Gaseous Microemboli During Blood Sampling, Drug Administration and Venting

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Slide 1 : Heart Health Innovators Gaseous Microemboli During Blood Sampling, Drug Administration and Venting Gerard J Myers CCP, Cheri Voorhees BAH, CPT, Rob Haynes BA, Bob Eke BA QEII and IWK Health Sciences Centers Halifax, Nova Scotia Canada
Slide 2 : Heart Health Innovators Disclosure Studies conducted in this paper were done at the Sorin Group Research Facilities in Denver, Colorado No financial ties with any of the manufactures mentioned in this data No manufacturer has contributed to the costs of presenting at this venue
Slide 3 : Heart Health Innovators Gaseous Micro Emboli (GME) Microemboli is < 1000 µm (1 mm) Most Bubble detectors do not detect emboli <300 µm Arterial filters 20, 37, 40 and 42 µm Coated in protein Large wall thickness ; hard to break/absorb Much less buoyant than larger bubbles Sensed only by ultrasonic type instruments Effects of GME are similar to effects of solid emboli Barak, M – Microbubbles : Pathophysiology and Clinical Implications -Chest,Oct. 2005 Capillaries range between 5 and 10 µm in diameter Berne,RM and Levy MN – Cardiovascular Physiology 4th Ed - 1981
Slide 4 : Heart Health Innovators Integral Cardiotomy Filters Routine practice to bleed arterial filters into the oxygenators integral cardiotomy filter during CPB During bypass routine to add fluids through integral cardiotomy filters Integral cardiotomy filters used to collect vent return and/or cardiotomy suction blood
Slide 5 : Heart Health Innovators Perfusionist Interventions During CPB Withdrawing blood samples and purging syringes from the oxygenators sampling manifold Injection of bolus medications into the oxygenators sampling manifold
Slide 6 : Heart Health Innovators Introduction Taylor, R.L et al: Cerebral Microemboli During Cardiopulmonary Bypass: increased emboli during perfusionist intervention Ann Thorac Surg 1999;68-89-93 Borger et al: Neuropsychological Impairment After Coronary Bypass Surgery: Effect of Gaseous Microemboli During Perfusionists Interventions J Thorac Cardiovasc Surg 2001; 121:743-9 Rodriguez et al: Effect of perfusionist technique on cerebral embolization during cardiopulmonary bypass Perfusion 2005; 20:3-10
Slide 7 : Heart Health Innovators Study Design Three hard shell coated membrane oxygenators - Sorin PrimeO2x (x3) - Terumo Capiox SX25 (x3) - Sorin Synthesis (x3) 2 lpm CO2 flush for 15 min Perfusionist blinded to results Bovine blood/Saline – Hct 27% Pump flow – 4.0 lpm Gas Flow 4.3 lpm (7% CO2) Hatteland CMD20 Microbubble Detector (Bubmon Software V1.0) Positive displacement pump Transonic HT110 Bypass Flowmeter 40 µm Arterial Filter ACT > 600 sec Temperature 30oC Arterial pressure-175-180 mmHg Oxygenator level 500 ml Blood gases (Alpha Stat) pH–7.33, PO2–151, PCO2– 49 Excel Data Pack Software
Slide 8 : Heart Health Innovators Manifold
Slide 9 : Heart Health Innovators
Slide 10 : Heart Health Innovators
Slide 11 : Heart Health Innovators
Slide 12 : Heart Health Innovators
Slide 13 : Heart Health Innovators Collection Methods Hatteland probe was placed 24” post arterial filter Challenge (per oxygenator) 10 ml of air injected: Conventional shunt (venous line) method x 5 Emboli shunt (external cardiotomy) method x 5 Data was collected continuously for 3 minutes after each challenge 10-15 minutes of ‘settle time’ between each challenge 10-15 minutes of ‘settle time’ between each of the three oxygenators
Slide 14 : Heart Health Innovators (10-20 Micron Bubbles) Student T-test assuming equal and unequal variances (p value < 0.05) (20-30 Micron Bubbles) Current versus Shunting
Slide 15 : Heart Health Innovators Conclusion Using the Oxygenators Cardiotomy Filter to shunt blood sampling and drug injections will dramatically reduce or eliminate GME transmission during perfusionists interventions with both the Synthesis and PrimeOX2 oxygenators How much GME is transmitted through an Integral Cardiotomy reservoir during routine venting?
Slide 16 : Heart Health Innovators Literature Search Stump DA, Rogers AT, Hammon JW et al: Cerebral emboli and cognitative outcome after cardiac surgery J Cardiothorac Vasc Anesth 1995; 10:113-19 Pearson, DT, Watson, BG and Waterhouse, PS: An ultrasonic analysis of the comparative efficiency of various cardiotomy reservoirs and micropore blood filters Thorax 1978; June 33(3):352-58 Solis, RT and Horak, J: Evaluation of a new cardiotomy blood filter Ann Thorac Surg 1979 Nov 28(5):487-8
Slide 17 : Heart Health Innovators Groups Five hard shell coated membrane oxygenators were matched with their associated coated filters - Medtronic Affinity NT and Medtronic 351T Filter / Trillium coated - Sorin Synthesis and Integrated Filter / Phosphorylcholine coated - Terumo Capiox RX25 and CXAF200X Filter / X coated - Gish Vision and GAF40GBS-2 Filter / GBS coated - Jostra Quadrox and Quart HBF140 Filter / Bioline coated
Slide 18 : Heart Health Innovators Design/Equipment 2 lpm CO2 flush for 15 min Bovine blood/Saline Hct - 29% Platelets stripped (mean-354- 44) ACT > 600 sec Positive displacement pump Pump flow – 4.0 lpm Transonic HT110 Bypass Flowmeter Gas Flow 4.3 lpm (7% CO2) Hatteland CMD20 Microbubble Detector (Bubmon Software V1.0) Temperature 32oC Arterial pressure-176-181 mmHg Oxygenator level 500 ml Blood gases (Alpha Stat) pH–7.33, PO2–151, PCO2– 49 Excel Data Pack Software
Slide 19 : Heart Health Innovators
Slide 20 : Heart Health Innovators
Slide 21 : Heart Health Innovators Methods Probe placement: Oxygenator Reservoir outlet (4”) Post arterial filter (12”) Measurements (During BFR of 4.0 LPM): 1. Filter Purge line open (Control) – 3 samples/trial for 3 trials (n=9) 2. Control + vent on at 500 mls/min – 3 samples/trial for 3 trials (n=9) 3. Control + vent on at 500 mls/min + 200 mls/min of air – 3 samples/trial for 3 trials (n=9) 3 oxygenators tested in each of 5 groups All data collected for 3 minutes 10-15 minute settle down time between tests and oxygenator change
Slide 22 : Heart Health Innovators
Slide 23 : Heart Health Innovators 510 10 17 153 444 43 2 0 2 46 Total
Slide 24 : Heart Health Innovators 670 464 668 315 685 131 4 7 3 343 Total
Slide 25 : Heart Health Innovators 681 512 677 662 686 107 5 12 9 305 Total
Slide 26 : Heart Health Innovators Conclusions Results of this study indicate that routine use of the vent during CPB dramatically increases GME activity in all of the five integral cardiotomies in this study This study should encourage manufacturers to review and make appropriate changes to their integral components that may affect GME generation in all bypass equipment Considering the results of this study, perfusionists should make every effort to minimize ALL sources of rapid fluid entry into an oxygenators integral cardiotomy
Slide 27 : Heart Health Innovators
Slide 28 : Heart Health Innovators Average GME per minute Reservoir OutletPost Arterial Filter

 



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