However the use of colloidsduring coronary bypass surgery has been limited due to associated increase incidence of anaphylactoidreactions and clinical coagulopathy.Aim: In this study we compared the effects of using 20 % Albumin versus 6 % Hydroxyethyl starch (HES) in theratio of 1:5 and 1:2 respectively for the priming of CPB circuit in adult patients undergoing coronary arterybypass grafting (CABG).Methodology: Sixty patients of either sex in the range of 40-70 years of age undergoing CABG with the use ofCPB were studied. The patients were randomly divided in following two groups (A & B). In group A (n=30), 20% Albumin solution with lactated Ringer’s solution and in group B (n=30), 6 % HES solution with lactatedRinger’s solution was used for priming the CPB circuit. All the surgeries were conducted by using same surgical, anesthetic and perfusion techniques. Variousparameters compared between the two groups were Hb/HCT, PaO2, PaCO2, SO2 (%), urine output, serumCreatinine, blood urea, blood sugar, requirement of blood/ blood products and requirement of any otheradditions like hemostatic agents.Conclusion: Hospital mortality rate was zero in both the groups. However it was found that 6 % hydroxyethylstarch can be used as an alternative along with Ringer’s lactate in the ratio of 1:2 for priming the CPB circuitwithout any adverse effect or any contradiction. 6 % HES is a safe alternative colloid for priming thecardiopulmonary bypass circuit and volume replacement in patients undergoing coronary artery bypass surgeryas compared to 20 % Albumin.

Key Words: Cardiopulmonary Bypass, Priming solution, crystalloids and colloids, Albumin, Hydroxyethyl starch,inflammatory responses.

NAMITA MISHRA : A COMPARATIVE STUDY OF ALBUMIN VERSUS 6 % HYDROXYETHYL STARCH

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology14

Introduction

The main objective of Cardiopulmonary bypass(CPB) is to provide a still and bloodless heart with bloodflow temporarily diverted to an extracorporeal circuitthat functionally replaces the heart and lung(1).Priming of the CPB circuit is an important task for theperfusionist. Generally the main objectives of primingare to deair the CPB circuit, check for any leaks in thecircuit, for providing sufficient haemodilution and tokeep the volume level of the reservoir towards the saferside, while on CPB.

It is a standard practice to use a non blood CPBprime because of benefits of haemodilution and concernsabout blood borne diseases (2). Haemodilution worksto limit the complications related to CPB (neurological,renal, and pulmonary), by significantly reducing bloodviscosity during bypass. A haemoglobin concentrationof 10g/dl was traditionally accepted as adequate forpatients undergoing non cardiac surgery (3). There arethree major factors which should be considered by theperfusionist when selecting a solution to prime thecardiopulmonary bypass circuit (4):

Address for correspondence:

Ms Namita MishraClinical PerfusionistDepartment of Cardio-Thoracic and Vascular Surgery (O.T.)1st Floor, C.N. CentreAll India Institute of Medical Sciences (AIIMS)Ansari Nagar, New DelhiEmail: namitamishra7@gmail.com

a) Osmolarity: isotonic solution preserves theinterstitial-intravascular fluid balance.

b) Electrolyte: The concentration of the importantelectrolytes in the prime fluid should approachnormal plasma levels.

c) Dilution: Priming volume should be sufficient toallow for adequate flow rates.

Generally priming solutions can be classified into twocategories which are as follows:

Crystalloids (5) are electrolyte solutions with smallmolecules that can diffuse freely throughout theextracellular space. In general crystalloids are simplevolume expanding solutions that mimic the normalplasma electrolyte concentration but they lack oncoticactivity. Various crystalloids generally used are dextrose,mannitol, balanced crystalloid fluid, ringer’s lactatesolution etc.

Colloids (6) are large molecular weight solutions.They are important in capillary fluid dynamics becausethey are the only constituents which are effective atexerting an osmotic force across the wall of thecapillaries. This helps in keeping water in the vascularspace and prevents tissue edema. Colloids have theadvantage in maintaining the colloid oncotic pressure(7). Various colloid solutions commonly used arehydroxyl ethyl starch (HES), albumin, dextran, gelatinetc. There is no general consensus with regards ofselecting the priming solution for CPB circuit.

Mw = Weight average molecular weight; Mn = Number average molecular weight; COP = Colloid osmoticpressure; T1/2 = Half life of concentration; PVE = Plasma volume expansion; Gelatin-U = urea linked gelatin;Gelatin-S = succinyl-linked gelatin; HES = hydroxyethyl starch.

Table 1 : Physicochemical characteristics of priming solutions forcardiopulmonary bypass (colloids) (8)

ALBUM DEXT DEXT GELA GELA HES HESIN 5% RAN-40 10% RAN-70 6% TIN-U 3.5% TIN-S 3% 6% 10%

Mw(Daltons) 69,000 40,000 70,000 35,000 35,000 450,000 264,000

Mn(Daltons) 69,000 25,000 39,000 15,000 14,000 71,000 63,000

Osmolality (mmol/kg) 300 308 308 302 310 354

COP(mmHg) 19-20 160 78 - - 25-30 55-60

T1/2(hr) 2-5 25.5 2.5 - 25.5 2.5

Duration of PVE (h) 2-8 2-12 6-48 2-4 - 6-24 2-12

Elimination(h) 17 12-45 - 168 168 24-67 1.9days Days Days

15

Material and Methods

In this randomized prospective study we included 60adult patients of either sex in the range of 40-70 yearsold of age undergoing coronary artery bypass grafting(CABG) with use of cardiopulmonary bypass.

Exclusion criteria: Patients with a preoperativeserum albumin level of 30g/l or less and Patients withthe history of renal or pulmonary disease, knownbleeding disorder and liver dysfunction were excludedfrom the study. We also did not include patients withsevere LV dysfunction, patients who had undergonerepeat CABG or patients who had undergone CABGincidental to heart valve repair or replacement, resectionof a ventricular aneurysm, or some other surgicalprocedure.

Study protocol: The patients were randomly dividedinto two groups (A & B). In group A (n=30), the CPBcircuit was primed with crystalloid (Ringer’s Lactate)and colloid solution (Albumin) in 1:5 ratio. Whereas ingroup B (n=30), the solution used for priming the CPBcircuit consisted of crystalloid prime (Ringer’s lactate)along with a colloid solution (6 % HES) in the ratio 1:2.

Conduct of CPB: A standardized protocol for theselection of CPB circuit components was followedthroughout the study period. The surgical, anesthetictechniques, pump flows, conduct of bypass,hypothermia was similar in both groups except for thechoice of priming solution used in the CPB circuit.

Before CPB was initiated, anticoagulation wasachieved by the administration of 300 IU/kg heparinsodium with the goal of achieving an activated clottingtime of >480 seconds. The myocardial preservation donewith St. Thomas based blood cardioplegia solution wasinfused after cross clamp in an induction dose of 20 ml/kg and was repeated at an interval of 20-30 minutes asrequired.

Arterial blood gas samples were done before, duringCPB at intervals of 15 to 20 minutes and after CPB tomaintain pO2, pCO2, pH, BE to the normal value. Urineoutput and electrolyte composition was noted inperioperative period.

After the corrective surgery the patients wererewarmed to a nasopharyngeal temperature of 37°C. Atthe termination of CPB, anticoagulation was reversedwith protamine sulphate. After surgery patients wereshifted to intensive care unit (ICU).

Study Analysis: The following data was recordedintraoperatively: the type and volume of priming,blood/blood products administered, duration of aorticcross clamp, and duration of CPB. Postoperatively,following data was documented: requirement oftransfusion, diuretic usage, urine and chest tube output.Postoperative adverse events such as renal events likeacute renal failure, hemodynamic events like bleeding,re-exploration and need of extracorporeal membraneoxygenation were recorded. The duration of ventilatorsupport, length of ICU stay was also recorded.

Statistical analysis: Statistical comparison of resultswas made using analysis of variance of non-parametrictest. All the results are expressed as mean ± standarddeviation. Inter group comparison between variableswas made by the unpaired ‘t’ test and Mann- Whitney.A probability value of less than 0.05 was regarded asstatistically significant.

Results

The two groups (A & B) were comparable in termsof demographic specifications such as age, height,weight, BSA, and the risk factors like diabetes,hypertension, number of grafts and left internalmammary artery (LIMA) usage.

Table 2: Showing demographic data

PARAMETERS GROUP A GROUP B P value

AGE (years) 56.20±7.321 55.40±9.356 0.80

HEIGTH(in cm) 163.87±8.48 163.97±9.39 0.98

WEIGHT (in Kg) 64.6±10.39 68.88±13.91 0.36

BSA (m2) 1.83±0.10 1.70±1.66 0.021

DIABETES 0.67±0.49 0.60±0.51 0.71

HYPERTENSION 0.47±0.52 0.60±0.51 0.74

NO. OF GRAFTS 4.22±5.60 4.22±5.60 1.00

LIMA USAGE 1.00±0.00 1.00±0.00 NS

Mean ± standard deviation values are taken foranalysis; P value0.05). But base excess was foundstatistically significant (P=0.010). Need for correcting

NAMITA MISHRA : A COMPARATIVE STUDY OF ALBUMIN VERSUS 6 % HYDROXYETHYL STARCH

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology16

base deficit was also found significant pre bypass ingroup A (Figure 3).

Table 3: Showing Preoperative data

PARAMETERS GROUP A GROUP B P value

BP (mm Hg) 141.73±19.33 134.53±21.21 0.340

PULSE 78.67±9.74 78.00±11.81 0.870

Hb (g/dl) 16.53±8.84 14.15±2.77 0.334

HCT (%) 40.79±12.18 39.87±5.73 0.793

PLATELET COUNT(COUNT * 103/ì l) 195.47±91.280 196.80±51.70 0.961

WBC COUNT(COUNT/ì l) 8773.33±3756.42 9853.73±2512.23 0.364

PCV (%) 39.17±3.82 37.81±3.71 0.333

pH 7.41±0.06 7.44±0.043 0.093

PaO2 (mmHg) 186.39±72.47 188.93±79.11 0.928

PaCO2 (mmHg) 37.63±4.778 36.89±4.27 0.661

HCO3- (mmol/l) 24.13±3.51 25.45±2.04 0.221

BE (mmol/l) -0.92±2.45 1.34±2.06 0.011

K+ (mmol/l) 3.73±0.56 3.85±0.544 0.569

Na+ (mmol/l) 135.71±3.39 136.400±3.58 0.594

BLOODSUGAR (mg/dl) 133.80±43.65 122.60±42.05 0.480

CREATININE (mg. %) 0.84±0.23 0.89±0.23 0.581

UREA (mg. %) 29.53±7.63 27.53±9.50 0.530

URIC ACID (mg. %) 6.27±0.74 6.18±0.94 0.782

PHOSPHATE (mg. %) 3.07±0.748 3.53±0.94 0.150

SGOT (AST) I.U 38.53±10.70 50.00±28.73 0.165

SGPT (ALT) I.U 28.00±9.43 37.53±26.86 0.212

TOTAL PROTEIN(gm %) 7.55±0.60 7.37±0.44 0.341

ALBUMIN (gm %) 4.00±0.36 3.71±0.48 0.051

GLOBULIN (gm %) 3.56±0.48 3.72±0.51 0.385

BILIRUBIN (mg %) 0.84±0.46 0.93±0.67 0.706

OSMOLARITY(mOsm/Kg) 272.07±4.49 270.6±6.10 0.489

COP (mmHg) 16.15±0.78 15.82±0.36 0.152

SAT (%) 98.90±1.60 99.14±1.51 0.676

URINE OUTPUT (ml) 256.67±129.38 248.00±145.07 0.864

BP- blood pressure, Hb- Hemoglobin, HCT-Haematocrit, COP- colloid oncotic pressure.Mean ± standard deviation values are taken foranalysis. P value < 0.05 is statistically significant

The two group were comparable regarding theparameters during CPB such as the bypass time, aorticcross clamp time, total cardioplegia delivery and urineoutput which on analysis showed no statisticallysignificant differences. It was observed that there wasno requirement of ultrafiltration during bypass in boththe groups.

Operative data was collected at 30 minutes, 60minutes and 90 minutes of onset of cardiopulmonarybypass. No statistically significant difference wasobserved while considering the mean perfusionpressure (MPP) (mmHg), pH, PaCO3 (mmHg), PaO2(mmHg), HCO3 (mmol/l), Na

+ (mmol/l), K+ (mmol/l)and sugar (g/dl) at perioperative period of bypass(Table 4).

Table 4: perfusion pressure, acid base status andbiochemical parameters at 30 minutes of onset of CPB

PARAMETERS GROUP A GROUP B P value

MPP (mmHg) 55.07±11.42 63.27±16.79 0.131

Ph 7.41±0.04 7.42±0.05 0.639

PaO2 (mmHg) 290.80±53.42 261.15±61.14 0.168

PaCO2 (mmHg) 36.34±3.47 37.19±5.25 0.650

HCO3 (mmol/l) 23.27±2.11 23.88±2.75 0.495

BE (mmol/l) -0.94±2.29 -0.41±2.80 0.578

K+ (mmol/l) 4.37±0.77 4.53±0.87 0.602

Na+ (mmol/l) 130.90±2.30 132.00±2.75 0.248

Hb (g/dl) 8.38±1.22 7.36±0.99 0.019

HCT (%) 24.45±3.54 20.11±2.79 0.010

SAT (%) 99.73±0.42 99.99±0.02 0.034

BLOODSUGAR (mg/dl) 140.07±40.42 138.20±39.04 0.899

OSMOLARITY(mOsm/Kg) 264.58±5.88 271.533±5.39 0.002

COP (mmHg) 15.51±0.35 15.93±0.32 0.002

* Mean ± standard deviation values are taken for analysis

However osmolarity (mOsm/Kg) was foundstatistically significant at 30 minutes of onset of bypass.The group B showed higher mean osmolarity (mOsm/Kg) values than group A but the mean values werewithin the normal range.

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Also the hemoglobin, haematocrit and saturation (%)were significant statistically at each of the time intervalsduring CPB. However Group B showed lower mean Hb(g/dl) and HCT (%) values than group A but these meanvalues were within the normal range. Whereas GroupB showed higher mean SO2 (%) values than group A but

again these mean values were also within the normalrange.

Postoperative data analysis at the 1st, 6th , 12th and 24th

hour showed no statistically significant differencebetween the two groups with respect to PaO2 (mmHg),PaCO2 (mmHg), hemoglobin (g/dl), haematocrit (%),saturation (%), osmolarity (mOsm/l), COP (mmHg) andurine output (ml) at these time intervals. K+ (mmol/l)also showed statistically significant difference at 1st hourpostoperatively (P value

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology18

Use of furosemide in 24th hour postoperatively forrenal support was more in group B (6 % HES) ascompared to the group A (Albumin) although it wasstatistically non significant (p=0.619).

WBC count was higher in group A (Albumin) ascompared to group B (6 % HES) at 24th postoperativelyhour, but the mean values were within the normal range.It was also statistically nonsignificant (p=0.946).

A similar finding was also observed for the plateletcount among the two groups. Time of ventilationpostoperatively and ICU stay was statistically nonsignificant. There was no mortality in either of the twogroups.

Discussion

A recent systematic review of randomized clinicalstudies on the use of fluid therapy in various types ofsurgical procedures found no evidence to recommendone type of fluid therapy over another. There was notsufficient evidence to provide guidance on the optimalamount of fluid to use in elective surgical procedures (9).Despite the absence of clear recommendations for anyparticular fluid therapy, there is plentiful debate aboutthe relative merits of crystalloid or colloid, and evenabout different types of colloids. As recently remarkedby Boldt in an editorial, “Researchers who showcrystalloid to be superior always find crystalloidsuperior, whereas colloid supporters always favorcolloids” (10). Adequate restoration of intravascularvolume remains the crucial therapeutic maneuver inmanaging the surgical patient. It is generally believedthat three to four times more crystalloid than colloidvolume is needed to achieve an equivalent plasmavolume expansion. However, in the SAFE trial, (11) inwhich fluid administration was blinded, the ratio ofalbumin to saline was 1:1.4 and thus much less thanexpected. While the choice between colloid andcrystalloid solutions continues to generate controversy,the dispute has been enlarged to a colloid/colloid debate(e.g., Dextrans, gelatins, HES solutions).

Colloid fluid solutions are frequently used as plasmavolume expanders in the critically ill. Intravascularvolume overload, dilutional coagulopathy,extravascular, extravasations across leaky capillarymembranes, and anaphylactic reactions may all occurwith administration of any colloid. In addition,individual agents have unique toxic effects. Renaldysfunction has been associated with dextran 40,myocardial depression with albumin, hypotension withpurified plasma protein, and hyperamylasemia with

hetastarch. Because no ideal colloidal solution exists,knowledge of type, severity, and clinical significance ofadverse effects is important in determining theappropriate plasma volume expander and monitoring itseffects. HES130/0.4 is effective for volume therapy andis less expensive than human albumin. Its effects oncoagulation and renal function are manageable; it mayameliorate pulmonary permeability and reduceinflammation and lipopolysaccharide-inducedmyocardial dysfunction (12).

In contrast, colloids may decrease pulmonary fluidextravasation and the formation of pulmonary edemabecause of their capacity to increase Colloidal OncoticPressures (COP).

The so-called colloid-crystalloid controversy includesthe relative propensity of fluid types to evokepulmonary edema, which is not yet settled in theabsence of direct permeability and edema measurementsin most studies (13).

Our study did not show any difference in durationof ventilation in both the groups. As with all forms oftrauma, surgery triggers a systemic inflammatoryresponse with the release of inflammatory mediators intothe systemic circulation. It was found that 6% HESproved to be better regarding the additional volumerequirement during CPB as compared to Albumin. Therewas no significant difference established between thetwo groups regarding the intensive care duration andmortality rate. Nevertheless it was demonstrated that themean value of ICU stay was shorter in group B (6%HES).

The Hemoglobin and Haematocrit values tendedtowards the lower limits in the group B (6% HES) duringCPB. Although the mean values were within the normalrange, this significant difference between the two groupsfavours the use of Albumin along with Ringer’s Lactateon CPB.

The difference in post operative chest tube drainagealthough not statistically significant, was more in groupA (Albumin) as compared to group B (6% HES). Thedifference in the platelet count between the two groupswas not statistically significant but the count was foundlower in group A (Albumin) as compared to group B (6% HES). The platelet count was decreased after thesurgery in both the groups but it was much lower ingroup A (Albumin) as compared to group B (6 % HES).Whereas the WBC count was more in group A(Albumin) as compared to Group B (6 % HES) but it wasnot statistically significant. The WBC count was

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increased after the surgery in the 24th postoperative hour,and it was found higher in group A (Albumin) patientsthan in group B (6 % HES) patients showinginflammatory responses of the body to the naturalcolloid (Albumin) to be more as compared to that ofsynthetic colloid (6 % HES). This may be because of thelarge molecules of Albumin being retained in thereticuloendothelial system of the body. But the meanvalues for WBC count was within the normal range soit may not cause any serious deleterious effects to thepatients.

The effect of colloidal solutions on the renal functionis a point of discussion. In our study, it was found thatmean values for Urea and Creatinine were within thenormal range in both the groups and were comparableas the difference was not statistically significant.However cautions must be taken while using it inpatients with renal insufficiency.

The cost of Albumin has lead to an increase in anoverall expenditure of the surgery in group A, where asthe cost of 6 % HES though high as compared to the costof crystalloid but was much lower than that ofAlbumin.

Conclusion

6% HES can be used as an alternative along withRinger’s Lactate in the ratio of 1:2 for priming theCardiopulmonary bypass circuit without any adverseeffect or any contradictions. 6 % HES is safe to use forplasma substitution next to albumin for CPB circuit.Albumin because of its high cost and possibility of theanaphylactic reaction that it may cause is not usedfrequently for priming the CPB circuit. 6 % HES helpsto maintain osmolarity during CPB and preserve plateletcount after the surgery. Anaphylactoid reactions are notobserved with 6 % HES as compared to albumin. Useof 6 % HES is found cost effective as compared toalbumin. But cautions must be taken while using it inpatients in acute or chronic renal failure.

References

1. Charles C Reed BS, Traudi B Stafford BS. CCPCardiopulmonary bypass conduct of perfusion.2nd Edition, Texas 1985-399-415.

2. Boonstra PW, GU YJ. Priming fluids forcardiopulmonary bypass. In Kay PH and MunchCM, editors. Techniques on extracorporealcirculation, 4th Edition. London: Arnold.2004; 99-107.

3. Carson JL poses RM, Spence RK et al. Severity ofanemia and operative mortality and morbidity.Lancet 1998; 1 (8588): 727-729.

4. Charles C Reed B S, Traudi B Stafford BS CCP.Cardiopulmonary bypass-fluid, balance andselection. 2nd Edition, Texas 1985-258-263.

5. Jackson EV Jr.Weise J Sigal B, et al. effects ofcrystalloid solution on circulating lactateconcentration part I: implication for the properhandling of blood specimens obtained fromcritically ill patients. Crit Care Med 1997; 25:1840-1846.

6. Tigchelaar I, Gallandat Huet RC, Korsten J,Boonstra PW, van Oeveren W. hemostatic effectsof three colloids plasma substitutes for primingsolution in cardiopulmonary bypass. Eur JCardiothorac Surg 1997; 74:1447-1451.

7. Tolofsrud S, Svennevig JL, BreivikHet et al. Fluidbalance and pulmonary functions during and aftercoronary artery surgery: Ringer’s acetatecompared with dextran, poilygeline or albumin.Acta Anaesthesiol Scand 1995; 39:671-7.

8. Y John Gu and Piet W Boonstra. Selection ofsolution for CPB in adult C 2006. EuropeanAssociation of Cardiothorasic surgery.

9. Holte K, Kehlet H. Fluid therapy and surgicaloutcomes in elective surgery: A need forreassessment in fast-track surgery. J Am Coll Surg.2006; 202:971–989.

10. Boldt J. Pro use of colloids in cardiac surgery. JCardiothorac Vasc Anesth. 2007; 21:453–456.

11. Finfer S, Bellomo R, Boyce N, French J, MyburghJ, Norton R.A comparison of albumin and salinefor fluid resuscitation in the intensive care unit. NEngl J Med. 2004; 350:2247–2256.

12. Boutros AR, Ruess R, Olson L, Hoyt JL, Baker WH.Comparison of hemodynamic, pulmonary, andrenal effects of use of three types of fluid aftermajor surgical procedures on the abdominal aorta.Crit Care Med. 1979; 7:9–13.

13. Sibbald WJ, Driedger AA, Wells GA, Myers ML,Lefcoe M. The shortterm effects of increasingplasma colloid osmotic pressure in patients withnon-cardiac pulmonary edema. Surgery. 1983; 93:620–636.

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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology20

Case Report

Introduction

A 58 yr old man was taken for elective pulmonarythrombo endarterectomy.

On technically the procedure was straight forwardand all the thrombus from both sides were removed,while coming off CPB severe bleeding from ET tube wasnoticed, hence a double lumen tube was placed to isolatethe lungs. As the bleeding was torrential, it was decidedto put him on VA ECMO and give full dose protamine,this brought down the ACT level to 176 sec. Then thebleeding stopped within the first12 hrs and the patientwas weaned off from ECMO after 24 hours.

Although the refinement in technique of cardiopulmonary bypass has progressively improved thecurrent surgical trends yet the outcome of diseases andpost operative CPB induced lung problems still remainas a serious complication that could lead to lifethreatening problems

Case Report:

A 58 yr old man was diagnosed with- chronicthrombo embolic pulmonary hypertension (CTEPH) andsevere right ventricular dysfunction. Severe tricuspidregurgitation, H/O DVT, normal LV and normalcoronaries, was admitted for pulmonary thromboendarterectomy surgery. Regular central cannulationwas planned for this patient Aortic-24Fr Edwardscannula, 20Fr and 24 Fr Rt angled metal tip DLP venouscannulae were used. CPB was initiated and cooling wasstarted. When patient’s temperature reached 22’C, aorticcross clamp was applied. 20ml/kg blood cardioplegiawas given by using blood cardioplegia delivery system

Address for correspondence:

Senthil kumaran, Junior consultant, Perfusion DepartmentNarayana Hrudayalaya Institute of medical sciencesE-mail: dsentdil@gmail.com*Perfusionist, **junior consultant Perfusionist , ***consultantsenior Perfusionist, ****senor consultant cardiac surgeon

Novel technique for managing intrapulmonary massive haemorrhage, following Pulmonary ThromboEndarterectomy

Senthil Kumaran.D**, P.V.S.Prakash***, Sunil Mekala***, Sunil.L.G*, Dr.Binoy***,Dr.Devi Prasad Shetty****

Abstract

A 58yr old gentleman with chronic pulmonary embolism underwent PTE. While weaning off CPB, hehad a massive and intractable bleeding which was observed through the endotracheal tube. ET suction wasdone and weaning off CPB was tried, but the saturation was not being maintained and bleeding persisted.Hence CPB was reinstated.

The only option to get the patient out of CPB was to first stop the bleeding and this was not possiblebecause the ACT was maintained above 480 seconds. It needs to be brought down to less than 200 sec. Sothe patient was put on ECMO with same cannulation and protamine was given to neutralise heparin. ACTwas brought down to 150 seconds .The patient was stabilised on ECMO and the ECMO support wascontinued to rest the lungs till the bronchial bleeding totally stopped. .After 24hrs patient was taken to OTand re-explored, bronchoscopy showed a clear field. No bleeding was found in the endotracheal tube.Patient was weaned off, ECMO shifted to ITU.

Key Words: Management of intrapulmonary massive haemorrhage, ECMO.

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at 8’C. Myocardium was protected well, patient wascooled to 19’C, arterial blood gases were maintained inalpha stat (higher PCo2). Cerebral protective drugs weregiven (barbiturates like thiopentone-2-5mg/kg) andintermittent TCA was performed, all the thrombi fromboth sides were removed and rewarming was startedand continued up to normal temperature.

• Blood froth flooding in the ET tube was makingventilation difficult.

• On bronchoscopy-it was identified that the rightlung was bleeding massively, the source ofbleeding could not be found.

• The right lung was first isolated with a doublelumen tube-but it was difficult to come off bypassdue to profuse bleeding and there was a loss ofvolume in the right lung and PA pressures werehigh.

(Haemodynamics were alright)

Perfusionist was getting ready to wean OFF CPBas per anaesthetist protocols with ET tubesuctioning. At that time they encountered massivebleeding via the endotracheal tube. ET suction wasdone. Once again wearning off CPB was tried butpressures and saturation were not holding.Bleeding was persistent, so CPB was restored.There was only one option to get the patient outof CPB, this was to stop the bleeding and bringdown the ACT levels to less than 200 sec. Patientwas put on ECMO with the same cannulae andpartial protamine was given.

Management

• Balance must be maintained belowanticoagulation to avoid circuit thrombi andcoagulation to avoid bleeding.

• 2 units of packed cells and 1 unit of whole bloodwere given to bring up Hct from 19.2% to 32%.

• 8 units of cryoprecipitate were used

1V dose-1-10 units (1 units/5 kg)

Discussion

Various techniques had been followed in order totackle post cardiotomy bypass bleeding, especially thatwhich follows pulmonary endarterectomy poses a biggerchallenge because of persistent hypothermia,uncorrected hemodilution, low platelet count andfibrinogen levels leading to DIC, prolonged CPB,prolonged ACT>220 sec.

Finding out reason for bleeding and treating the samewould be a correct treatment for the patients with theabovementioned symptoms.

Hence ECMO with low level ACT was maintainedand hemodynamics was taken care of. ECMO wassuccessfully weaned off.

• After 22hrs the patient was taken to OT and re-explored.

• Bronchoscopy was done. No bleeders were foundin endotracheal tube. Patient was successfullyweaned off ECMO, he was hemodynamicallystable and shifted to ITU.

What would be the causes of intrapulmonary bleeding:

• Endothelial injury

• SIRS-(leukocyte mediated)

• Pulmonary hypertension

• Catheter induced (Swan Ganz and vents)

Conclusion

• Pulmonary arterial bleeding after pulmonarythrombo endarterectomy is a difficult problem.

• Early recognition inside the OR and promptmanagement of pulmonary artery bleeding isimportant in rectifying the situation.

• ECMO offers an additional strategy to facepulmonary and circulatory failure, reducing therisk of recurrent bleeding and avoidingpulmonary resection.

• This technique can provide favourable support inthe management of such a complication.

SENTHIL KUMARAN : CASE REPORT

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology22

Perspectives in Vascular Surgery and other Non-CPBProtocols a perfusionist can involve

Introduction:

Innovations in Cardiopulmonary Bypass that tookplace during the middle of the 20th century opened newavenues in cardiac surgery. With the advent of HeartLung Machine and Blood oxygenator, intra cardiacrepairs and heart valve replacements became possible.In a conventional setup; cardiothoracic surgery had tobe contented either one operating room or had to shareon weekday basis with other specialties; mostly withNeurosurgery. Cases done under cardiopulmonarybypass (CPB) were a few and there were instances that aperfusionist was assigned as a physician assistant whoassisted the surgeon in minor procedures as well as attendclinic or assist investigations on non-operating days.

Major vascular surgeries like Excision of Aneurysmof the Aortic Arch, cranial surgeries involving Bacillary

Hareendran A, BSc, DPTech.

Abstract:

Advent of Heart Lung Machine and the innovations in CPB variegated the concept of Cardio-thoracic intoCardiac Surgery and Vascular Surgery. Many veteran surgeons continued to practise both the specialtieseither on academic interest or limited number of cardiac cases admitted in a general hospital or even somemedical college hospitals having a few hundreds of cases per annum. Perfusionist also may take care ofIntra-Aortic Balloon Pump in the post-operative period. Ultrafiltration continued after the termination of CPBwas a turning point in clinical involvement.Even though Offcab and interventional procedures of septal closures and even valve replacements took awaythe role of a perfusionist, receding to standby, various vascular surgical procedures demand require ourservice. Perfusionists gained insight in other fields such as Life support systems viz. Intra-aortic BalloonPump, RV and LV Assist Devices, Extracorporeal Membrane Oxygenation, Isolated Organ Perfusion etc.Analysis of Blood Gases and Activated Clotting Time became a part of the perfusion protocol. Someperfusionists assisted the surgeon in various procedures like Doppler study etc. With the development ofHeart Transplant for which donor heart has to be fetched from distant place, a new category as Transplantcoordinator paves more insight for a perfusionist.

Key words: Aortic Arch Aneurysm, Assist Devices, Auto transfusion system, Bacillary Artery Aneurysm,Extra-corporeal Life Support, Hemoconcentrator, Intra-Aortic Balloon Pump, Isolated Organ Perfusion, ModifiedUltrafiltration, Off cab, Retrograde Cerebral Perfusion, Selective Ante-grade Cerebral Perfusion, Ultrasonic DopplerStudy.

Review Article:

Artery Aneurysm etc. opened a broad avenue forperfusion management beyond the horizons of open heartsurgery. Involvement of vasculature makes the task of aperfusionist more conspicuous. Excision and Repair ofaortic arch aneurysm often demands total shut down ofblood flow to vital organs still continues as a greatchallenge to the perfusion team. I recall that, some thirtyyears back, a perfusionist required a six module pumpwhile even Cardioplegia was not a standard practice; andmany surgeons followed intermittent clamping andadministering potassium solution. Perfusionist had to setup the multiple bifurcation circuits for Aortic ArchAneurysm Repairs (AAAR), where, the upper and lowerportions required to be perfused separately [1].

Later on, Total Circulatory Arrest (TCA) under deephypothermia also referred as Deep HypothermicCirculatory Arrest (DHTCA) got adopted, incorporating

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a recirculation line to the then prevailing bubbleoxygenator circuit to avoid platelet aggregation in thestagnated blood. Another challenge was the ischemicsafety period where there had been arguments on safeduration without circulation. Introduction of ContinuedRetrograde Cerebral Perfusion which was first institutedin 1997 for removal of massive air embolism became acharm for AAAR for a few years, but the distribution ofblood flow into both arms made a second thinking onthe adequacy of blood flow to cerebral area and itsquantitation methods like Internal Jugular venousPressure, frequent assessment of desaturation level incarotid artery etc. gave a second thought [2] and SelectiveAnte-grade Cerebral Perfusion incorporated with axillary[3] / innominate artery cannulation [4] which has beenused when pathology precludes standard cannulation ofthe ascending aorta. Moreover, cannulation of the leftcommon carotid artery technique for proximal aorticrepair was followed in the patients in whom a femoralcannulation was not feasible [5] came back into practice.

Thoraco-Abdominal Surgical Procedures generally donot require the service of a perfusionist. Supra-renalabdominal aortic aneurysm (AAA) having a great riskfactor of postoperative renal dysfunction/acute renalfailure is overcome by renoplegia [6] administered by theanaesthesiologist. Whereas, depending the magnitude ofbleeding, either a cell saver or an Auto TransfusionSystem (ATS) is set up to minimize allogenicperioperative transfusion. Use of a conventionalcardiotomy reservoir (BCR) which had been establishedfor post-operative re-infusion of mediastenal blood [7]whereas a BCR, can be used for perioperative collectionand transfusion. Since the outlet is 3/8", it can beconverted to appropriate size using 3/8" x ¼” reducerand a ¼ x Luer male Cardioplegia connector. Blood canbe transferred into citrated bags via 3 way for cell wash.Partially citrated blood may be used for immediatetransfusion. Gravity collection to blood bag can bemanaged by an assistant, whereas, rapid transfusionthrough a pump requires an experienced perfusionist.Hemodynamic effects of cardiotomy blood may resultvasodilation which is proportional to the inflammatoryactivation of suction blood. This can be reduced byprocessing suction blood with a cell-saving device beforere-transfusion [8].

III POST-BYPASS PROCEDURES:Modified Ultrafiltration

Ultrafiltration (UF) differs from dialysis which is apassive that works on the principle of gradient ofcomponents using a dialysate; whereas a Hemofilterfunctions by pressure difference. Even though

ultrafiltration conforms to an optional component in theCPB circuit, where, Zero balance Ultrafiltration (ZBUF)used for replacing prime with blood as well asinflammatory media removal during CPB [9] orConventional Ultrafiltration (CUF) performed duringCPB to remove excess circulating fluid, its modified useafter termination of CPB has been dealt here.

Modified Ultrafiltration (MUF) is an establishedmethod in removing inflammatory mediators, reducingthe need for homologous donor blood and decreasingpulmonary vascular resistance after CPB [10]. MUF circuitexcludes the venous reservoir and the oxygenator hasbeen summarized herein. Arterial blood is withdrawn ata speed of less than 10 ml/kg. Body weight, and passedthrough the Ultra filter. Either a partial resistance withoverpressure cutoff or a controlled vacuum of is applied.Hemoglobin improves as the water is removed. Thisconcentrated blood in infused back to the venous linethrough the cardioplegia system to maintain the patienttemperature [11].

IV LIFE SUPPORT SYSTEMS:

CPB is a Life support that temporarily substitutes the

Figure 1: CPB Circuit Diagram of Modified Ultrafiltration

HAREENDRAN : PERSPECTIVES IN VASCULAR SURGERY AND OTHER NON-CPB....

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology24

functions of heart and Lungs while the patient is undergeneral anesthesia for cardiac surgery. RetrogradeCerebral Perfusion (RCP) and Selective Ante gradeCerebral Perfusion (SACP) comes as a portion of theprocedure under Circulatory Arrest. Other Life Supportsystems include Intra-Aortic Balloon Pump (IABP), Extra-corporeal Membrane Oxygenation (ECMO), CirculatorySupport devices like Left / Right Heart AssistDevices(LVAD), Isolated Organ Perfusion etc. which maybe under local anesthesia.

1. Isolated Organ Perfusion

The lung is the site of many neoplasms includingsarcoma, melanoma, renal cell cancer, and metastaticgastrointestinal disease that, because of location, size, ormultiplicity, are un-resectable. ILuP is conducted aftercannulation of the concerned Pulmonary Artery and twopulmonary veins and done under Normothermia orhyperthermia of 42°C. Staged thoracotomies are done forbilateral disease, staged with an interval of 4-8 weeks [12].Hyperthermic isolated limb perfusion (HILP) in locallyadvanced soft tissue sarcoma and progressive desmoid-

Figure 2: Table showing Life Support System

Figure 3: Isolated Limb Perfusion of Left Leg

type fibromatosis with TNF 1 mg and melphalan (T1-MHILP) is safe and efficient. Some patients were previouslyirradiated or had received systemic chemotherapy beforeHILP [13].

2. Intra-Aortic Balloon Pump

Intra-Aortic Balloon Pump IABP and Left VentricularAssist Devices (LVAD) are viewed as escalating methodsalong with hydraulic considerations which allow non-invasive determination of stroke volume [14]. Intra-aorticballoon pump counter-pulsation (IABP) is currently themost commonly used mechanical assist device forpatients with cardiogenic shock due to acute myocardialinfarction [15]. IABP Console triggers from the ECG orPressure wave and inflate the balloon insertedpercutaneously into the descending aorta. The Ballooninflated by Helium and squeezes 40 ml volume of bloodout of the aorta. Heart Muscles dilated during diastoletakes up more blood. Owing to low solubility in aqueousmedium, it was a chosen to minimize decompressionsyndrome, and became the chosen gas due to the diffusionproperties. It cannot safeguard an event of BalloonRupture, and only precaution is to avoid reuse of theBalloon. Picture shows the screen displays all parametersincluding the amount of Helium in the tank.

3. Extra Corporeal Membrane Oxygenation

Since a positive pressure needs to be maintainedduring the use of an oxygenator, the pump in a Veno-Venous ECMO (VV-ECMO) functions as a supportivedevice, and this type of ECMO provides only respiratorysupport. It has been reported that ECMO via subclavian

Figure.4: IABP Screenshot

25

catheter has been successfully performed for severepostoperative bacterial pneumonia unresponsive toconventional treatment following a failed renaltransplant, and the patient was placed on low flow VV-ECMO as an adjuvant to antibiotic therapy and maximalventilatory support. Venous ECMO resulted in rapidimprovement and the patient was successfully weanedafter 48 hours [16]. Sometimes VV ECMO may exert somedisadvantages such as a longer operative time to placethe cannulas, groin wound problems, and persistent leg

swelling necessitate conversion to VA ECMO. [17].ECMO is said to be superior to Right Heart assist devices[18].

4. Left Ventricular Assist devices

Left ventricular assist devices (LVAD) are analyzedas extravascular in-series or parallel volume-capturing/ ejecting devices and as true blood pumps which can beimplanted. Centrifugal Blood Pump (Heart Ware) can beimplanted as LVAD by hemi-sternatomy combined withanterio-lateral thoracotomy [19]. The abdominal leftventricular assist device (ALVAD) is implanted in theabdomen, and is driven by a pneumatic pump [20]. TheLVAD functions as a bridge for heart transplant untilsuitable donor heart is obtained [21]. Sometimes, a LVADmay impair RV function [22]. Extracorporeal life support(ECLS) is indicated following left ventricular assist device(LVAD) implant for right heart failure or pulmonarydysfunction [23].

Figure 5: Veno-Venous ECMO

Figure: 6: LVAD

5. Right Ventricular Assist Devices:

Disastrous complication of LVAD leading to Rightheart impairment necessitates a secondary right heartassist device (RVAD) [24]. right ventricular failure stilloccurs in about 44 % of patients after continuous-flowleft ventricular assist device insertion.[25].

Figure 7: Right Heart Assist Device Implanted

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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology26

V CLINICAL / LABORATORY INVESTIGATIONS:

1. Ultrasound Doppler

Ultrasound Doppler is non-invasive equipment thatcan be used for Blood flow Studies and Blood Pressuremeasurement when Echo lab or pressure transducerswere uncommon. Ether stand required Patient's arm incaudad position (opposite to head end) making thebrachial region inaccessible for stethoscope or palpationof pulse. has a pair of peizo-electric crystal among whichone vibrates at a frequenzy of 10 MHz. (20 kHz isinaudible to human ears, and termed as Ultrasonic.)whereas the second one detects blood flow velocity byDoppler shift ( Change in in frequency caused by themoving medium).

Adult and Pediatric models of flat probes used foroperating room use, whereas a pencil probe used forDoppler studies. The study includes the Assessment ofBlood flow Velocity in Axillary, Brachial and radio-ulnarregions of the upper extremities, and femoral, popliteal,dorsalis pedis and Posterior Tibial Arteries; as well asupper and lower limb pressure assessments. Owing to

Figure 8: Ultrasound Doppler made by Parks MedicalElectronics Inc, USA

various reasons such as resonance and higher readingscaused by standard pressure cuff, a 12 cms wide cuff asrecommended by the manufacturer may be used [26].Since vascular diseases involve blockage of blood vessels,a drop in temperature is detected in case of arterialdiseases, whereas an increase in ankle temperature ofreturning blood, stated as an important nursingassessment parameter to evaluate worsening orimpending CVI complications [27].

2. Activated Clotting (Coagulation) Time

Activated Clotting Time (ACT) was first establishedby Hattersly in 1966 based on the principle of contactactivation using glass beads to detect hemorrhagicdiatheses [28]. Many Cardiothoracic procedures requirethe patients to be anticoagulated to prevent clotting andthrombotic complications. Blood Clotting is time isartificially prolonged using Heparin. ECMO) therapy alsorequire anticoagulation. There are several bedside wholeblood microcoagulation systems available to determineactivated clotting time (ACT) levels. Hemocron ACT

Figure 9: Chart: Doppler study Chart

27

machines have Celite Glass Mixture [29]. Kaolin used inmany other models are proven to be superior in accuracyand reproduciblilty [30]. Even though ACT have been astandard protocol in Cardiovascular surgery for overthree decades, Thromboelastography became a turningpoint in coagulation management [31].

VI Conclusion:

Developments in pediatric heart surgery diversifiedthe specialty of Cardiovascular and Thoracic surgery intothree groups namely, Acquired Heart Surgery,Congenital Heart Surgery and Vascular & ThoracicSurgeries. Further developments took place in CoronaryArtery Bypass Graft (CABG) Surgery. Coronary Artery,being the Blood Vessel catering the walls of the heart iscategorized as a major cardiac procedure. Aortic ArchAneurysm Repair, considered as a Thoracic procedure,the involvement of Coronary Root Replacement are donewith the support or guidance of coronary surgeons.Thoraco-abdominal procedures, even though do notrequire cardiopulmonary bypass; chances of massivebleeding requiring auto-transfusion is managed by theperfusion team. The perfusionist gets involved with Auto-transfusion for vascular procedures; where the shedblood is transfused after getting the cells washed andconcentrated in the Blood Bank. Blood collected in aReservoir is either transfused through pump ortransferred into blood bags and sent to blood bank withentries for dispatch and follow up. Continuous Cell andPlasma Separators brought the whole work into theoperation room.

Development of tissue stabilizers made CABG feasiblewithout CPB that derived a term OPCAB reduced thefunctional role of a perfusionist into standby. Impact ofinterventional procedures further reduced the need forcardiopulmonary bypass took the major portion of workout of the hands of the perfusionist. A Modernperfusionist has to take of advanced equipment andnewer concepts. Apart from CPB, a perfusionist may getinvolved with various means of life support system. Someare circulatory support systems. Intra-Aortic BalloonPump, which is sometimes required for CABG patientswho cannot be weaned off, is often managed by theperfusion team. The system functions on the principleinflation of a balloon which is inserted into the descendingaorta. The inflation is synchronized with diastolic so thatmore blood flows through the coronaries.

Extra Corporeal Life Support (ECLIS) became a newmeans of therapy for failing lungs, especially in patientssuffering from avian flu. Extra Corporeal MembraneOxygenation and Left Heart support Devices which is a

bridge for Heart Transplantation became a new tool forthe modern perfusionist. With development of HeartTransplant for which donor heart has to be fetched fromdistant place, a new category as Transplant coordinatorcame to exist. Perspectives of organ preservation withemphasis to the beneficial effects of normothermicperfusion over hypothermic storage is an awesome topicfor a perfusionist [32]

References:

1. HAREENDRAN A, Vascular Surgery, APerfusionist’s Perspective; 12th Annual conferenceof Vascular Society of India, Souvenir cumAbstract journal, 2005 ; 51-53.

2. TETSUYA HIGAMI, MD, SYUICHI KOZAWA,MD, TATSURO ASADA, MD, et al; Retrogradecerebral perfusion versus selective cerebralperfusion as evaluated by cerebral oxygensaturation during aortic arch reconstruction; AnnThorac Surg 1999;67:1091-1096.

3. DAVIDE CALVARUSO, PIERRE VOISINE,SIAMAK MOHAMMADI, ERIC DUMONT ANDFRANÇOIS DAGENAIS; Axillary arterycannulation; Multimedia Manual Cardio-ThoracicSurgery; Volume.2012 : 10.1093

4. KYRIAKOS ANASTASIADIS, POLYCHRONISANTONITSIS* AND CHRISTOSPAPAKONSTANTINOU, Innominate arterycannulation,, Multimedia Manual Cardio-Thoracic Surgery;Volume 2008, Issue 1006,10.1510.

5. PAUL P. URBANSKI, MD, Cannulation of the leftcommon carotid artery for proximal aortic repair;J Thorac Cardiovasc Surg 2003;126:887-888.

6. NGUYEN QUOC KINH, NGUYEN HUU UOC;Reno-Protective “In-Situ Renoplegia” In A PatientWith A Single Kidney Undergoing Surgical GraftFor The Dissection Of Total Abdominal AorticAneurysm; ASEAN J. Anaesthesiology, Volume8, May 2007; 37-40

7. HARTZ RS, SMITH JA, GREEN D.;Autotransfusion after cardiac operation.Assessment of hemostatic factors. J ThoracCardiovasc Surg. 1988 Jul;96(1):178-82.

8. WESTERBERG M, GÄBEL J, BENGTSSON A,SELLGREN J, EIDEM O, JEPPSSON A.;Hemodynamic effects of cardiotomy suction

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blood; J Thorac Cardiovasc Surg. 2006Jun;131(6):1352-7.

9. TALLMAN RD, DUMOND M, BROWN D.Inflammatory mediator removal by zero-balanceultrafiltration during cardiopulmonary bypass.Perfusion. 2002 Mar;17(2):111-5.

10. MOHANLALL, RAKESH, Venoarterial modifiedultrafiltration versus conventional arteriovenousmodified ultrafiltration during cardiopulmonarybypass surgery; Doctorate Thesis, ClinicalTechnology, Durban University of Technology,2009.

11. FAWZY G. ESTAFANOUS, PAUL G. BARASH,J. G. REVES ,Modified Ultrafiltration; CardiacAnesthesia: Pinciples and clinical practice (2ndEdition) p365.

12. J. M. H. HENDRIKS, S. ROMIJN, B. VAN PUTTE,B. STOCKMAN, P. TEN BROECKE, P. VANSCHIL; Isolated Lung Perfusion for the Treatmentof Pulmonary Metastatic Disease: a Review; Actachir belg, 2005, 105, 338-343.

13. BONVALOT S, RIMAREIX F, CAUSERET S, LEPÉCHOUX C, BOULET B, TERRIER P, LE CESNEA, MURET J., Hyperthermic isolated limbperfusion in locally advanced soft tissue sarcomaand progressive desmoid-type fibromatosis withTNF 1 mg and melphalan (T1-M HILP) is safe andefficient. Ann Surg Oncol. 2009;16(12):3350.

14. NORMAN JC, IGO SR, Mechanical circulatoryassistance: established (IABP) and evolving(LVAD). A narrative summary. ThoracCardiovasc Surg. 1985 Jun;33(3):133-45..

15. UNVERZAGT S, MACHEMER MT, SOLMS A,THIELE H, BURKHOFF D, SEYFARTH M, DEWAHA A, OHMAN EM, BUERKE M,HAERTING J, WERDAN K, PRONDZINSKY R. ,Intra-aortic balloon pump counterpulsation(IABP) for myocardial infarction complicated bycardiogenic shock; Cochrane Database Syst Rev.2011 Jul 6;(7).

16. CALDERÓN M, REYES P, TOVAR A, NUÑEZ E,LAGUNAS J, SOBERANES A, LOZANO V,JAQUEZ A, MARTÍNEZ E. Low flow veno-venous ECMO via subclavian dialysis catheter forsevere respiratory failure. Heart Surg Forum.1999;2(1):38-40.

17. M D KLEIN, A F ANDREWS, J R WESLEY, JTOOMASIAN, C NIXON, D ROLOFF, AND R HBARTLETT, Veno-venous perfusion in ECMO fornewborn respiratory insufficiency. A clinicalcomparison with venoarterial perfusion. AnnSurg. 1985 April; 201(4): 520–526.

18. TAGHAVI S, ZUCKERMANN A, ANKERSMITJ, WIESELTHALER G, RAJEK A, LAUFER G,WOLNER E, GRIMM M.; Extracorporealmembrane oxygenation is superior to rightventricular assist device for acute right ventricularfailure after heart transplantation; Ann ThoracSurg. 2004 Nov;78(5):1644-9.

19. JAN D. SCHMITTO, MD, ULRICH MOLITORIS,MD, AXEL HAVERICH, MD, MARTINSTRUEBER, MD; Implantation of a centrifugalpump as a left ventricular assist device through anovel, minimized approach: Upperhemisternotomy combined with anterolateralthoracotomy; J Thorac Cardiovasc Surg2012;143:511-513.

20. JOHN C. NORMAN, M.D. An Abdominal LeftVentricular Assist Device (ALVAD) Perspectivesand prospects; Tex Heart Inst J. 2004; 31(3): 289–302.

21. MARK S. SLAUGHTER, MD, FRANCIS D.PAGANI, MD, JOSEPH G. ROGERS, MD, et al;Clinical management of continuous-flow leftventricular assist devices in advanced heartfailure; The Journal of Heart and LungTransplantation, Vol 29, No 4S, April 2010; pp S1-S37.

22. ROMEO LAINEZ, MD, GENE PARRINO, MD,AND MICHAEL BATES, MD; Right VentricularFunction and Left Ventricular Assist DevicePlacement: Clinical Considerations andOutcomes; Ochsner J. 2010 Winter; 10(4): 241–244.

23. WUDEL JH, HLOZEK CC, SMEDIRA NG,MCCARTHY PM. Extracorporeal life support asa post left ventricular assist device implantsupplement. ASAIO J. 1997 Sep-Oct;43(5):M441-3.

24. STRAUCH JT, FRANKE UF, MADERSHAHIANN, WAHLERS T. Right ventricular assist deviceimplantation—a new transcutaneous approach.Thorac Cardiovasc Surg. 2004 Dec; 52(6):378-9.

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25. Fukamachi K, Shiose A, Massiello AL, HorvathDJ, Golding LA, Lee S, Starling RC. Implantablecontinuous-flow right ventricular assist device:lessons learned in the development of a clevelandclinic device. Ann Thorac Surg. 2012May;93(5):1746-52. Epub 2012 Mar 27.

26. W. B. CAMPBELL, Doppler waveform analysisin the management of lower limb arterial disease.Ann R Coll Surg Engl. 1986 March; 68(2): 103–106.

27. KELECHI TJ, HAIGHT BK, HERMAN J, MICHELY, BROTHERS T, EDLUND B.; Skin temperatureand chronic venous insufficiency. J WoundOstomy Continence Nurs. 2003 Jan;30(1):17-24.

28. PAUL G. HATTERSLEY, MD; ActivatedCoagulation Time of Whole Blood ; JAMA. 1966;196(5):436-440.

29. COLBY CE, SHEEHAN A, BENITZ W, VANMEURS K, HALAMEK LP, MOSS RL. ;Maintaining adequate anticoagulation onextracorporeal membrane oxygenation therapy:

Hemochron Junior Low Range versusHemochron 400. J Extra Corpor Technol. 2003Mar;35(1):35-8.

30. M L ZUCKER, C JOBES, M SIEGEL, D JOBES, FM LA DUCA ; Activated clotting time (ACT)testing: analysis of reproducibility. J Extra CorporTechnol. 1999 Sep; 31 (3):130-4.

31. Britta U. O’Carroll-Kuehn, MD FRCA and HanifMeeran, MBBS FRCA ; Management ofcoagulation during cardiopulmonary bypass; BJA:CEACCP, 2007 Volume 7, Issue 6, pp. 195-198.

32. Maathuis MH, Leuvenink HG, Ploeg RJ.;Perspectives in organ preservation.Transplantation. 2007 May 27;83(10):1289-98.

Contact Address:

Hareendran A, Sharanya, TC12/1756, Poonthi Road,Medical College PO, Thiruvananthapuram 695011.Phone: 04712553922; Mob: 09446178885; Email:hareendrana@gmail.com

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Vol. 23, 2014Indian Journal of Extra-Corporeal Technology30

FOR YOUR KIND ATTENTION!

This is for your kind notice that there is an article that had been published in VOLUME 22of the Indian journal of extra corporeal technology (IJECT) of 2012 which is calling forremedy now. The article entitled "Modified circuit for 1:4 blood cardioplegia delivery"whose authorship or co-authorship is perhaps controversial and demands rectification oreven deletion. An email is addressed to me by DR.SHIV CHOWDHARY whose name wasin the list of co-authors in the aforesaid article. I received this mail on 13th February 2014.Hedisclaims his co-authorship from the article as his consent according to him, was not soughtbefore its publication. The past editor and co-author of the article MR.RAJEEV GUPTAalso sent me an email with regret asking for DR.SK CHOUDHARY'S name to be removedfrom its coauthor's list on the 14th February. However, I sent a reply to DR.SKCHOUDHARY promising him that I would do the needful very soon. Although thisincident which is claimed by them happened during the previous tenure and now a neweditor and editorial committee has assumed office and we are neither directly nor indirectlyimplicated in that issue, yet we cannot connive at it. After a serious discussion with someexperienced members in the editorial committee, a decision is taken to remove or excludeDR.SK CHOUDHARY's name from the co-authors list from the above article (the article isrepublished in the next page with the rectifications) for everyone's notice.

Thus it makes inevitable that in future the signatures of the author and co-authors areindispensable for an article before its publication. This discipline would be stringentlyreviewed henceforth. Moreover it would help to avoid further undesirable precipitationof matters in these kinds of issues.

Thank you

RegardsEditor IJECT

(N.B.: This is the first issue of the journal during my tenure, please refer to the letter from theeditor's desk)

31FOR YOUR KIND ATTENTION!

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology32

Blood Conservation During CPB - Role OfPerfusionist without ↑Cost

Modifications are:-

1. ↓Prime volume by Circuits design & OxygenatorPlacement;

2. ↓Prime volume by retrograde/anterogradeautologous priming;

3. Ultrafiltration with Cost Effective Method.

4. Microplegia.

And also use the devises i.e.Vacum assist device,Ultrafiltration. But In the view business accept, introducethe modern device is directly effect to ↑cost of Surgery-Package that’s why Patient is also suffer for same. Ouraim, without ↑Surgery cost blood should be conserve forpatient benefit.

Saurav Sengupta,Sr Clinical Perfusionist Desun Hospital & Hesrt Institution Kolkata, Westbengal

Abstract:

Objectives:In cardiopulmonary bypass Extreme haemodilution due to crystalloid priming? transfusion ofstored Blood in small adult cardiac surgical patients. And homologousblood transfusion during cardiacsurgery?morbidity and mortality.Therefore we examined whether some modification ofour self to reducinghemodilution andred cell transfusion

METHODS: 96 patientsof 2011-2012 with a bodysurface area of ~ 1.3m2 -1.5m2 undergoing first-time,cardiac surgerywere randomized to either the Standardgroup or the Modified group.

1. Reduction in prime volume using a reduced bypasscircuit

Reduction in prime volume is a major factor in bloodconservation.

Phase – I Before Reduce the Circuit

We assume a blood volume of adult patient is 70 mL/kg & in general Priming volume is around 1650(Circuit+ Oxygenator+ Heat-exchanger+ filter+ with 200 mlminimum Reservoir level)

The two membrane oxygenators Sorin EVO & Affinity NT are in major use in our institute.

33

Phase – II After Reduce the Circuit

We assume a blood volume of adult patient is 70mL/kg & in general Priming volume is around ↓ 300,total PV is 1350(Circuit + Oxygenator+ Heat-exchanger+filter+ with 200 ml minimum Reservoir level), But heredrastically ↓ the circuit volume due to the PlegiaTechnique.

2. Plegia Technique.

Microplegia:The original composition of bloodcardioplegia described by Buckberg was a 4:1 ratio (BCDChamber) blood -crystalloid; this has become thestandard for cold blood cardioplegia. And also some usethe Kolies Chamber but both the methods are ↑ volumerelated. Alternatively we proposed to use a type ofsolution which can ↓volume requirement & also the↓ prime which is Microplegia.

Microplegia is one type of blood plegia and itsClassical technique for continuous or discontinuous withperfusion temperature is identical for ↓ Priming.

TECHNIQUE:

The cardioplegia circuit is very simple. The cardioplegicline is composed of pvc tubing with an internal diameterof 1/4inch. Make with a Y connector (fig 1).

The total prime volume of the cardioplegia circuit isbetween 25 ml for neonates and 35 ml for older Adult.Oxygenated warm blood is withdrawn directly from theoxygenator or from the origin of the arterial line by anocclusive roller pump. The cardioplegic solution isdelivered by an electrical syringe pump that is connectedto the cardioplegic circuit via a Y type connectordownstream of the occlusive roller pump (fig 2).

Figure 2 - Cardioplegic circuit. Roller on the left isthe arterial pump, performing the total bypass flow.Roller on the right is the cardioplegia pump, diverting

the blood component of the warm blood microplegia.The syringe pump injects the CP solution.

The crystalloid component each ml Contain / Flowratio:

Figure 1 - Cardioplegic circuit made by ¼ inch PVC with Yconnectors.

SAURAV SENGUPTA: BLOOD CONSERVATION DURING CPB - ROLE OF PERFUSIONIST WITHOUT COST

Vol. 23, 2014Indian Journal of Extra-Corporeal Technology34

3. Autologous priming

Retrograde or antrigrade autologous priming consistsof total or partial replacement of the crystalloid primeby using the patient’s blood being drained from thearterial and venous lines (mean volume withdrawal:650 ±100 ml). During this drainage, the bloodless primeis collect to Empty RI/RL bottle.

Thus, the total crystalloid Priming Volume becameis average 700 ±100 ml.

Perfusion and anesthetic techniques wereotherwiseidentical for the two groups.

Why try to Reduce Surgery Cost ?

World Economic Status shows that India is a poorCountry & Rheumatic Heart Disease is most commoncause for Valve Surgery.

RESULTS:

Patient characteristics and operative parameters wereequal for patients in both groups. With autologouspriming, a mean crystalloid Priming Volume is 700 ±100ml. This allowed a significantly higher haematocrit valueduring cardiopulmonary bypass. Red blood celltransfusion was necessary in approx. 78 % of patientsof the standard priming group on pump; whereas only16.5% of patients of the modified group requiredtransfusion .The overall transfusion rate of the modifiedgroup was significantly less than that in the standardpriming group during the hospitalization.

CONCLUSION

There are many ways to ↓ the number of stored bloodtransfusions.

The major techniques are as follows:

(1) ↓bypass circuit which decreases dilution anddilutional coagulopathy;

(2) Microplegia;

(3) Retrograde or antrigrade autologous priming.

These three techniques are simple, inexpensive, safeand efficient in all patients regardless of age or weight.The other techniques (cell-salvage, ultrafiltration,Vacuum assist device) could be used in combinationwith the major t