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The AustrAliAn And new ZeAlAnd College of Perfusionists gAZette APril 2013 www.anzcp.org Gazette Issue 04 13 TABLE OF CONTENTS Page 2 Page 2 Page 4 Page 6 Page 7 A Message from the editor Martin gill. A Message from the President Jane ottens. registration Committee report Alison Horton. simulation report. the ABCP report Clarke thuys. Page 28 Q&A the editorial team. Case Presentation Page 31 Antiphospholipid syndrome and cardiopulmonary bypass department of Cardiac surgery Bs Varghese et al. rescue Cardiopulmonary Bypass after failed laser extraction of iCd defibrillator lead Ci Mcdonald et al. transesophageal echocardiography and near-infrared spectroscopy Provide Methods of Microemboli detection during Cardiopulmonary Bypass david P. webb. Page 24 A Museum tour of london Martin gill. Perfusion News Page 9 Page 10 Page 10 Page 10 Page 11 Page 12 Page 13 Page 14 Opinion Page 17 Page 19 teg webinar review Martin gill. development of the Heart-lung Apparatus A review of a presentation by John H gibb on Jr. Martin gill. talking up the value of gPs. implementing the Pronto Procedure ray swart. Around the (distant) Pump room Martin gill. Annual scientific Meeting Blog. A fond farewell. 29th Annual scientific Meeting Award winners. world Congress - A review Alison Horton. Blood Conservation Pocket guidelines. international Consortium for evidence based Perfusion (iCeBP) newsletter 12. the Pumpers Quiz. Page 34 Page 32 Original Article Page 37 should Air Bubble detectors Be used to Quantify Microbubble Activity during CPB r newland et al. Conference Corner Clarke thuys. Page 43 Page 44-59 Abstracts from the AnZCP 29th Annual scientific Meeting uluru. Page 61 Page 64 the top ten the editorial team. Calendar of events. Page 22 Page 23 Lifesaver Lifesaver Lifesaver f fe 3030 Years of Hollow FiberOxygenator Innovation Years of Hollow Fiber Oxygenator Innovation Leading to Improved Patient Outcomes Leading to Improved Patient Outcomes Terumo Terumo Manufactures Its Own Own Manufactures Its Hollow Fiber Fiber Hollow 1982 1982 CAPIOX II II CAPIOX Oxygenator Oxygenator 1988 1988 CAPIOX E E CAPIOX Oxygenator Oxygenator 1993 1993 CAPIOX SX CAPIOX SX Oxygenator Oxygenator 2000 2000 CAPIOX RX CAPIOX RX Oxygenator Oxygenator 2008 2008 CAPIOX CAPIOX FX FX Oxygenator with Oxygenator with Integrated Arterial Filter Integrated Arterial Filter As As the pioneer of hollow ber oxygenator technology Terumo has led the way in in oxygenator the pioneer of hollow ber oxygenator technology Terumo has led the way oxygenator innovation and quality for more than 30 innovation and quality for more than 30 years. Today we oo er aa full range of oxygenators giving Today we er full range of oxygenators giving you the freedom to choose the right size CAPIOX oxygenator for every patient any size. you the freedom to choose the right size CAPIOX oxygenator for every patient of of any size. Terumo manufactures its own hollow ber ensuring consistency and quality the Terumo manufactures its own hollow ber ensuring consistency and quality in in the manufacturing process. To learn more about this unique process visit manufacturing process. To learn more about this unique process visit www.terumo-cvs.com hollow ber30 www.terumo-cvs.com hollow ber30 Terumo and CAPIOX are registered trademarks of Terumo Corporation. 2012 Terumo Cardiovascular Systems Corporation Terumo and CAPIOX are registered trademarks of Terumo Corporation. 2012 Terumo Cardiovascular Systems Corporation Terumo Australia Pty Limited Terumo Australia Pty Limited Level 4 Building B 11 Talavera Road Level 4 Building B 11 Talavera Road Macquarie Park NSW 2113 Macquarie Park NSW 2113 T 61 2 9878 5122 T 61 2 9878 5122 F 61 2 9878 5085 F 61 2 9878 5085 T 1800 837 866 T 1800 837 866 F 1800 334 190 F 1800 334 190 E cs_australia terumo.co.jp E cs_australia terumo.co.jp CVS130313D453V1 CVS130313D453V1 PO Box 137-059 Parnell PO Box 137-059 Parnell Auckland 1151 New Zealand Auckland 1151 New Zealand T 0800 66 77 57 T 0800 66 77 57 F 0800 66 99 88 F 0800 66 99 88 The AustrAliAn And new ZeAlAnd College of Perfusionists gAZette www.anzcp.org EdiTOr Martin C. Gill CCP Perfusion department Heart Centre for Children the Children s Hospital at westmead locked Bag 4001 westmead nsw 2145 tel. 02 98453425 email. gazette anzcp.org AdvErTiSiNG to advertise in the Australian and new Zealand College of Perfusionists gazette contact the gazette editor. tel. 02 98453425 email. gazette anzcp.org. EdiTOriAL COrrESPONdENCE editorial correspondence should be addressed to the gazette editor gazette anzcp.org (postal address as above). The ANZCP Gazette is the official publication of the Australian and new Zealand College of Perfusionists. Copyright 2007 by the AnZCP inc. All rights are reserved. no part of this publication may be reproduced or transmitted in any form or by any means. Permission for reprinting should be obtained from the gazette editor. ASSOCiATEd EdiTOrS Patrick O Neil CCP st Vincent s Public Hospital Melbourne email. Patrick.oneill svhm.org.au Chris Morley CCP geelong Hospital Victoria email. chrismo barwonhealth.org.au Killian O Shaughnessy CCP the Children s Hospital at westmead sydney email. killian.oshaughnessy health.nsw.gov Hayden dando CCP the Children s Hospital at westmead sydney email. hayden ausbm.net diSCLAiMEr All views expressed are that of an individual or institution and are not necessarily the expressed views of the editors the AnZCP executive Committee or Members of the AnZCP. EdiTOriAL POLiCiES Manuscripts are accepted for consideration on the condition that the editorial Committee has the final decision on publication. the editorial Committee reserves the right to reject or edit any material submitted for publication without reason. Preparing material for publication Preferred delivery method is by e-mail using document attachment in Microsoft word to the editorial correspondence address. Authors who do not have access to e-mail please mail material. Correspondence should be on A4 paper type written with double-spaced lines. Please do not fold mail use an A4 sized envelope. Please supply direct contact numbers and address for the corresponding author. Material should contain (1) title (2) subject (3) Author(s) (4) Co-author(s) and (5) institution(s). British Australian english is the preferred language. SuBSCriPTiONS subscription is only available through membership of the AnZCP. Please visit www.anzcp.org for the latest membership rates terms and conditions. note that all monies quoted are in Australian dollars and are inclusive of gst. new Zealand Members fees for Australian Members less gst. one year free subscription is available to student perfusionists enrolled in the ABCP course. for further information on membership subscription please contact the AnZCP secretary c - Po Box 921 Parkville Victoria 3025 Australia. AddrESS FOr SuBSCriPTiON Change of address including both the old and new addresses of the member subscription should be forwarded to the AnZCP secretary at least one month in advance. This edition of the Gazette has been proudly supported by Cellplex. APril 2013 www.anzcp.org 1 A MessAge froM tHe editor by Martin gill CCP. on behalf of our editorial team i welcome you all to the latest issue of the gazette. As always we aim to bring you the latest details from the College sub-committees perfusion news from around AnZ opinion pieces case reports and original articles. i am slowly becoming confident that we have developed a format for this publication that is meeting the primary aim we set out to fulfill- mainly to construct a publication that is an effective vehicle for communication between perfusionists in our region. Please do not forget that the gazette is available as an egazette on the College website for direct viewing or download. in addition to this we also continue to put up online content for viewing within the gazette section also on the College website. whilst running the risk of sounding like the orphan oliver twist asking Mr. Bumble for more porridge... i still want more i want to hear all about what you get up to in your individual institutions. i want to hear about the fruits of your projects your opinion on new pieces of kit what you thought about a recent article... pretty much anything. As always new material is eligible for two no strings cash prizes (just ask richard and Charles). this edition of the gazette also bids farewell to Brad schultz from the editorial team. Brad has been a tremendous servant to this publication from his time as editor overseeing its transition to me taking over the reigns and then agreeing to stay on as an associated editor. i am sure you will all join me in thanking Brad for his outstanding contributions. i sincerely hope you enjoy this edition of the gazette i believe that the team have put together an edition that really does have something for everyone- i can not urge you all strongly enough to get online to view the gibbon video that is reviewed in this edition- it truly is a treat enjoy Martin gill the gazette editor. A MessAge froM tHe President by Jane ottens CCP. this year the college will hold its 30th Annual scientific Meeting (AsM) in Melbourne from the 7th -9th november. in the past thirty years the meeting has circumnavigated Australia and new Zealand with the help of many planning and scientific committees whom all have contributed to the continuing growth and development of our meeting. the first AsM held in sydney back in 1984 was a joining of perfusionists from around Australia and new Zealand with the common goal to form a society for perfusionists and to share information. while the society is now a College the sharing of information continues with the annual meeting. from those original one day meetings that largely consisted of corporate input on new devices we have grown to hold a 2.5 day event full of our own work expertise and include invited speakers from all over the world. this year will also include the first student session where current students of the ABCP diploma will present papers as a part of the revised course. from my perspective on how we have grown over the past 30 years in holding these meetings we as a profession have been incredibly lucky with the passionate individuals that have guided our college over the years to where we are today. from the early days of don Pastoriza-Pinol Paul Bernhard sid Yarrow richard Mullaly nick James and tim wilcox leading the way (i am sure many of us still remember the sunday morning AgM s of which the lively debates went on for hours to form the infrastructure of the society) through to our more contemporary leaders being darryl McMillan Alison Horton Arthur Preovolos Clarke thuys Killian o shaughnessy Hayden dando richard newland and rob Baker who over the past 15 years have all contributed to produce the exceptional standard that our Annual scientific Meetings are today along with their input into our education system professionalism and standing within the worldwide perfusion community. 2 APril 2013 www.anzcp.org while the AsM was a venue to bring together perfusionists within our area it has been the basis of many formed alliances with our colleagues from overseas often invited speakers. from these alliances fi rstly via Al stammers and then more recently Bob groom the American society of extraCorporeal technology s Journal of extraCorporeal technology has been publishing abstracts from our meetings for many years as well as supporting the AnZCP by providing advertising. while continuing education by attending scientific meetings is an important component of our recertification access to journals is also part of that process. the recertification guideline for Category C individual educational and self study activities allocates 5 Ceu points for a subscription to a professionally relevant journal . Many years ago the College tried to produce a journal but due to our small population this was not viable. the Perfusion newsletter was formed which then morphed into the gazette an important tool of communication for our College and something that we should all be extremely proud and continue to support. it gives me great pleasure to announce in this edition of the gazette a formal partnership between AnZCP and Amsect (American society of extraCorporeal technology). The Journal of ExtraCorporeal Technology (JECT) will now be the Official Journal of the ANZCP. This will entitle all ANZCP members electronic access to the Journal which will also include all 44 archived volumes. Furthermore this will also provide all ANZCP members with 5 CEU recertification points. the formalizing of this relationship is something that has been discussed over many years (past and present executive) as JeCt has always been supportive of our college. to quote Bob groom editor of JeCt on the Power of Partnerships which will appear in the next volume of JeCt. The Power of Partnerships The challenging economic climate has had an extraordinary effect on hospitals and health care providers. The silver lining of this economic storm cloud has been the great gains realized by mergers alliances and partnerships. over the past decade we have seen increasing number of physician group practices join hospitals and numerous hospitals become aligned as large health systems that share resources thereby reducing waste and improving efficiency. on another level there are quality collaboratives like the northern new england Cardiovascular Disease study Group that seek to improve by sharing information about outcomes and best practices. Recently a voluntary collaborative of collaboratives has formed called the national Cardiac surgery Quality Improvement network (IMPRoVe) . The IMPRoVe network members are The Clinical outcomes Assessment Program Maritime Cardiovascular Quality Initiative Michigan society of Thoracic and Cardiovascular surgeons northern new england Cardiovascular Disease study Group and Providence Health & services Cardiovascular Disease study Group. IMPRoVe s mission is to improve the value of cardiovascular surgical care by developing sharing best practice knowledge coordinating undertaking evaluating and disseminating quality improvement projects across our member organizations. When knowledge and other resources are shared everybody wins especially the patients. I am pleased to announce a partnership between the Australian and new Zealand College of Perfusion (AnZCP) and the American society of extraCorporeal Technology. The Journal of extraCorporeal Technology is now the official Journal of the AnZCP. This means AnZCP members will have electronic access to the Journal including all of archived volumes going back to 1974. This partnership will result in a broader readership for the Journal and perhaps an increase in submissions to the Journal. It is good for the AnZCP in that it helps them to fulfil their mission of supporting their members by offering this tangible benefit of a journal to the membership. The American society of extraCorporeal Technology warmly welcomes our colleagues from Downunder. We look forward to a long successful partnership as we strive to foster improved patient care and safety by expanding and disseminating the published knowledge related to extraCorporeal Technology. no one of us is smarter than all of us. -Japanese Proverb http www.improvenetwork.org (accessed March 12 2013). we are excited about this collaboration with Amsect and the provision of continuing education via the journal to our membership. President APril 2013 www.anzcp.org 3 ReGIsTRATIon CoMMittee rePort by Alsion Horton CCP. in september 2012 Michael whitburn and i were formally appointed to the MBs Medical expert standing Panel (MesP). we were asked to review a protocol document prepared by HealthConsult Pty. ltd. outlining the methodology for providing evidence based analysis to support the review of services for the perfusion services (MBs items 22060 22065 22070 and 22075). the document was based on the original submissions that all Perfusionists and the public had made to the MBs in 2011. this was released for review by the public again in february 2013 and i hope everyone took the time to reply again as your letters will provide the MBs with additional information for the Medical specialist Advisory Committee the next stage of the review process. the MBs has asked the College to provide representation of the AnZCP on the Medicare specialist Advisory Committee. Michael whitburn and stephen Horton have agreed to represent us on this committee. thank you to everyone at the AgM who voted for the College to support the business plan of national Association of selfregulating Health Professionals to set up a licensing company for un-registered Allied Health Professionals. despite the initial enthusiasm by all of the nine groups two of the larger ones wanted more time to discuss the concept with their members and Boards. the dieticians felt that they had spent a lot of time and money on branding and that this concept was not going to endorse their profession further. the social workers are being considered by CoAg for possible future registration even though they think this is a delaying tactic to saying no and couldn t commit at this early stage. due to everyone feeling a little under pressure with the proposed timeline of the business plan we plan on going a little slower waiting for the review and report on AHPr A to be published and to gauge the governments response to the review registration Boards. nAsrHP have submitted a business plan to the department of Health and Ageing seeking government funding for the project entitled towards an evidence-based model of health practitioner self-regulation - ensuring consumer safety and quality service delivery by Allied Health Professionals not covered by the national registration and Accreditation scheme. the word going around the bureaucratic circles is that the government has little appetite to increase the number of registered Professionals. the white paper regarding unregistered health practitioners that came out a few years ago has not been put to CoAg yet and we are wondering if it will form part of the general review of AHPrA. the state governments are legislating to increase the powers of the Health Commissioner s and want to use negative licensing to remove practitioners with dubious practices. we regard this as reactive rather than proactive. this does not solve the issue of government funding and healthcare committees that only support registered professions. the unregistered health workers who perform essential roles have the same issues as registered professions they need funding to promote safety and education. they are also facing workforce shortages in the future. i will continue to attend as many meetings as i can and help this Alliance push our agenda of a uniform health service with all health care professionals appropriately educated registered and practicing safely. AnZCP struCture The Executive Jane ottens - President Jonathon Cropper - Vice President Matt sheminant - secretary wendy saad - treasurer Jon Van de Berg - nZ representative The Board Clarke thuys - Chairman Mark Mennen - secretary Chris Morley - Course Coordinator Andrew lahanas - Member Sub-Committees Matt sheminant - Head of College registration Alison Horton - registration Committee Jane ottens - simulation Committee tim wilcox - Pirs editor 4 APril 2013 www.anzcp.org ER ... B M TO E M IT RE BM SU Perfusion Incident Reporting System What is PIRS PIRS further information see www.anzcp.org. PIRS is a voluntary system for reporting perfusion related incidents and accidents open to the international perfusion community. Confidentiality is assured by de-identification and anonymity. PIRS data will not be passed to any third party or regulatory body. For TO SUBMIT TO PIRS VISIT www.anzcp.org ...and hit the PIRS tab. APril 2013 www.anzcp.org 5 The siMulAtion rePort the AnZCP owned simulator has been used twice since the last edition of the gazette and here are the reports. ray Miraziz Westmead Hospital NSW. November 2012 westmead Hospital acquired the orPHeus in november 2012. during the three month trial the simulator was used to modify a few of our protocols and to re-enforce the main protocols that we encounter in our every day cardiopulmonary bypass situation as well as the ones that may complicate the conduct of perfusion. the troubleshooting techniques and drills were customised and refined in an easier safer and more efficient manner to provide the best outcome for the patient. it was also useful at a training level and as a refresher for the skilled professionals. Although it is well documented that training in simulation is the key element in any skilled job people learn best by experience. it is impossible to replace real experience from simulated training. However simulators can be a cost effective way to increase professional skills and provide additional confidence during real life-threatening situations where automatic reactions are crucial. while both of us are experienced Perfusionists with over 48 years clinical experience between us the newer technology while not difficult to use is different after using the same heart lung machine for the past 13 years. Hence the expression can you teach old dogs new tricks in fact this has already proven to be true as over the past 13 years many new techniques and devices have been added to our practice with much success of which we didn t require simulation to aid us. what the simulator has enabled us to do was ensure the new HlM (sorin s5) new monitoring (spectrum Medical M4) and all other devices work as they should especially as we were decommissioning an old HlM at the same time. the setting up of the HlM and positioning all of its bells and whistles onto the poles was similar to what we already had but by utilising the simulator in the theatre with every device attached working and providing a simulated output allowed us to fine tune device positions (this was important when the two perfusionists using the pump vary in height by about 2m). this setup enabled us to simulate high pressures low blood levels air in the venous line and power failures and to practice how to come to terms with the different alarm systems and learn how to shut them up quickly without compromising patient safety and annoying everyone in the operating theatre. we were also able to pick up a number of minor faults in equipment that needed to be altered fixed replaced prior to clinical use. Based on this to use a HlM without using it with the simulator first may have caused a major monitoring device to fail and ensuing patient harm. As with all equipment while manufactured to the highest specifications and quality control occasionally faults get past inspection and or damaged in long distance transport. with the new heart lung machine we also purchased a spectrum Medical M4 continuous blood gas monitoring Jane Ottens and Andrew Sanderson Ashford Hospital Adelaide February 2013 (Teaching old dogs new tricks) Cardiopulmonary bypass allows lifesaving surgical procedures but it also has the potential to injure a patient due to equipment malfunction or operator error. simulation allows us to present scenarios and emergency situations in a real time but non-clinical environment. it provides a unique and valuable tool to enable us to practise the responses and skills our profession requires and reduce error due to human factors. simulation is growing in momentum in perfusion and being used for teaching training and crisis management worldwide. while all of these are beneficial in education or maintaining clinical competency the use of simulation to ensure new equipment introduced into a unit is safe has not been widely published. with the increasing age of perfusionists within the country well maybe just our unit (both turn 50 this year) and the introduction of new equipment (at least these are replaced) it was decided that prior to any clinical use of the new system the AnZCP orpheus simulator would be used to ensure the competency of the perfusion staff using this device prior to any clinical use. 6 APril 2013 www.anzcp.org device. using this device allowed us to fine tune the accuracy of the individual pumps without having to resort to a bucket of water and a stopwatch. Below you can see that the difference in the flow of the pump and the recorded flow was .01 of a litre (and within allowed specification of the pumps). simulator use for a new HlM not only aids the perfusionist to become clinically competent with all components of its use but provides the ability to be able to test the set up and use of every device including data management (with the generated MAP and CVP s) by using mock bypass runs and provides confidence that the machine and perfusionist is ready for clinical use. on the left the arterial pump Flow of 1.95LPM. on the right the spectrum medical display showing thearterial flow (in blue) as 1.96LPM tHe AustrAlAsiAn BoArd of CArdioVAsCulAr Perfusion BoArd rePort by Clarke thuys CCP. the Board commenced its autotransfusion course this month. the numbers for the first course are small but there will be greater numbers enrolled for the second course. this was due to the short time between promoting the course and the commencement date. there does appear to be a good deal of interest in it. Please contact Chris Morley chrismo BarwonHealth.org.au or Andrew lahanas andrewlahanas optusnet.com.au for details. Certification exams will be held on feb 28 and March 1. the date for the August exams is not yet set but will be either 21 & 22 or 28 & 29 August. there will be at least three candidates sitting these exams all of whom are foreign qualified. i am concerned that there appear to be more foreign qualified perfusionists applying for certification exams than in the past while the number of trainees enrolled in the diploma of Perfusion is at a low point. i suspect that this is because of the units are looking for immediate solutions to staffing issues. there has been a delay in sending out recertification documentation. the documents should be sent by the end of february with a due date of 31 5 2013 rather than the usual end of March. this does however mean that there is a very short time between the due date and the end of the current certification period so please do not delay getting your completed forms and payment back to Mark Mennen (M.Mennen alfred.org.au). we have changed the size of the recertification certificate back to A4 to make postage easier. the 1st term of 2013 has started with 1 new trainee enrolled from the national Heart Centre singapore where one of our dip Perf graduates has taken the role of supervisor. we wish esther James (supervisor) and Chiu Kit Yi success with the course. this year we have made the changes in the course to allow it to be completed in 2 years as a result the trainees who completed the first 4 modules last year will do 3 modules for each of the first 2 terms and 2 modules in the last term hopefully sitting exams next february. the course will now run 2 modules per term with 3 terms per year. APril 2013 www.anzcp.org 7 ABCP AUTOTRANSFUSION ABCP AUTOTRANSFUSION COURSE COURSE to autotransfusion. The course is not restricted to the pe Course details profession. It is available to all staff currently employe Students enrolling in the coursepublic weekly lessons in the form of Powerpoint setting. will receive or private Healthcare presentations and other educational material through electronic correspondence. The self-study modules cover subjects such as blood physiology coagulation blood conservation techniques transfusion issues blood collection separation techniques autotransfusion equipment and autologous component therapy. The Autotransfusion Course is a ten week course run three times per year as listed below. The Australasian Board of Cardiovascular Perfusion is proud to announce the commencement of the Autotransfusion course. The Australasian February 2013. The purpose of the The first course is to start in Board of Cardiovascular Perfusion is p course is to provide students with theoretical knowledge relating announce the commencement of the Autotransfusion c to autotransfusion. The course is not restricted to the perfusion The first available is to start in February 2013. The purpos profession. It is course to all staff currently employed in the public or private students with course is to provide Healthcare setting. theoretical knowledge Course details Students enrolling in the course will receive weekly lessons in the form of presentations and other educational material through electronic correspond 2013 Term Dates self-study modules cover subjects such as blood physiology coagulation b conservation techniques transfusion issues blood collection separation tec Course Start Dates Course End dates th autotransfusion 18 2013 and autologous component therapy. Monday February equipment Friday April 26th 2013 Monday May 27th 2013 Monday September 2nd 2013 The Autotransfusion Course below. is Friday August 2nd 2013 Friday November 8th run a ten week course 2013 three times per year a At the completion of the course students are expected to undertake a written examination. Successful applicants will be awarded a Certificate of Completion. 2013 Term How to enrol Dates 8 Course Start Dates Course End date Monday February 18 2013 Friday April 26th 20 For additional information please contact the course co-ordinator Chris Monday May 27th 2013 Friday August 2nd 2 Morley at chrismo BarwonHealth.org.au Monday September 2nd 2013 Friday November 8th APril 2013 www.anzcp.org The course is available at no cost to Australian and New Zealand College of Perfusionist (ANZCP) members. Non-member fees are 250.00 (incl. GST). Application forms can be downloaded from www.anzcp.org th Perfusion news Around tHe (distAnt) PuMP rooM by Martin gill CCP. for this edition of Around the Pump room we are going to break with tradition slightly by taking this feature on the road . this edition of Around the Pump room is coming from great ormond street Hospital for Children (gosH) london uK. in January this year i was fortunate enough to spend a week with the gosH perfusion team. the team is made up of 4.5 full time equivalent perfusionists plus one trainee perfusionist. they cover 2 cardiac theatres 5 days per week and have a limited involvement in the reasonably active eCMo program. Besides routine cardiac surgery gosH have a heart and lung transplant program with associated VAd program. the perfusion office as seems to be the norm in most hospitals (apart from my own) is within the theatre complex. the start of the day is no different from any other for the perfusionist with one notable exception at approximately 0830 each morning the perfusionist surgeons anaesthetist theatre nurses cardiologist and intensivist have what is referred to as a group hug . this is actually a brief meeting discussing the day s cardiac list. following everyone introducing themselves each party is given opportunity to give input into the pre intra and post-operative plan for the patients in the cardiac theatre that day. once complete it is back to business. i felt that this group hug was a great idea especially getting the intensive care team actively invested in the care of the patient from the pre-operative phase. the cardiac theatres in gosH are all newly built. there are two dedicated cardiac operating rooms plus a hybrid theatre. the operating rooms are fairly large with three video displays. Also available is a video link and two way audio to a conference room for teaching purposes and for when a large amount of visitors are in town. the pre-operative time-out is also slightly more involved than i am used to. Before the time out can commence a perfusionist anaesthetist surgeon and scrub nurse must be present. Besides checking the patient details are correct once again each profession is given time to have input. the surgeon describes in detail his operative plan the anaesthetist describes his plan for the immediate postoperative course. the perfusionist details his cannula choice and changes to normal perfusion practice for the particular case and also if he plans to carry out Muf. once again i was quite taken with this attention to detail. this process ensured that each part of the team was fully aware of the plan and projected course of the patient. with regard to perfusion hardware and disposables only a few differences took me by surprise. the team at gosH did not utilise an arterial line filter within the bypass circuit and nor did they use a pre bypass filter. the lack of either of these devices was primarily due to a lack of belief in the benefit of either when weighed against the potential addition to circuit prime and cost. each heart lung machine had mounted on it a gAMPt microemboli counter for use if the perfusionist so desired. these devices were used on every case by one of the perfusionists who then printed out a report and placed it in the perfusion record which went in the patients notes. the other perfusionists only used this device occasionally. one advantage of the gAMPt in comparison to the edAC (which i admittedly only have had a brief flirtation with) is that the probes are clip on whereas the edAC cuvettes need cutting into the circuit. this obviously eradicates disposable costs and permits addition of the device whenever whimsy dictates. one novel adjunct to standard perfusion hardware which the guys at gosH were particularly enthusiastic about was a bar code scanner which plugged into the usB port on their data management system. this device which was purchased off the shelf in an office supply outlet once plugged in would recognise all the bar codes on perfusion products blood products and patient labelsthus eradicating the need to tediously manually enter all the lot numbers. the team at gosH are just about fully staffed for their current workload following a lengthy period of being understaffed. for this reason they have not been overly active in the research field of late. this is something they are hoping to rectify over the coming year. gosH if you are not aware is slap bang in the middle of the city. due to its location it is particularly challenging (financially speaking) for those that work at the hospital to live close by. the majority of the perfusion team live around one hour away from the hospital. As is often the case much emergency work takes place after hours. for this reason they are about to embark upon a trial of the on-call perfusionist (who starts a little later in the day) actually staying in the hospital overnight. in recompense for this that person would then get an additional day off. what i am not sure of is if they are renumerated for the night whilst in hospital. whilst at the hospital they had three patients on eCMo in the CiCu. one patient had swine flu one rsV bronchiolitis and one post-operative cardiac patient. At gosH the perfusionists are present for eCMo initiation cessation and trouble shooting. Besides this they have little involvement in the day to day running of the eCMo or indeed the nursing education. this is a situation which came about due to low perfusion staffing levels and one which is regretted to some extent. i can certainly empathise with this situation. i personally believe that although cardiac theatre may be our bread and butter keeping an active role in perfusion related duties such as eCMo cell salvage point of care haematological monitoring research etc is vital to the longevity of our profession. Having transferred patients on eCMo around our hospital one ongoing issue is the fitting into the elevator with all associated equipment and manpower. due to gosH having a newly built cardiac complex they also paid careful attention to the choosing of an elevator to transport their patients from the theatre up to the CiCu and beyond (although i do not believe it extended all the way to heaven). they elevator they choose not only had a power outlet it was also the largest elevator available in europe. it was really quite something- i truthfully maintain that a Mini Cooper (one of the new ones) could either drive straight in or be parked sideways in the elevator. over all i really enjoyed my week at gosH. they have a good team and do some very good work. it is also always refreshing to go and visit other units to see that there really are many ways to skin a cat and i am certain we can all take some useful and some not so useful attributes from other centres. But what is important is that we are open to new ideas and continually challenge what we believe to be true. APril 2013 www.anzcp.org 9 Perfusion news AnnuAl sCientifiC Meeting Blog blog bl g Noun - A Web site on which an individual or group of users record opinions information etc. on a regular basis. verb - Add new material to or regularly update a blog. it would appear that over the last few years blogging has become an increasingly popular way of disseminating information to groups of people who may have shared interests or just a healthy curiosity about certain subject matters. Having read a few blogs myself i find this method of communication both informative and at times entertaining- like reading the news without the stuffiness. one proviso i would however offer is that blogs can be far more opinionated than more conventional methods of information sharing. for the last two years an effort has been made to chronicle our Annual scientific Meetings in the form of a blog. this blog until now has been solely available to visitors or subscribers to the Circuit surfers website (www.circuitsurfers.com). whilst i know many perfusionists in Australia and new Zealand visit circuitsurfers.com i felt that open access to this material should be made available to College members via the College website. if you are interested in taking a look at the last two years AsM Blogs visit www.anzcp.org and hit the gazette tab along the top tool bar. A fond fArewell lesley Hines has totally retired from her carrier as a perfusionist she ended her roster from westmead Private in mid January (previously retired from westmead Public in 2007). lesley is one of a kind and she is not easily replaced. she has worked so hard and given so much to westmead Hospitals. Her dedication and commitment to the work force has inspired many in her field. in fact her friendship and guidance will be missed most. recently lesley has been spotted on the beach with her grandchildren and boating around the harbour enjoying life. we would like to congratulate lesley on her decision and wish her good luck in the new chapter of her life. 29tH AnnuAl sCientifiC Meeting AwArd winners The Terumo Award Best Scientific Paper Charles Mcdonald The Prince Charles Hospital Brisbane. ANZCP Educational Award (Best Student) Joshua Byrne The Alfred Hospital Melbourne. The Medtronic Scientific Encouragement Award sara tayeh Perfusion services Melbourne. The Gazette Award Outstanding Contribution The ANZCP Meritorius Award richard newland et al Flinders Medical Centre Adelaide. Charles Mcdonald et al The Prince Charles Hospital Brisbane. The Perfusion unit of the Year the Heart Centre for Children The Children s Hospital at Westmead sydney. richard newland Flinders Medical Centre Adelaide. Bruno Mario The Austin Hospital Heidelberg. ANZCP Best Trade display Cellplex Pty. ltd. 10 APril 2013 www.anzcp.org Perfusion news world Congress PAediAtriC CArdiologY And CArdiAC surgerY CAPe town 2013 A reView by Alison Horton CCP. the trip started well after a sunny swim in Port Phillip Bay we flew to Cape town south Africa and the 6th world Congress on Pediatric Cardiology and Cardiac surgery. thirty-one hours later past a flock of pink flamingoes by the river we arrived at a sumptuous hotel near the wharf area. friends had given us a list of things to experience in Cape town and i was looking forward to a couple of days sightseeing before the conference started. After a good nights sleep we decided to tackle table Mountain with a walk up to the top. we started with high spirits half a litre of water each and some gospel singers using the acoustics of the mountain to belt out some amazing songs. unfortunately they didn t continue up with us and my progress slowed to a crawl up the steep rocky climb. Many rest periods were required and at one stage i thought i was going to faint die with the heat and the strenuousness of the activity. it was more difficult to go down so i struggled on up to the top. we arrived after 2 hours and really appreciated the view of the indian and Atlantic oceans Cape Horn and the beers. we took the cable car down the next day i took the tourist bus learnt about apartheid discovered the city and braved a swim in the Atlantic which was about 11 degrees no wonder only a few tourists were in the water paddling. the conference started that evening with a few speeches and spectacular rendition of songs sung in english Zulu and swahili by the Pro Cantu and Cape town Youth Choir and the Youth orchestra. the audience loved a rendition of Queen s song somebody to love . the deputy Health Minister of south Africa then opened the meeting with a long speech. with more than four thousand registrants this was going to be one huge event. each evening i went through the program for the following day selected the talks i wanted to hear and made up an itinerary so that i had an idea of where to go and at what time. the day s started at 7am with breakfast symposiums and half-ended at 5pm after which began the dinner symposiums to 10pm sponsored by medical companies and some usA hospitals. the Congress separated the specialties into 9 huge conference rooms or auditoriums. Cardiologists were also treated to live catheter cases streamed in from around the world. surgeons continued to argue amongst themselves the merits of different surgical techniques. Perioperative services included iCu medicine anaesthetists Perfusion nursing health managers and research scientists. there was also a daily section on Adult Congenital Heart disease addressing the growing issue of management of the young patients growing into adults. there was also a large component on athletes and exercise and monitoring for heart disease. often there were two simultaneous sessions of interest which made it hard to choose. 10 rooms with 20 plus speakers each day plus the symposiums adds up to a lot of work for the organizing committee. each day there were four plenary speakers covering subjects from my favourite was on living with congenital heart disease by Amy Verstappen (51 years old) who was diagnosed with cctgA. she was an advocate for long-term patient survival without medical intervention if the pathology allows it. other talks included investing in your arteries from childhood heart surgery is risky business doing it safer for less and starting a heart program in Africa lessons from rwanda were fantastic. speakers on anaesthesia and the long term neurological outcome nirs robotic surgery biotechnology growing heart valves ischemic preconditioning glycogen kinase 3 inhibition and managing pregnant women were just a few of the topics i heard. A neurosurgeon talked about which monitoring technique is most reliable such as nirs doppler and subcutaneous probes to monitor blood flow and oxygen delivery during and for prevention of neurological injury. A full day was allocated to Perfusion and stephen Horton who was on the scientific Committee and faculty put together the program and invited speakers based on the brief from the organisers. stephen gave us an insight into the history and a look into the future along with a discussion on what can go wrong what did go wrong and what i did about it. Martin Bennett spoke on transport of eCMo patients. we covered VAd s anticoagulation difficulties haematocrit and pH management platelet function and novel applications for life support. the talks were all videoed and will be made available on line through the website http wcpccs2013.co.za so if you have time have a look at the website and if you want to enjoy this wonderful meeting the next and 7th world Congress will be in istanbul in 2017. finally i did squeeze in a few wild animals a couple of wineries and a trip to the Cape of good Hope. APril 2013 www.anzcp.org 11 Perfusion news Blood Conservation PoCKet guidelines within the october issue of the gazette many of you may have seen the Ats Blood Conservation webinar review. some of you may have even viewed the actual webinar via the sts website. those that did may have taken the time to follow the rather useful link to the sts Blood Conservation Pocket guidelines. whilst it may be debatable whether or not these guidelines could fit into the average sized pocket what is clear is the useful nature of this document. As one can see below the document lists all the salient interventions from the unabridged sts Blood Conservation guidelines lists them in a logical format and even includes the associated evidence classification. for those of you (myself included) that may need a quick reminder of the evidence classification definitions i have included one prior to the guidelines. Evidence Classification level i evidence obtained from at least one properly designed randomised controlled trial. level iia evidence obtained from well-designed controlled trials without randomization. level iib evidence obtained from well-designed cohort or case control - analytic studies preferably from more than one center or research group. level iic evidence obtained from multiple time series with or without the intervention. dramatic results in uncontrolled trials might also be regarded as this type of evidence. level iii opinions of respected authorities based on clinical experience descriptive studies or reports of expert committees. for those of you that would like to download a copy of the Pocket guidelines directly please follow this link... http www.sts.org sites default files documents sts%20 Blood%20Conservation%20pocket%20guideline%20reV.pdf 2011 The Society of Thoracic Surgeons Blood Conservation Guidelines MANAGEMENT OF BLOOD RESOURCES Intervention Multidisciplinary blood management teams Evidence IIa (level B) 2011 STS Blood Conservation Guidelines--Page 2 MINIMALLY INVASIVE PROCEDURES www.sts.org 2011 The Society of Thoracic Surgeons Intervention Evidence Blood repair (TEVAR) I (level B) Thoracic endovascular aortic Conservation Guidelines OPCAB for blood conservation IIa (level A) MANAGEMENT OF BLOOD RESOURCES Intervention Intervention BLOOD DERIVITIVES FOR BLOOD MANAGEMENT FFP for factor deficiency only Evidence Evidence IIa (level B) III (level A) IIa (level B) IIb (level B) IIa (level B) Multidisciplinary blood management teams Prophylactic FFP for bleeding patient IIa (level B) PREOPERATIVE INTERVENTIONS Intervention Stop P2Y12 inhibitors Evidence Class I (level B) PREOPERATIVE INTERVENTIONS Intervention Leukoreduced PRBC for transfusion Prothrombin complex concentrate for warfarin reversal FFP for massive transfusion protocol (2 1) Evidence StopIntraoperative platelet plasmapheresis P2Y12 inhibitors Anti thrombin for AT3 deficiency Class I IIa (level A) (level B) I (level A) Point of care test to help with decision about stopping P2Y12 IIb (Level C) P2Y12 inhibitors added to ASA after CABG for patients with acute coronary syndrome Preop Erythropoietin plus iron I (level A) IIa (level B) Point of care test factor VIIa for decision about stopping P2Y12 (level B) C) Recombinant to help with intractable bleeding IIb IIb (Level P2Y12 inhibitors added to ASA after CABG for patients withIIb (level C) A) I (level AT3 for multi disciplinary blood management acute coronary syndrome high risk (e.g. Jehovah s) Factor IX concentates for IIb (level C) Preop Erythropoietin plus iron IIa (level B) Evidence Evidence PERFUSION INTERVENTIONS Intervention DRUGS USED FOR INTRA OPERATIVE BLOOD MANAGEMENT Intervention Evidence DRUGS USED FOR INTRA OPERATIVE BLOOD MANAGEMENT B) Microplegia IIb (level Alternate Intervention anticoagulants for HIT Mini circuits Lysine analogues Biocompatible CPB circuits Modified ultrafiltration Zero balance ultrafiltration Evidence I (level C) I (level A) IIb (level C) IIb (level C) I (level A) IIb (level A) Lysine analogues Aprotinin I (level A) III (level A) I (level A) Vacuum Aprotinin assisted venous drainage III (level A) BLOOD SALVAGE Intervention Evidence BLOOD SALVAGE Intervention Cell salvage using centrifugation for all patients Pump salvage Centriguation of pump salvaged blood rather than direct re infusion IIb (level B) IIa (level C) IIa (level A) Cell salvage using centrifugation for all patients TOPICAL HEMOSTATIC AGENTS Intervention Pump salvage IIb (level B) IIa (level C) Evidence Topical hemostatic salvaged blood rather than Centriguation of pumpagents IIa (level A) IIb (level C) Anti infusion IIa (level B) direct re fibrinolytic solutions into wound at end of CPB) 12 APril 2013 www.anzcp.org internAtionAl ConsortiuM for eVidenCe BAsed Perfusion (iCeBP) newsletter 12 Perfusion Task Force update the Perfusion task force an initiative of the iCeBP in partnership with the society of thoracic surgeons and the society of Cardiovascular Anaesthesiology has been working on preparing a series of Clinical Practice guidelines in Cardiopulmonary Bypass. the first to go to review is titled Attenuating the systemic inflammatory response. this has pulled together the contemporary literature from 2002 -2011 and developed class iia through iii level Clinical recommendations on over 30 anti-inflammatory interventions. this will be the first of the series with the next three looking at temperature management renal protection and anticoagulation. we will let everyone know when the first of these comes to print. Update on International Registries we had a great session on clinical registries at last year s meeting in san diego. we have listed below some highlights from each of the registries that presented at the 2012 conference PERForm European Perfusion Registry Luc Puis the european Perfusion registry is gaining more momentum by adhering to the european Association of Cardiothoracic surgery Quality improvement Program (eACts QuiP). through the formation of a network for outcomes research 12 centers accross europe will plan the next steps looking at practice variability through an international survey identifying quality indicators through a literature review and setting up a clinical database are amongst them. the purpose of the ePr will be to develop tools for performance assessment and quality improvement of clinical practice. National Registry Of Perfusion Spanish Society Of Perfusionists Theron Paugh we currently have 8 572 records in the database that have been linked to surgical data comprising 17 sites in Michigan. An addition site has joined outside of Michigan. two others outside of Michigan are in the fi nal stages of contracts. we are pleased to have our fi rst publication on the validation of our registry. we have been presenting on the relationship between haematocrit and transfusions and perioperative outcomes at AmseCt international. we have had an information session at AmseCt international on March 5 from 1pm-4pm. More than a dozen individuals convened prior to the AmseCt international convention for our fi rst Perform summit. individuals were introduced to the argument for a registry and its intended value. Attendees were walked through the current quality assurance reports and asked to provide critical feedback to its content and format. At the end of the summit attendees were provided with information concerning who they might join the registry which now has sites outside of Michigan. for those that are interested please contact donald likosky (likosky med. umich.edu) theron Paugh (circtech med.umich.edu) or timothy dickinson (tim.dickinson specialtycare.net). we plan on having a summit prior to this year s Best Practices in Perfusion conference in san Antonio october 2013. Northern New England Cardiac Disease Study Group Gordon Defoe the nneCdsg Perfusion registry established in 1996 currently contains over 60 000 patient records from eight participating programs which are linked to our cardiac surgical database established in 1987 and validated against governmental data every two years. individual programs are sent reports twice a year showing their performance typically over the last 200 procedures compared to both other member programs and the shann guidelines. we are currently closely examining the proposed essentials and guidelines from AmseCt to identify opportunities for regional Quality improvement projects based upon implementation of the proposal. Best Practices in Perfusion October 9-12th 2013 SAvE THE dATE Best Practices in Perfusion 2013 october 9 - 12 2013 Marriott riverwalk san Antonio tX we are thrilled to have our annual Best Practices in Perfusion Conference back in san Antonio. the theme for this year s meeting is developing High functioning Clinical teams . the planning committee is already meeting and is ensuring that each session adds value to this theme. we plan on having ample question-and-answer time across the sessions. Additionally we will be bringing back many of the hallmarks of our 2012 program namely simulation workshops and pro-con debates. of course for those interested in attending and participating we will have the iCeBP steering Committee held on wednesday october 9th from 10am-12pm. Mario Garcia sonia Pe ate Marisol Garc a Diego solis and Jose Luis Arteaga soto objective to establish a model for the collection of data of the activity of Perfusionist. Bringing a tool within reach of all perfusionist that can measure easily the healthcare activity of each team and the whole collective. describe the annual healthcare activity of the perfusion services units facilitate observation of changes as many parameters of the patients the type of procedure the incidence of urgent activity as materials used. Material Accepted database with spanish perfusionists easy to use that identifies the required parameters that simplify information retrieval and praise an analysis that reflecting our activity. result Presentation of the results and their interpretation of all data collected since 2002. we had around twelve thousand of registries valid in 2011. evolution of the average age of the patients (patients are older) changes in the practice of perfusion (gradual incorporation of the centrifugal pump the unanimous acceptance of the blood filter the almost disappearance of crystalloid cardioloplejia) increased of the combined surgery deviations of the incidence of urgent activities and gradual increase of the number of units that record (45 public centres and 47 private centres). in addition to need to update review and agree on new registration parameters that facilitate the development of a useful and complete register of Perfusion. PERForm Summit at Amsect International More than a dozen individuals convened prior to the AmseCt international convention for our first Perform summit. individuals were introduced to the argument for a registry and its intended value. Attendees were walked through the current quality assurance reports and asked to provide critical feedback to its content and format. At the end of the summit attendees were provided with information concerning who they might join the registry which now has sites outside of Michigan. Perfusion Downunder Collaborative Database Richard newland we now have 9 hospitals contributing to the Perfusion downunder Collaboration which represents at least one major center from 6 out of the 8 major cities in Australia and new Zealand. in our most recent data harvest we collected data from 10 869 procedures. our current areas of interest include acute kidney injury benchmarking of Perfusion quality indicators (Qi) including pCo2 arterial outlet temperature and blood glucose management. our baseline incidence of these Qi was published last year (J extra Corpor technol. 2012 44(1) 26-33) more recently we have been able to demonstrate improvement in practice since the initiation of the benchmarking process. At this years meeting on Hayman island in september (http www.perfusiondownunder.com) we plan to also focus on benchmarking transfusion providing the opportunity for each participating center to present their experience in blood management and utilise their collected data to compare the influence of these practices on outcome. Collaboration with ISMICS isMiCs 2013 in Prague 12-15th June (http meetings.ismics.org ) is running a Perfusion session on thursday the 13th from 1500-1800. the session titled least invasive Perfusion will explore topics related to support devices technology and Blood Conservation. Come join us in Prague dave fitzgerald and rob Baker Co-chairs Perfusion track 2013 isMiCs Annual scientific Meeting APril 2013 www.anzcp.org 13 The PuMPers QuiZ Questions courtesy of www.perfline.com 1. During pregnancy maternal blood reaches the fetal circulation by flowing through A. ductus arteriosus C. umbilical veins B. umbilical artery d. ductus venosus 7. Heparin resistance is defined as a failure to raise the ACT to the expected levels despite adequate dose and plasma concentration of heparin. The most common cause of heparin resistance is A. Plasmin deficiency B. At deficiency C. Hemodilution d. sepsis 2. All of the following statements regarding atrioventricular canal defects (AVC) are true except A. AVC defect is the most common cardiac defect in infants with down s syndrome. B. Pulmonary hypertension is unusual during the first year of age. C. the complete form has always a single common AV valve. d. the defects can be associated with tetralogy of fallot. 8. Heparin-induced thrombocytopenia (HIT) can be identified in about A. 20% of patients receiving heparin. B. 15% of patients receiving heparin. C. 10% of patients receiving heparin. d. 5% of patients receiving heparin. 3. Reducing body temperature from 38 C to 20 C increases the amount of oxygen dissolved in plasma by A. 50% C. 30% B. 40% d. 20% 9. All drugs below are direct thrombin inhibitors except A. Hexadimethrine C. lepidurin B. Argatroban d. Bivalirudin 4. The drug of election to treat malignant hyperthermia is A. dantrolene C. pancuronium B. halothane d. lidocaine 10. All of the following statements regarding Lepidurin are true except A. lepidurin is a recombinant analogue of the anticoagulant hirudin produced in leech saliva. B. lepidurin has a short half-life of 80 minutes and is monitored via activated partial thromboplastin time (aPtt) or ACt and has no antidote. C. lepidurin can not be eliminated by ultrafiltration. d. lepidurin is metabolized by the kidney requiring dose adjustements in patients with renal insufficiency. 5. A single anomalous pulmonary vein most commonly is anatomically attached to the A. left atrium C. inferior vena cava B. coronary sinus d. superior vena cava 6. Answer the following question by using the key outlined below A. if 1 2 and 3 are correct C. if only 4 is correct B. if 1 and 3 are correct d. if all four are correct. 1. thorough preoperative planning is essential to reducing or avoiding perioperative allogeneic transfusion. 2. Preoperative assessment requires accurate history taking and physical examination with particular attention to any personal or family history of bleeding disorders. 3. Preadmission testing should take place well in advance (eg 30 days) of elective surgery to allow time for adequate identification evaluation and management of anemia. 4. Patients with low hemoglobin levels prior to surgery are at higher risk of receiving allogeneic transfusion. For the correct answers turn to page 64 14 APril 2013 www.anzcp.org of Critical Real-Time the Leading the World in Non-Invasive Measurement Parameters. World in the Leading the Measurement Non-Invasive of Critical Real-Time Non-Invasive Measurement of Critical Real-Time the Parameters. World in Leading the of Critical Real-Time the Parameters. World in Leading the Measurement Non-Invasive Parameters. Measurement Non-Invasive of Critical Real-Time of Critical Real-Time Parameters. Parameters. Take a look at your world look at Take aour way your world look at Take aour way yourBY SPONSORED world look at Take aour way yourBY SPONSORED world look at Proudly distributed by CellplexTake aour way yourBY Pty Ltd SPONSORED world look at Proudly distributed by CellplexTake aour way your Pty Ltd opinion teg weBinAr reView by Martin gill CCP. thromboelastography (teg) or thromboelastometry (teM) depending on the system you choose to employ is essentially a point of care measurement tool for the assessment of clotting efficiency in blood. speaking to perfusionists throughout Australasia and following perfusion blogs it becomes rapidly apparent that this is a technology that is becoming increasingly embraced in the cardiac theatre and perhaps more pertinently as a part of the perfusionists role. thrombelastography is not as new a monitoring modality as one might initially think. it was fi rst described by Hartert in 1948. what is however relatively new is its now portable appearance and integration with computer software making the carrying out of tests and there interpretation much easier. for those unfamiliar with this technology a brief description of the procedure and equipment involved may be of use. the user places 340 360 l blood in an oscillating cup which is maintained at 37 C or at the patient s current temperature. A pin is suspended in the cup from a torsion wire with an electrical transducer. At the start of the procedure no clot should be evident and therefore the cup motion does not impact on the suspended pin resulting in a straight line on the display. once clot begins to form in the cup the motion of the cup does impact on the wire this movement is then transmitted to the pin and recorded on the display. the user would then interpret the display with the aid of pre-defi ned ranges. in order to speed up the procedure the blood can be activated before placement in the cup by the addition of kaolin a celite which increases the surface (intrinsic activation) or with tissue factor (extrinsic activation rapidteg). Heparinase cups are also available permitting assessment of underlying clot formation once circulating heparin has been reversed. Platelet mapping to assess platelet function and fibrinogen testing are also available. in January the perfusion website perfusion.com hosted a webinar addressing the clinical value of the teg haemostasis analyser system from the perspective of a cardiac surgeon. the cardiac surgeon in question is william Kessler who is the director of Mechanical Circulatory Assist devices at seton Heart speciality Care and transplant Centre in Austin texas. dr Kessler is a part of a group consisting of 20 surgeons- cardio and vascular which covers 10 hospitals that carry out over 1500 pump cases per year. it was with a certain degree of eagerness that i logged in to take part in this webinar. what follows is a description of the key points presented mixed with a smattering of my own interpretation and thoughts on some of the more salient issues. it is probably also worthwhile mentioning that both the event and dr Kessler are sponsored by Haemonetics who are the manufacturer of teg. Prior to teg use dr Kessler utilised the classic coagulation profi le measurements such as platelet count inr Pt APtt and anti-Xa in the care of his cardiothoracic surgical patients. this empirical approach to transfusion medicine was felt to be akin to a shotgun approach. during this period it would not be uncommon for a patient to return an elevated post bypass Pt and inr which unsurprisingly would result in at the very least a ffP transfusion. with the advent of teg this group of patients despite the elevated Pt and inr show a teg picture which is often hypercoagulable. this hypercoagulable picture is felt to be far more reflective of the clinical picture as opposed to the laboratory picture. therefore greater consideration is now given to this group of patients prior to administration of a ffP transfusion. Another group of patients that previously received multiple blood product transfusions and now do not were the postoperative VAd insertion patients treat by dr Kesslers group. teg utilisation has shown these patients to often be also in a hypercoagulable state most likely due to blood activation. with regards to the eCMo patient dr Kessler advocates the use of teg in order to monitor anticoagulation. He feels that all too often the standard laboratory coagulation tests do not reflect the clinical picture within the patient or indeed the extracorporeal circuit. teg on the other hand often reflects the clinical picture far more accurately. Perhaps even more interestingly he goes on to suggest that once one obtains a teg showing the desired level of anticoagulation one may recalibrate their desired ACt value to the teg. for example if you set out aiming for an ACt of 200 seconds yet the teg shows adequate anticoagulation at a point where the ACt actually reads 260 seconds then perhaps one should consider aiming for the higher ACt value. As with any new or innovative monitoring test getting buy in from colleagues and administrators can be the greatest challenge. teg is no exception to this rule. dr Kessler advocates open communication and sharing of evidence as the best method for dealing with this issue. Clinicians are mostly driven by outcomes whereas administrators are driven by issues such as cost and length of stay. the best approach would be therefore to demonstrate improved patient outcome due to reduced blood product exposure reduced cost due to shorter hospital stays reduced co-morbidities and reduced resource utilisation. to facilitate the adoption process further it is recommended to expand the educational process beyond standard teaching sessions for users. this expansion should even include grand rounds. the hospitals it department can also possibly assist in making the technology more accessible by making results available at home or even on smart phones. APril 2013 www.anzcp.org 17 in the early days of teg use within dr Kessler s group not all of the surgeons embraced the technology. in order to assist the other surgeons in becoming more open to teg he showed them a graph displaying length of stay for teg using surgeons and non-teg using surgeons. this proved to be a very effective strategy. since wider adoption the group has demonstrated a 47% drop in the average number of blood product units given in patients in which teg and platelet mapping have been used. with the resultant cost savings reduced patient length of stay and of course reduced blood product transfusion rates dr Kesslers group are now involved in discussions with the broader hospital network about whether teg should be adopted as a standard of care and even supersede conventional coagulation testing methods due to their inherent limitations. this is quite an evolution for a monitoring modality that started in VAd use then transplant then cardiac surgery and now approximately 80% of patients that come through the cardiac theatre will get a teg. Adoption of a teg protocol for differing specialities based upon their requirement can improve the standardisation of care. for cardiac patients dr Kessler suggests pre-operative teg with platelet mapping on pump teg to be used as a predictor post protamine teg and then an iCu teg. Adopting this level of standardisation would no doubt ensure a patient specific coagulation profile is obtained and therefore a patient specific approach to transfusion. Platelet mapping is an adjunct to the standard teg monitoring and one i am personally not familiar with. dr Kessler finds the platelet mapping a valuable part of the assessment of the multiple systems involved in haemostasis. Platelet mapping can even impact the timing of surgery predominantly by identifying non-responders to Plavix- which is said to be approximately one quarter of people on that particular drug. Besides those already mentioned other challenges one can expect to encounter when implementing teg are the relatively steep learning curve in the early stages of the systems use coupled together with an element of ignoring instinct and experience in favour of the information the teg will give you. Many centres also report laboratory resistance as an additional obstacle. depending upon the location of your teg machine the coordination for specimen transport to permit a timely result can be another factor worthy of consideration. with an open inclusive approach to these and previously mentioned obstacles one should be able to implement and integrate this monitoring modality into the care of their particular patient group. obviously teg comes at a cost and one may wish to ensure appropriate company support and education is factored into the purchasing price of such a device. what dr Kessler is hopeful of with the adoption of teg is a specific guided therapy for blood products with a resultant improvement in quality. following the more didactic part of the webinar dr Keesler proceeded to present several case studies in which the use of teg has proved to be instrumental in patient care. one particular case study that stood out was an adult eCMo case on VV eCMo following a diagnosis of H1n1. this patient s anticoagulation was monitored successfully with teg and even continued to be useful during the patient s subsequent diagnosis of Hitt and subsequent treatment with argatroban. As seems to be the norm with this method of education participants to the webinar had the ability to interact with the speaker via text or spoken word using the software employed for the event. there was time for several questions some of which centred on the use of rapidteg. Conventional teg measurement activates the blood with kaolin prior to placement in the measurement cup. the rapidteg utilises a kaolin tissue factor activator. this permits measurement of the interaction and simultaneous contribution of the intrinsic and extrinsic coagulation pathways which initiate and result in clot formation. this rapidteg reagent can deliver results faster than activating with Kaolin alone. this protocol will however only assess one aspect of the clot formation- namely the maximum dynamic properties of fibrin and platelet bonding via gPiib iiia that represents the ultimate strength of the fibrin clot essentially representing platelet function. At my institution we have now been using teg for a few years and have quite a mix of emotions where it is concerned. with our post-operative liver transplant patients are concerned teg is of tremendous use. the clinicians have embraced the technology wholeheartedly and base clinical management decisions largely on the results of the teg. within the cardiac theatre the impact of teg has been somewhat variable. working in paediatrics with the unavoidable massive dilutional coagulopathy a large proportion of patients are going to receive platelets ffP cryoprecipitate and bank blood regardless. therefore before the teg results are returned the clinical picture has already changed dramatically due to ongoing transfusion. we have attempted to ameliorate this by carrying out a heparinase teg (i.e. reversing the effect of any circulating heparin to display underlying clot function) upon rewarming in order to guide post protamine product administration. this can be successful but even being proactive we still occasionally demonstrate hypercoagulable states yet still hear the call go out for recombinant factor seven. i believe that persuading a surgeon that bleeding may actually be surgical is at times one challenge to many. within our institution it is also worthy of mention that teg testing is a part of the perfusionists role. the maintenance and QC of the device are carried out by the hospital biomedical engineering department. this model works very well for us and to a larger extent the perfusion department is very happy with the teg being a part of our domain. speaking to the liver transplant surgeons who probably place the most heed in the teg results they would not have the same level of confidence in the results if they were being carried out by a larger professional group such as nurses. i guess the expansion of the perfusionist role into a test directly related to blood management seems a logical step...... if you disagree i would love to hear from you and furthermore gladly publish your response. if you would like to view this webinar please visit... http www.perfusion.com cgi-bin absolutenm templates articledisplay.asp articleid 4640&zoneid 4 18 APril 2013 www.anzcp.org opinion deVeloPMent of tHe HeArt-lung APPArAtus A reView of A PresentAtion BY JoHn H giBBon Jr. by Martin gill CCP. At the recent Annual scientific Meeting in uluru we were fortunate enough to have as an invited speaker the well-known perfusionist and perfusion historian steve sutton from texas usA. Apart from steve s outstanding contribution to the scientific program steve also gave out a number of dVd s. the dVd s relayed a presentation given by none other than John H. gibbon Jr. at Baylor university Medical Centre in november 1972. the presentation related to the development of the heart lung apparatus. As is often the case one does not know something is going to be of historical value when it is occurring. dr gibbon s presentation is no exception to this. the sound quality is variable and some of the slides under discussion are missing. steve sutton has actually restored this presentation to a very watchable format. of course on the one hand the missing slides are somewhat of a disappointment on the other hand this gives the viewer a sense that one is watching authentic historical footage- which indeed they are i am certain that we are all well aware of dr gibbon s achievements and are all reasonably well versed via textbooks such as gravlee and Mora about how these achievements came to pass. what i am not so sure about is how many amongst us have actually had the opportunity to listen to the man himself speak at times quite candidly about these achievements in his own words. i have received permission to make this presentation available to you all by way of the gazette section within the college website. what follows is a short synopsis of the presentation to wet your apetite. dr gibbon s introduction to the stage at Baylor university Medical Centre consisted of an overview of his life. this began with a look at some rare family photographs of a young gibbon with his father (himself an eminent surgeon) and even a photograph of a 3 year old young man pretending to puff upon his fathers pipe. we were then treat to the story of his burgeoning professional career including medical training at Princeton and Jefferson medical College. two rather nice photographs contained within this introduction were not of the professional man but of the man at rest and play enjoying his favorite pastimes namely tennis and painting. following the introduction dr gibbon made his way to the stage clearly uneasy with the praise bestowed upon him during the introduction. nevertheless dr gibbon pretty much picked up the story of his life at about the time his was in medical training and in order to earn some extra money carried out odd jobs. one such job consisted of a 17-hour shift during which a young dr gibbon was required to carry out vital sign observations on a patient that had suffered a pulmonary embolism. this patient actually did quite well for the majority of the night whilst gibbon maintained a bedside vigil. the patient then acutely deteriorated and subsequently underwent emergency removal of the pulmonary embolism. this procedure which was not terribly successful in the 1930 s took 6 minutes 30 seconds and unfortunately although not surprisingly ended up with the patient dying. now it is often said that it is what we take from life s experiences that shape whom we become. this is certainly pertinent to this story. it was during dr gibbon s mammoth 17-hour shift that a thought took hold in his mind. this thought was directly related to his patients condition more specifically related to how one could take blood out of the patients distended venous system carry out effective gas exchange and then pump the oxygenated blood back into a peripheral artery thus permitting effective and safe surgical removal of the pulmonary embolism. this thought did not as many do gradually disappear from mind despite a lack of support from his professional peers. Quite the reverse this thought process grew and eventually bore fruit. it was around this time that dr gibbon also met fell in love with and married a research assistant Mary. Mary not only became dr gibbons life long companion but also his professional collaborator in both clinical practice and research. this personal and professional association was only briefly interrupted by the involvement of the usA in the ongoing second world war. following the war dr gibbon resumed his endeavor in his own laboratory in Jefferson. By this time dr gibbon was well on the way to solving the problem of how to adequately oxygenate blood outside of the body. earlier attempts had consisted of a vertical revolving cylinder within which a film of blood was created upon a central revolving column. through the cylinder was pumped oxygen thus contacting the blood film and therefore resulting in gas exchange. dr gibbon persevered with this form of oxygenation partly due to earlier success for many years. Quite insightfully dr gibbon admits that he stuck with this idea for longer than he should. He went on to admit that it is often difficult to change direction when a great deal of effort has been applied and some success gained. i think this is a sentiment that any researcher can relate too. with this early apparatus dr gibbon was able to demonstrate how this form of extracorporeal circulation could be essential to life. during compression of an animal s pulmonary artery in graduations one can witness a reduction in blood pressure and ultimately cessation of respiration. upon commencement of the heart lung machine one would then bare witness to the blood pressure picking up and respiration being restored. the cause of much jubilation was when the vessel continued to be clamped fully once on the heart lung machine and respiration and blood pressure maintained. the pumps in these early heart lung machines were actually roller pumps driven by an external motor. Perhaps most surprisingly was that the pumps were servo controlled with a blood reservoir level detector. this i found particularly amazing as i trained with perfusionists who did not use level detectors some 10-15 years ago yet here was dr gibbon employing such safety features shortly after the end of the second world war. APril 2013 www.anzcp.org 19 By now dr gibbon could support a cat or dog on his apparatus but in order to oxygenate an adult human he speculated that his revolving cylinder might need to be up to two stories high. A size i dare say would not have been deemed to be practical. it was with the insight of two interns that a more practical solution was suggested and trialed. the creation of turbulence in order to enhance the degree of oxygenation without increasing the size of the device was deemed to be worthy of investigation. the main concern when embarking upon this endeavor was the avoidance of foaming within the blood. they lined the cylinder with a screen over which blood passed resulting in turbulence and an increase in efficiency of 8 times. Various types of screens were subsequently tried in order to obtain the optimum features. the desire was to have the blood film stay thin pile up on cross wires then become thin again. too thick and it will fall too rapidly. the travelling speed of the blood became a real issue. it had to be economical but also needed a certain amount of blood to permit adequate oxygen uptake. to overcome this the amount of screens was increased and extra pumps employed including a recirculation pump in order to ensure that a constant blood volume was maintained within the patient and machine. dr gibbon was also looking at this early stage at the wider haematological picture. He was aware of the degree of haemolysis impact upon platelet count white cell count and anemia caused by his machine. Quite surprisingly the screen heart lung machine caused no anemia. one can only wonder at the amount of blood products used to prime this machine. following numerous successes with dogs closing both atrial and ventricular septal defects dr gibbon now felt ready to tackle a human with his heart lung machine. in May of 1953 dr gibbon repaired an atrial septal defect in an 18-year-old girl using his screen oxygenator. the young lady was on the gibbon heart lung machine for 45minutes of which 27 of them the screen oxygenator completely supported all of her cardiorespiratory functions. 31 days following the procedure she left hospital and returned home. A few photos were taken in the operating room on the landmark day of this Asd closure. dr gibbon did not know that they were being taken and actually admits that had he known of this intention he would not have permitted it. i for one am glad that they were taken as i think he may also have been years later. Besides showing a short news video in which you can actually hear the rather noisy apparatus at work that pretty much concluded dr gibbon s presentation. no mention was made of later failed attempts at the use of this machine nor was any mention made of his subsequent premature retirement from his life s work. A part of me wished that further information had been shared about what he was thinking at this time. one can only imagine how hard it must be to turn ones back on over 30 years of research. it would also have been great to hear dr gibbon s thoughts on the direction cardiovascular surgery had taken in the 20 years since he successfully closed that Asd. one must however accept that people reserve the right to share what they desire and keep some things to themselves. for myself the most memorable part of the entire presentation was when dr gibbon recalled the fondest memory of his professional career. this was the day back in his lab when he was dancing for joy after realising that he could completely support an animal s circulation on his apparatus. this was obviously a landmark event on the way to the event from which all the accolades are bestowed yet it is this event and not the latter that was recalled. the contribution of dr gibbon s work to what we do every day can not be over stated. we truly do stand on the shoulder of giants. to view the video please visit.... www.anzcp.org ..... and click the gazette tab. what follows is an email response i got from steve sutton when i asked him if we could upload the gibbon video that he put together on to our College website. i am reproducing his reply here as i believe it gives an additional layer to the story- i hope you agree. You may use the video in the manner you described my only restraints with the gibbon family and all other entities are that it be used for educational purposes. we cannot reproduce it for distribution or sale for monetary benefit. Please use it in the manner you describe and we are fine. that was the whole purpose for producing it. i hope all enjoy. Dr. Gibbon was very personal and very private in his era. There was actually only one (1) photograph taken that monumental day by one of his colleagues and Gibbon knew nothing of this. The associate stated at the fiftieth anniversary that had he known of the photograph he would have fired me. That photo is the least clear and one can tell it was amateurishly taken. All other photos are reproductions made in mock form 30 days after the procedure which Gibbon agreed to. He accepted no remuneration for his endeavor no copyright and no royalties for his work. Rather amazing. He gave his whole adult life in developing this machine and only did five cases. Four died. it was the era when the listening ear with stethoscope was used to diagnose cardiac anomalies along with a good physical exam and a chest x-ray - that was about it. He placed a moratorium on any future use until John Kirklin whom he gave his third machine could perfect it. He retired from cardiovascular surgery and spent the remainder of his career in general thoracic surgery. An amazing tale if you want to read more in depth about him there are two really good books (1) A dream of the Heart by Harris schumacher M.d. (gibbon s closest friend) and the other (2) is John gibbon and His Heart lung Machine by Ada romaine davis. these authors allowed me to create the video utilizing some of their work. i met Bernie Miller who was a surgeon scrubbed in on the case May 6 1953 he said that they almost lost Cecilia Bavolek (18 y o) the patient that day when he noticed the heparin dose was underestimated and the machine began to clot. He corrected this and she did fine. A little note he thought he had lung cancer and finally agreed to a chest x-ray on himself. He was at the AAts or sts Meeting in florida when he had a heart attack while playing tennis with Mary his wife louise Cooley (denton s wife) and Harris schumacher. they managed to get him to his hotel room and Mary called dr. Cooley to his room. they begged him to go Houston and let dr. Cooley do bypass surgery on him he refused and died several months later. enjoy steve sutton 20 APril 2013 www.anzcp.org Easy rapid and precise temperature control are essential requirements for a hypo- hyperthermia unit for use during extracorporeal circulation. MAQUET s HCU 40 combines the latest proven technology with outstanding performance and unique usability. It delivers very precise fast and independent regulation of both patient and ca cardioplegia circuit temperatures intuitively controllable with a color touch screen display. Always reliable always safe. MAQUET The Gold Standard. MAQUET Australia Pty Ltd PO Box 3451 Tingalpa DC QLD 4173 Phone 61 07 3339 3900 Fax 61 07 3339 3910 sales.au maquet.com APril 2013 www.anzcp.org 21 opinion tAlKing uP tHe VAlue of gPs since taking over the role as editor of the AnZCP gazette i have maintained that the aim of this publication is communication between perfusionists in AnZ and beyond. when perfusionists get together not everything we talk about relates to perfusion and the gazette is not exempt from this. what follows is not an article on the latest perfusion principals nor does it directly relate to perfusion. i would however mount an argument that it indireCtlY relates to the patients we see on a daily basis. this article was written by david Brill back in August 2010 and was published in the Medical observer. the Medical observer is essentially a weekly publication aimed at gP s that endeavours to provide quality and practical information in the form of news and features. You may be forgiven for wondering how i came across this article well i actually received the article via email about a year ago from dr liebhold s step-son Peter Jurukovski who heads up the Cardiac Physiological services department at the Heart Centre for Children sydney. the article really struck a chord with me and i therefore now share it with you all. 17th Aug 2010 By david Brill. one of Australia s long-standing champions for universal healthcare dr Alf liebhold tells david Brill why modern medicine isn t fixing people. stress and sadness often look like illness says the sign on the side of the bus. Hugs are therapeutic reads another. food is filling not fulfilling says a third. if you haven t seen this ad campaign it s because dr Alf liebhold never became Australia s Health Minister. if he had the country would be a very different place. there d be a doctor on every street corner people could drop in for a chat any time of day consults would last as long as they needed to and nobody would pay a cent. Australians would be happier and healthier and psychologists and social workers would be freed up to take on the neediest cases. dr liebhold s vision may sound idealistic or unfashionable but with 50 years of inner-city general practice behind him along with firsthand knowledge of the impacts of social hardship his views should not be taken lightly. dr liebhold was just 10 when his family arrived in Australia in 1938. As socialists in germany they had been acutely aware of the rise of fascism in europe and decided to make a fresh start far away choosing Australia for its democracy and reliable legal system. dr liebhold has been a vocal figure in health politics. As a founding member of the doctors reform society in 1973 he supported reshaping of Australia s healthcare system. in opposition to the AMA the group publicly backed the whitlam government s radical health reforms that paved the way for Medibank in 1974 and the birth of Australia s universal health insurance system. in 1978 as society president dr liebhold fought to preserve bulkbilling and ensure all Australians would be able to see a doctor regardless of income. thirty-two years later bulk-billing is still hanging on but dr liebhold has deepened his view of what s ailing Australia. universal healthcare may have banished the malnutrition and diseases of poverty which used to keep him working all hours in his overcrowded live-in practice in sydney s newtown. But where poverty was making his patients physically sick it was also making them depressed exhausted and alcohol-dependent and these conditions have not been cured. our whole approach to healthcare is on an individual basis we ll cure one work-related headache at a time or one depressed unemployed person at a time says dr liebhold who now practises part-time in sydney s Marrickville. But the real elephant in the room is society itself. ours is not meeting people s needs and it s showing up in emotional disturbance risky behaviour drugs crime you name it. we call it an obesity epidemic or a mental health epidemic but what is it really we can t alter the damaging effects of our lifestyles. it s crazy to expect medicine to fix that. the best we can do as doctors is avoid unnecessary medicalisation. the challenge now facing Australia dr liebhold says is to reform the health system so doctors actually have time to dig below the surface and discover what is truly troubling their patients. we ve lost the whole concept of care by commodifying the idea of the relationship between a doctor and a patient. they come to get something and the doctor has to give them something he says. He recalls a patient who asked for antibiotics for a throat infection but quickly broke down in tears about the recent death of her husband of 50 years. A diagnosis of depression and a referral to a psychologist might be the protocol but the moment of crisis would have passed. dr liebhold was lucky he had time that day to offer a good old-fashioned shoulder to cry on. if i d gone along with the idea that the patient came in with then she wouldn t have got better and she wouldn t be getting good value he says. Hippocrates said first do no harm . well doctors are doing harm these days not deliberately but by not explaining the real problem. it s not easy to talk... but a conversation is worth thousands of dollars of investigations. dr liebhold s election manifesto may not be splashed on the side of buses but he hopes desperately that someone is listening. And if politicians will put gPs not just on every corner but at the centre of Australia s health well they might just get his vote. 22 APril 2013 www.anzcp.org if you make it difficult for people to get simple healthcare it comes out in some much more expensive way he says. it s very important that people can come and talk to their gP at any time. the article was reproduced with permission from the Medical observer. no funds were paid for the rights to reproduce this article. if you wish to learn more about the Medical observer please visit.... www.medicalobserver.com.au if you wish to view this article on line please visit... www.medicalobserver.com.au news talking-up-the-value-of-gps opinion iMPleMenting tHe Pronto ProCedure by ray swart CCP. it s great to come away from a scientific meeting and apply what you have learned to clinical practice. in 2011 was fortunate to attend the winter meeting of the society of Cardiothoracic Anaesthetists at whistler-Blackcomb in Canada. the 8-day conference was held at the fairmont Chateau at Blackcomb. the presentations from the keynote speakers were excellent. there were various clinical workshops that could be attended also. in one such workshop we were shown the technique of a Parallel replacement of the oxygenator that is not transferring oxygen the Pronto procedure 1. Presented was a technique to replace a failed oxygenator by inserting a second oxygenator in parallel (Pronto) within the cardiopulmonary bypass (CPB) circuit. we as perfusionists are all too aware of the potentially catastrophic results of a failed oxygenator when the heart has been arrested and the heart and aorta are not intact. this requires a swift precise and controlled response. it was shown that the technique minimises the amount of haemodilution associated with an oxygenator replacment and can be carried out without interrupting blood flow to the patient and its associated risks. we have adapted the only minor changes required for this technique to our CPB circuits further keeping patient safety as paramount and practice the procedure (which can be completed less than 90 seconds) during our in house workshops. there a number of articles on this procedure which are well worth a read references 1.rC groom et al. Parallel replacement of the oxygenator that is not transferring oxygen the Pronto procedure. Perfusion 2002 17 447-450 Comment i very much appreciated ray sending through this piece on the Pronto procedure. Being somewhat new to this profession the thought of an oxygenator failing fills me with what i deem to be a healthy amount of terror. Anything that can alleviate this terror and assist in making an oxygenator change out quicker and safer is at the very least worthy of further exploration. it was with this thought in mind that i eagerly sought out the referenced article by groom et al. As ray alluded to above the Pronto procedure requires the addition of a 10 inch shunt of desired tubing size to be placed between the inlet and outlet of the oxygenator. groom also recommends the addition of a leur lock connector being placed in the centre of the shunt to permit the measurement of arterial line pressure or with manipulation of a clamp the measurement of pre and post membrane pressures. in the event of a failing oxygenator a second clamp is applied to afore mentioned shunt line and then the tubing is cut followed by the connection of a new oxygenator to the cut ends of the tubing. recirculation lines are connected to the existing reservoir followed by antegrade priming with distal clamp still in position resulting in air being displaced to reservoir. the gas line would then be transferred recirculation lines closed distal shunt line clamp removed and placed proximal to failed oxygenator followed by conformation of improved oxygenation. it is probably fair to suggest that it is reasonable unlikely for a complete oxygenator failure therein lies the primary advantage of the Pronto procedure- the ability to add another oxygenator without interrupting blood flow to the patient in a quick and relatively controlled manner. i guess before changing ones practice one must way up what the risks are associated with having the shunt line insitu for all cases for that rare instance when an oxygenator fails. the potential downsides i can think of is an additional connector under high pressure increased turbulence as blood passes the additional Y-connectors and the stasis of blood as some enters the shunt line and sits there. that said.... if i was faced with having to change an oxygenator i might just wish that i had the ability to do so Pronto . APril 2013 www.anzcp.org 23 opinion A MuseuM tour of london by Martin gill CCP. during a recent trip to london i found myself as many tourists do trawling thought the endless museums on offer to the general public. one thing that struck me whilst endeavoring to get through as many as i could was the relative speed with which i could get through all the exhibits (even with my wife and four children). At first i could not put my finger on why i seemed to be rattling through all the exhibits- was i not appreciating them no that was not it. we were all ooing and ahhing at the size of the blue whale in the natural History Museum. were we rushing no that was not it. we spent a full ten minutes looking at Van goughs sunflowers before braving the gift shop to buy the obligatory post card of the same so we could spend even longer looking at a bunch of flowers in a vase every time we visited the refrigerator. so what was it After much head scratching whilst sipping on an over priced late in the museum caf it finally dawned on me- i did not have my father with me. My dad was strictly a one museum a day type of guy. this was not because he did not particularly like museums. on the contrary he would get us all up at the crack of dawn to ensure we were first in the queue when the doors were thrown open and we would invariably be the last out often been ushered towards the exit by the curator. My father would read everything within the whole building every plaque on every exhibit would be studied re-studied and then read to the rest of the family. in fact i would swear that he even knew who made the porcelain used in the toilet and where the hand towels came from. this was not my style i was a far more visual museum visitor. that was of course until i discovered that many of the museums had a certain amount of medical and surgical history on display. the science museum for example had an original eMi Brain scanner from 1971. this is now more commonly called a Ct scanner. what is perhaps little known is that eMi s investment in medical technology was actually made possible due to the success of the Beatles records released on eMi s Parlophone label. unfortunately eMi could not keep pace with overseas medical device companies and within a decade had no further input into this field. not far from what i was now referring to as the Beatle scanner i was delighted to find on display an early Mri machine from 1983. when i say early with this technology it is worth remembering that it was only in 1980 that the Aberdeen royal infirmary used a machine not dissimilar to this in order to obtain the first clinically useful images of a patients living tissue using magnetic resonance imaging. Above Aberdeen Magnetic Resonance Imager 1983. one other piece of equipment on display at the science Museum that i was drawn to was an early dialysis machine. this was particularly interesting due to the way it looked and also the year that it was produced. for me that has all the hallmarks of an early heart lung machine. this device was referred to as a rotating Coil Artificial Kidney Machine from 1955. it was apparently the first of its type to be used in Britain following its import from across the Channel to the Hammersmith Hospital in 1955. the device mirrored the design of willem Kolff who performed the first successful human dialysis in the netherlands back in 1943. the machine pictured was actually produced by a company better known for freeze-drying equipment namely societe usifroid. the necker Hospital in Paris was the first hospital that had such a device specially made. As far as operation was concerned osmosis was as it still is the method of filtration employed. within this device blood would run through the cellophane tubing wound around a central drum which rotated in a temperature controlled bath containing 100 liters of dialysate. Above Picture of eMI s 1971 Brain scanner 24 APril 2013 www.anzcp.org (1728-1793). the collection comprises more than 3 500 anatomical and pathological preparations fossils paintings and drawings. one particularly astounding specimen was the skeleton of the 7ft 7in tall irish giant Charles Byrne. this gentleman had exhibited himself for coin at sideshows during his relatively short life. As was the fashion in those days to show remains of people following their death and his desire for this not to occur the irish giant paid a sum of money for his remains to be buried at sea. unfortunately following his demise someone paid an even greater sum of money for his body not to be buried at sea and thus commenced showing it at sideshows for profit that was of course until it was acquired by the Hunterian Museum (which has free admission). despite the free admission at the museum i was still overcome with an urge to throw a fire extinguisher through the glass cabinet grab the skeleton run the 2 kilometers to the banks of the thames and through the skeleton in. As you have not read about this occurrence in the newspapers it is a reasonable assumption that i did not carry out this reckoning . Above Rotating Coil Artificial Kidney machine 1955. it was perhaps during the process of immersing myself in the functionality of the dialysis machine that i became aware of a tugging at my sleeve and a very frustrated voice breaking into my consciousness saying daaad are you going to read everything in here . i felt sick to my stomach After the scare of the earlier day and a very strong desire to avoid further comparison between me and my father i felt it only appropriate to embark upon further exploration without unwanted input from the rest of my family. i found about an extremely well regarded yet little known museum within the royal College of surgeons in lincolns inn fields the Hunterian Museum. so on a particularly cold January morning i made my way there. Above The inside of the Hunterian museum. i think it would be fair to say that the highlights of this museum are too numerous to mention. i will however endeavor to do so. on display is a large collection of surgical instruments dating from the seventeenth century carbolic sprays used by lister the pioneer of antiseptic surgery a tooth of a megatherium (an extinct giant sloth) donated by Charles darwin and winston Churchill s dentures. i must also admit to having a macabre fascination with the history of plastic surgery which really took off following the first world war with the multitude of blast and shrapnel injuries. tucked away in a distant corner of the museum my eyes fell upon a piece of equipment that looked vaguely familiar from a picture on the wall outside of our office back in Australia. Closer examination revealed that it was indeed a heart lung machine. in fact this was a partial reconstruction of europe s very fi rst heart lung machine. lillehei and dewall at the university of Minnesota developed the design of this particular unit in 1956. sheffield surgeon Judson Chesterman visited lillehei and dewall to learn their new techniques. whilst there he purchased the associated sigmamotor pump and upon returning to sheffield had the rest of the apparatus constructed locally by the hospital s Chief scientific officer Cliff lambourne. it was fi rst used clinically for the removal of an atrial myxoma on the 26th february 1957. Above The Royal College of surgeons Lincoln s Inn Fields London. the Hunterian Museum at the royal College of surgeons over the last two hundred years has boasted renowned collections of human anatomy and pathology as well as natural history and works of art. the museum houses one of the oldest collections of anatomical pathological and zoological specimens in the uK and is based on the items assembled by John Hunter surgeon and anatomist APril 2013 www.anzcp.org 25 Above View upon entering the Wellcome Museum. Above Lillehei-DeWall Cardiopulmonary Bypass Unit with sigmamotor T6s pump 1957. i was just about to conclude my visit to the Museum for the day and commence in-depth analysis of the local beverages on offer before heading home when i discovered that also contained within the College of surgeons was the oddly named wellcome Museum of Anatomy and Pathology. the wellcome Museum contains modern anatomical and pathological teaching collections consisting of preserved wet and dry bone and tissue. the collections include more than 800 prosections demonstrating human anatomy and over 2000 specimens illustrating all the important branches of surgical pathology. due to the modern date of the specimens the wellcome Museum is regulated by the Human tissue Authority and is required to comply with the Human tissue Act (2004). the wellcome Museum is therefore not open to the public and is only open to qualified practitioners and students on recognised courses in medicine nursing and allied health subjects. fortunately for me i had brought with me my hospital identification and secured a visit for the very next day. After once again braving another bitterly cold london Morning i found myself once again entering the royal College of surgeons. this time however i was shown to the far less grand but equally impressive wellcome Museum. upon entering the museum one is immediately struck by the design. it is one large long room with five separate sections along each side. each section pertains to a different region of the body and within each section one half is devoted to anatomical specimens whilst the other half to pathological specimens. After browsing through the initial sections relating to upper limbs lower limbs brain abdomen etc i was immediately taken aback by the foetal section. this is certainly not for the faint hearted. when viewing the foetal pathological samples one must suspend reality and forget that these are actually real human specimens. even though at this time i was the only person in the museum i did not want to linger in this section longer than i deemed necessary for a professional assessment of the specimens- and what a collection they are. i next made my way to the section i was looking forward to the most namely the cardiovascular section. it is worth making it clear that when viewing the specimens within the wellcome Museum in contrast to the Hunterian Museum one is permitted to pick up the glass cases that contain the specimens rotate them and read the associated text explaining the anatomy or pathological process involved. the range of specimens was astounding. As a paediatric perfusionist i have precious little first hand experience of adult cardiac pathological processes. Having the opportunity to see many conditions up close was a privilege. i first spent time with the anatomical samples. Many of these were cut human hearts permitting useful observation of the structural anatomy of the human heart. in order to view the hearts conduction system an ox heart was displayed. due to the size of this beast s heart the conduction system can be visualised with the naked eye. Particularly impressive were the casts made of the coronary circulation. the effort required to enable these specimens to be produced could not be overstated. Above Corrosion cast of the coronary arteries mounted in a solid resin block. when looking at the pathology samples a book is made available detailing the clinical presentation of the patient and subsequent explanation of the pathologists findings. when reading journals i have personally always found case studies to be the most fascinating to read. i believe that this is due to the reader being able to immerse him or herself in the story being told. Viewing these samples and reading the associated text took this to the next level. one could read the story and view the sample imagining the patients life and experience as illness progressed. 26 APril 2013 www.anzcp.org gAZette AwArd Please remember that if you contribute any material to the gazette you will be automatically considered for one of two 250.00 cash prizes. these awards can be given to any fi nancial member of the AnZCP whom the editorial committee deem to have made an outstanding contribution to the gazette. these awards carry with them no stipulation to how they should be spent and will be presented at the Annual scientific Meeting formal dinner. Above Heart specimen showing Aneurysm of the Left Ventricle. Above specimen showing Coarctation of the Aorta. one could literally spend days in the wellcome Museum. occasionally a surgeon or a pathologist is even on hand to take visitors through the samples. i have put together a document containing many more photographs and associated text and made this available on the College website within the gazette section. to view this just click on the link www.anzcp.org and hit the gazette tab along the top. for more information on the museum visit www.rcseng.ac.uk museums if you ever find yourself in london make sure to pop in and visit this often-overlooked treasure. Remember the Gazette is only as good as what YoU contribute to it for gazette online content www.anzcp.org APril 2013 www.anzcp.org 27 Perfusion Q&A by the editorial team the Perfusion Q&A this month puts another of AnZ s elder statesmen of perfusion under the spotlight. i am of course referring to none other than new Zealand s very own tim willcox. How did you begin your carrier in perfusion well as they say i was in the right place at the right time . i had transferred to green lane Hospital from Auckland Public Hospital in 1971 to train as an anesthetic technician. there were at the time only two in the country based at green lane. i had been there just under a year when there was an unexpected exodus of perfusionists from what was then known as the Bypass unit that was precipitated (as i was later to learn) by a bit of a falling out with the senior guy and his boss - both of whom shall remain nameless. the former s partner was also a Perfusionist and part of the exodus. some wise men in the department of anesthesia - drs. Basil ferguson and Basil Hutchinson - took me aside and suggested that i should apply for a position as a trainee in perfusion. they thought i was made of the right stuff. one is very fortunate in one s youth to have mentors. i was very fortunate. so i duly applied and got the position working with sir Brian Barratt-Boyes anaesthetists Basil fergus Basil Hutch eve seelye and Marie simpson with the inimitable sid Yarrow as my boss. Perfusion was then part of the department of physiology run by dr ed Harris and toby whitlock. this group was all constantly involved in innovative research under BB as sir Brian was known and we were exposed and involved to that from the outset of my career. i did my first year of perfusion using Pemco heart lung machines the size of a house and KayCross disk oxygenators that we rebuilt and sterilized for each case. there were absolutely no safety devices (low level alarms were unheard of) and it was at times pretty bloody scary. Over the years have you found it a challenge to balance being an active researcher with clinical responsibilities My first publication was in the Journal of Cardiovascular and thoracic surgery as a co-author on residual ethylene oxide in tubing packs. we built our own and sterilized them in the unit. our attention to environmental safety was relaxed to put it mildly. Jimmy the engineer lent us a small blowtorch with which we would check the sterilizer plumbing (the flame turned blue in the presence of the eto freon mix). ed Harris who was the senior author on that paper saw my interest in research and pursuing ideas and referred to me as faraday s assistant. Apparently according to the good dr. Harris Michael faraday had an assistant who did most of the original thinking and never got the acknowledgement. getting into research is not something that one can do without a certain amount of determination a lot of support from your immediate team a good research buddy and a novel finding that has legs. i was fortunate to have all of these the most important being my association with Associate Professor simon Mitchell with whom i have collaborated on many projects mostly to do with emboli but also to do with fine food and good red wine (an important requirement of innovation). the other aspect that propelled by research interests has been my association and friendship with Associate Professor rob Baker. our collaboration spans many years and Pdu has been a vehicle to sustain my interest in research. Balancing research clinical and administrative responsibilities is down to having a supportive team (i mean of perfusionists) without whom this would not have been possible and the ability cunning resourcefulness authority - call it what you will - to make it happen. if you want it bad enough anything is possible Over your career what has been the change in perfusion technique s that has had the greatest impact upon your practice i don t think that there has been a pivotal single change in technique that i would say has had the greatest impact on my practice. Certainly all of the work on emboli and my association and friendship with the Key west outcomes group specifically david stump and John Murkin has been hugely influential. More recently i have been significantly influenced by the work of Marco ranucci who has brought a clarity of understanding around adequacy of perfusion that has lacked so much evidence and been so vaguely described and so variably practiced. Throughout your career you have pumped both adults and children do you feel either of these groups benefited from your involvement with the other and if so how i have no doubt that experience with both adult and pediatric Perfusion enhances ones ability and is of benefit to all patients. there is increasing specialization especially in pediatrics in this part of the world. there are in my mind pluses and minuses. Paediatric patients can be 100 kg - well they can be in new Zealand - so there is some overlap. there is - or has been- more manipulation of blood gas management in kids on a day-to-day basis not seen in adults and the reserves and tolerances especially in neonates can be very tight. Clearly the challenges in adults are of a different nature particularly in complex aortic work. An in depth understanding of these differences has equipped me with skills and experience i would not have gleaned to the same extent had i not had the opportunity to practice in both fields. What do you perceive as the greatest threat to perfusion in ANZ education of perfusionists in my opinion (and with no disrespect to the stellar work of the Board) perfusionists are not primarily educators. today we need to have professional educators in a recognized tertiary system - a university - taking care of the academic requirements for Perfusionist training with the end game being a vocationally recognized post graduate qualification. this needs to be integrated with practical training and that is the role of the Board and the College. this remains a challenge but one that requires a lot of energy. the younger Perfusionists need to get involved actively with the College and the Board to help make this happen 28 APril 2013 www.anzcp.org As a Chief perfusionist how do you ensure the maintenance of standards Maintenance of standards while a responsibility of the chief Perfusionist is bigger than he or she. Compliance with College or Board recertification criteria getting staff to conferences and international symposia getting involved in benchmarking and QA activities are both an individual responsibility and an employer responsibility. i established education funding as part of employee contracts many years ago. while it is not on the same scale as our medical colleagues it is sufficient to get to national or international meetings. it is no longer acceptable to use lack of funding as a reason to not be able to meet vocational recertification requirements. there are many aspects to this question but creating a culture of responsibility and striving for excellence is critical. - things like incident reporting being considered the norm obviously something i have had an interest in. Additionally in your role as Chief how to you get the best out of your team the answer is in part dealt with above. recognizing individual differences strengths and weakness and then building on them or guidance where required. we have a large eclectic team with various strengths that complement each other. As a chief you need wisdom and that takes a long time to achieve. i am still striving. You need tolerance and understanding and it can be taxing at times. i guess leading by example is a key. i am very fortunate - they might be all crazy but they are good crazy. What qualities do you think make the best perfusionist Honesty truthfulness attention to detail good communication skills intelligence and a sense of humour (A taste for red wine is not a bad thing). in your role as PirS editor how would you like to see this grow over the next 12 months it has the potential to go international with the us being interested in using it. that being the case it s gonna be bigger than me and we are in the process of expanding the whole deal. What is the best book you have read in the last 12 months india there and back. it s the one i just wrote on my month in india and very likely to go viral. As one reader said move over leo tolstoy At the end of your career what would you like to be remembered for Contrary to popular belief i don t have an end of career in sight. if i did i guess it would be that i made a difference. However i am at some risk of being remembered for less noble achievements some of which would likely include a bubble bath and possum thongs. AnZCP 30tH AnnuAl sCientifiC Meeting The Langham Hotel southbank Melbourne november 7-9 2013 it will be during the spring racing Carnival. You need to book early to ensure room availability. the langham s number is 61 3 8698 8888. the group Code for booking is AnZ07noV. see the AnZCP website for more details AnZCP.org APril 2013 www.anzcp.org 29 EQUANO QUANOX Model7600 QUANOX Model 7600 EQUANOX Model 7600 EQUANOX Model 7600 EQUANOX Model 7600 TM TM TM TMTM Regiona egional Oximeter System gional Oximeter System Regional Oximeter System Regional Oximeter System Regional Oximeter System EQUANOXAdvanceTM Sensor EQUANOX EQUANOX Advance ith EQUANOX AdvanceSensor TM Sensor with AdvanceTM TM TM Sensor with EQUANOX AdvanceSensor del8004CA 8004CA el 8004CA odel 8004CA Model Model 8004CA RESPOND TO THIS AD TODAY - TRIAL YOUR FIRST 5 PATIENTS FOR FREE with EQUANOX A Model 8004CA Nowavailable Now available NowNow available available Now available withPhilips VueLink Philips VueLink withwith Philips VueLink VueLink with VueLink with Philips Philips interface andserial serial serial interface and and serial and serial interface interface interface and data output data data outputoutput output data output data olute Absolute Unparalleled Reliability and and Accuracy Unparalleled Reliability and olute Accuracy Accuracy Unparalleled Reliability and bsolute Accuracy Unparalleled Reliability and Absolute Accuracy Unparalleled Reliability matchedConvenience atched Convenience nmatched Convenience Unmatched Convenience Unmatched Convenience Absolute Accura Unmatched Con Portable versatile and intu e versatileand and intuitive Nonin Medical s EQUANOX Model Regional 7600 Regional offers and intuitive Nonin Nonin Medical s EQUANOX 7600 7600 Regional Oximeter e versatileversatile versatile andMedical s Nonin Medical s EQUANOX Model OximeterSystemOximeter System team ab table versatile intuitive Nonin Medical s EQUANOX Model ModelRegionalOximeter SystemSystem Portable Portable and intuitive intuitive EQUANOX Model 76007600 Regional Oximeter System the clinical the thethe team the clinicalaccuracy--ineither cerebralcerebral somatic positions--regardlessskinskin clinical clinicalabsoluteaccuracy--in either cerebralor somatic somatic positions--regardless of skin of skin teamabsolute team absolute accuracy--in or or or positions--regardless of of he clinicaloffers team absolute accuracy--in either cerebralsomaticpositions--regardless of skin type features or blemishe ers offers clinical team absolute accuracy--in either either cerebral or somatic positions--regardless eaturesor type blemishes. Proprietary EQUANOX regional oximetry technology eliminates surface aturesfeatures or blemishes. Proprietary EQUANOX regional oximetryoximetry technology eliminates surface measurem e featuresblemishes. Proprietary EQUANOX regional oximetry technology eliminates surface effects or features or blemishes. Proprietary EQUANOX regional technology eliminates type orblemishes. Proprietary EQUANOX regional oximetry technology eliminates surface surface isolating isolating effects isolating ofthe thethe cortex. cortex. With an intuitive intuitive easy-to-operate EQUANOX Model 760 isolatingmeasurements of of of cerebralthe Withan cortex. With an easy-to-operate user the measurements measurements of cortex. an an intuitive easy-to-operate interface ects isolating measurementsthecerebralcerebral WithWithintuitive easy-to-operate user user interface interface effects isolating measurements cerebral cortex. cerebral intuitive easy-to-operate userinterface user interface UANOX the EQUANOX Regional Oximeter System offers both state-of-the-art Bluetooth wireless wireless Model 7600 7600 Regional Oximeter offers System offers both Bluetooth wireless UANOX Model 76007600Model OximeterSystemOximeteroffers both state-of-the-art Bluetooth technology connectivity a EQUANOX Model Regional 7600 Regional System both state-of-the-art state-of-the-art Bluetooth the EQUANOX ModelRegionalOximeter Systemoffers both state-of-the-art Bluetooth wirelesswireless logy connectivity andserialserial data outputdatagreater flexibility in patient datapatient data reporting. rugged design w ogy connectivity and connectivity outputfor greater flexibilitygreater flexibility reporting.Its Its durable Its hnology connectivity and data output output for greater flexibility in data reporting. 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AUSTRALIA NEW ZEALAND 1800 429 551 0508 338 423 customers device.com.au customers device.co.nz www.device.com.au www.device.co.nz APril 2013 www.anzcp.org 30 CArdioPulMonArY BYPAss al Oximeter System OXTM Model Case Presentation 7600sYndroMe And AntiPHosPHoliPid Varghese Bs Collins PK Bhattarai K Peiris K Ariaratnam P singhal V. Department of Cardiac surgery The Canberra Hospital. Cardiopulmonary Bypass the HlM was set up patented bonded circuit was used as per routine. the prime used was Plasmalyte 148 and 15000 iu of heparin sodium. After induction baseline ACt and blood gas sample was taken as per routine. the base line ACt was 131seconds (K-ACt) and 125seconds (C-ACt) and after a heparin dose of 40 000iu the K-ACt was 727 s and C-ACt was 829 s. Additional 5000 iu of heparin was given and a bolus of 10000 iu of heparin was added in the prime. ACt was done before bypass. the K-ACt was 1274 s and C-ACt was 1200 s. during cardiopulmonary bypass ACt was done at regular intervals and bolus dose of Heparin sodium was given to maintain ACt above the recommended value. After uneventful weaning from cardiopulmonary bypass heparin was reversed with half the dose of Protamine sulphate. the x clamp time was 64 minutes and the bypass time was 80 minutes. Post protamine the ACt returned to the base line values which were 126 s and 130 s respectively. K-ACT and C- ACT 1400 1200 1000 800 ACT AdvanceTM Sensor Introduction Antiphospholipid syndrome (APls) is also known as Hughes syndrome. it is an autoimmune hypercoagulable state caused by antibodies against cell membrane phospholipids causing thrombosis1. the disease is characterized by antibodies against cardiolipin and 2 glycoprotein i. the most common event caused by APls is stroke and deep vein thrombosis. Clinical features of APls are arterial or venous thrombosis valve disease coronary artery disease intra cardiac thrombus formation pulmonary hypertension and dilated cardiomyopathy4. Now available with Philips VueLink interface and serial Mechanism data output APls is an autoimmune disease in which Antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant) react against protein that binds to anionic phospholipids on plasma membranes there by activating the coagulation system1. Case Report A 64 Year old male was transferred from a referral hospital for an angiogram for recurring shortness of breath and chest pain. He had a history of rheumatoid arthritis Antiphospholoipd syndrome hypertension gastro oesophageal reflux disease and gilbert syndrome. He was diagnosed with APls in1999 and was on warfarin. Coronary angiogram showed critical triple vessel diseases. pre bypass ACT 1 st ACT on bypass acy warfarin was stopped one week prior to surgery and therapeutic Unparalleled Reliability and enoxaparin was ceased the nvenience whichwas commenced. day before surgery and a Heparin infusion ACT heparin 10 000 IU K- ACT C-ACT 600 400 200 0 pre bypass ACT K-ACT and C- ACT 1400 1200 1000 uitive Nonin Medical s EQUANOX Model 7600 Regional Oximeter System bsoluteCoagulation monitors accuracy--in either cerebral or somatic positions--regardless of skin es. Proprietary sodium is the drug of oximetry technology eliminates surface Heparin EQUANOX regional choice for anticoagulation mentsduring cardiopulmonary bypass. Kaolinintuitive easy-to-operate user interface of the cerebral cortex. With an activated clotting time can be affected by APl antibodies therefore Celite ACt is Discussion 00 Regional Oximeteranticoagulation monitoring2. Higher ACt Bluetooth wireless System offers both state-of-the-art recommended for and serial data output for greater flexibility in patient data reporting.is an auto immune disorder of in-vivo hypercoagulation. AlPs Its values with both K-ACt and C-ACt are recommended during Hypercoagulation may be due to many processes including bypass.2 withstands rough treatment and it is backed by a world-class technical and Baseline 1 st ACT on bypass 10 05 post protamine 8 30 9 50 10 25 10 45 11 00 11 25 11 45 800 600 400 200 0 Time heparin 10 000 IU K- ACT C-ACT Baseline post protamine 8 30 suggested methods for monitoring anticoagulation are Heparin concentrations anti-factor Xa assays Heparin ACt titration curves and ACt. we monitored anticoagulation using Kaolin and Celite ACt on the sample using Hemochron response 3 . literature recommends K-ACt of 999 s and C-ACt above 550 s 4. 9 50 10 25 10 45 11 00 11 25 11 45 activation of 10 05 coagulation inhibition of plasminogen activators Time receptors activation of platelets reaction of antibodies to low-density lipoprotein and complement activation. Adequate anticoagulation is vital during cardiopulmonary bypass due to the increased risk of thrombosis there is no consensus in the literature as to the optimal method for assuring perioperative anticoagulation. APril 2013 www.anzcp.org 31 Heparin or Bivalirudin can be used for anticoagulation Bivalirudin has a longer half-life. An ecarin clotting time point of care analyser is not available in our unit and bivalirudin does not have a known antidote therefore heparin was the drug of choice for anticoagulation. the haematologist was contacted regarding the anticoagulation plan. the gold standard for monitoring anticoagulation is laboratory based Anti-Xa assay. it is impractical to do anti-Xa assay or monitor heparin concentration whilst on bypass we therefore decided to monitor anticoagulation by doing frequent ACt (K-ACt and C-ACt). literature suggests that Kaolin activated clotting time is affected by APls antibodies and that Celite ACt is recommended for monitoring anticoagulation 2. K-ACt above 999s and C-ACt above 550s was recommended. it was decided to monitor anticoagulation with a Celite ACt and Kaolin ACt using a Hemochron response ACt machine. the Hemochron response has two wells so the samples were done simultaneously. ACt was done at regular intervals and was treated accordingly. the lowest ACt recorded during bypass was K-ACt 964s and C- ACt 799s. Additional 10000 iu of heparin was administered and ACt was above the recommended range. the patient was weaned off bypass. Heparin was reversed with half the dose of protamine. the ACt returned to base line. the total heparin administered during bypass was 65000 iu and it was reversed with 200 mg of protamine sulphate. we recommend a protamine dose based on response due to hypercoagulation rather than the actual dose. the patient was transferred to the iCu. APtt was attended in the iCu and maintained between 40- 50 secs. Heparin infusion was started six hours post operation. warfarin was started on the first post operative day. the post operative inr was 1.3. Heparin infusion was stopped on the fifth post operative day and inr was therapeutic. Patient was discharged on the eight post operative day and was readmitted on the thirteenth post operative day with pleural effusion the inr was 8.9 which was corrected with prothrombinex and was managed with chest drainage. the haematologist was consulted he advised while chest drain is in situ to continue with subcutaneous heparin and to recommence warfarin after the chest drain was removed. the patient was discharged on the twentieth post operative day. References 1. 2. 3. 4. http en.wikipedia.org wiki Antiphospholipid_syndrome Antiphospholipid syndrome cardiac surgery and cardiopulmonary bypass. Annals of cardiac anaesthesia 2011 14 146-149 lupus anticoagulation Antiphospholipid syndrome and cardiac surgery. Anaesthesia and intensive care 2010 38 364-369 Antiphospholipid syndrome its implication in cardiovascular disease a review. Journal of cardiothoracic surgery2010 5 101 Case Presentation resCue CArdioPulMonArY BYPAss After fAiled lAser eXtrACtion of iCd defiBrillAtor leAd Mcdonald Ci.1 smith i2 rapchuk i2 denman r 3 Punterere B1 and thomson B.4 Department of Perfusion. The Prince Charles Hospital. Department of Anaesthesia. The Prince Charles Hospital. 3 The Department of Cardiology (electrophysiology). The Prince Charles Hospital. 4 Department of Cardiac surgery The Prince Charles hospital. 1 2 long-term implanted pacing and defibrillator leads can be removed with laser excision thereby obviating the need for open surgical removal.1 this technique involves passing a sheath over the pacing lead under fluoroscopic guidance. the tip of the sheath emits pulses of laser light freeing fibrotic attachments between the lead and the vasculature.2 retrospective studies suggest that this is a relatively successful procedure however there are significant risks involved if extraction of the leads proves difficult. Mortality rates for this procedure vary from 1.9-3.4%.1 Most deaths are due to laceration of the major veins. immediate cardiothoracic surgical intervention is required after venous or myocardial tears if the patient is to survive. this case report involves a 54-year-old female with Brugada syndrome. the patient had a left sided single chamber implantable cardioverter defibrillator (iCd) implanted in 2005. At review in 2012 the iCd lead was found to be generating noise and a CXr showed externalized conductors . An attempt to place a second lead in the left subclavian vein was unsuccessful because of a thrombosed vein. After discussion the patient elected to have the lead extracted and replaced with a new lead rather than implanting a new device on the right side. the theatre used for laser lead extraction of pacing wires was a hybrid cardiothoracic cardiology theatre with full cardiac surgical support. there was no other pertinent patient history of note prior to presentation for surgery and the patient had uneventful anesthetic induction. Access for the insertion of the 16fr laser sheath was via 32 APril 2013 www.anzcp.org left subclavian vein. the initial dissection was performed without incident. However as the active coaxial laser device was advanced through the superior vena cava into the right atrium the patient became immediately profoundly hypotensive. the hemodynamic state of the patient was immediately life threatening and MAP pressures were noted to be 30-40mmHg with minimal cardiac output cardiac tamponade was suspected. Chest compressions were commenced in conjunction with fluid resuscitation and the arrest alarm sounded. A cardiothoracic surgeon and perfusionist were among the responders and a plan for sternotomy with cardiopulmonary bypass (CPB) on standby was made. it is standard protocol at the Prince Charles Hospital (PCH) to have a wet-primed CPB circuit available at all times this was immediately taken to theatre. two perfusionists connected water lines air oxygen electricity and handed the primed lines up to the surgical table. the setup at the PCH used a Hl20 HlM affinity oxygenator and Cdi500 blood analyzer. A cell saver was also prepared for the surgeon. the sternotomy was performed and cardiac massage continued. the surgeon determined that the inominate vein was completely disrupted and the sVC torn along its full anterior wall to the right atrium juncture. Heparin was given through a peripheral vein and also directly into the right ventricle as the patient had no circulation to distribute the peripheral heparin at this point. An ACt was not returned prior to CPB. A 22fr aortic cannula was inserted into the distal ascending aorta and CPB commenced via sucker bypass. time from the arrest bell until the patient was supported by CPB was approximately 13 minutes. immediate active cooling was commenced from a neuroprotective perspective as well as prospectively preparing the patient for a period of hypothermic arrest to facilitate venous reconstruction. on CPB it was immediately obvious that the Hb was critically low (watery arterial blood). Po2 levels were intentionally increased to 400mmHg and a blood sample sent for blood gas analysis. the surgeon at this stage inserted a two stage venous cannula into the iVC and full CPB was initiated. the blood gas result confirmed that Hb was low measured at 12 g l (Hct 4.4%). pH 7.348 Co2 39.3mmHg and lactate 6.6 mmol l. Preoperative Hb had been 138 g l. the patient did not have cross-matched packed red blood cells available so o-negative blood was requested while a cross-match was performed. four units of o-negative PrBC were added to the CPB circuit and the Hb was raised to 43 g l. lactate was 8.7 mmol l and ABe -11.3 mmol l. the massive transfusion protocol was initiated by the anaesthetist. this protocol is a new initiative for the Prince Charles Hospital and had not been activated since it went live. the surgeon determined that deep hypothermic circulatory arrest (dHCA) was required to facilitate reconstruction. the patient was cooled to 24 C and cerebral protection adjuncts were given (thiopentone 6mg kg phenytoin 15mg kg lignocaine 100mg) as well as topical ice packs for the head. An additional 4 units of o-negative blood and 4 units ffP were added to the pump while saline and albumin were also being added to the CPB circuit due to a critical shortage of volume. At 24 C the CPB pump was stopped and circulatory arrest commenced to allow repair of the sVC with bovine pericardium and pericardial tube graft repair of inominate vein. Circulatory arrest was for 28 minutes. A second period of 18 minutes circulatory arrest was also required. At recommencement of circulation the surgeon asked for a full rewarm. rewarming would only commence when sVo2 was 75% and that rewarming would stop when the patient was 36.5 C to help preserve cerebral function. A head cooling jacket was also used when patient was warm and during transport to iCu. upon rewarming a blood sample was sent for roteM (thromboelastometry) and Multiplate (platelet function) analysis. these results demonstrated no fibrinogen present and very little platelet contribution to clot quality with no measurable platelet function consistent with a measured platelet count of 12 x109 l confirmed by film examination. it was estimated that 40 units of cryoprecipitate would be needed and blood bank was informed. ten units of cryopreciptate were added at this time to the CPB circuit. rewarming was uneventful and the patient was held at 36.5 C for 30 minutes. transfusion of 5 units of platelets postCPB increased platelet function to within normal reference range valves. roteM results demonstrated normal clot quality and strength was also achieved. Hemostasis was achieved within 40 minutes of separation from CPB. 7800ml of cell saved blood was processed in the cell saver returning approximately 1800ml washed red cells to the patient. in iCu there was minimal chest drainage and day 1 post-surgery the patient recognized family and obeyed verbal commands. on post-operative day 3 the patient was diagnosed with trAli and extubation delayed until day 4. High flow nasal prongs (HfnP) were used after extubation. Hb was 97 g l on post-operative day 5. on post-operative day 6 the patient was subsequently transferred to the ward with entirely stable haemodynamics and normal neurologic status and discharged from hospital on post-operative day 10. in summary this 54-year-old lady had approximately 25 minutes CPr and 241 minutes CPB with 38 minutes dHCA. the lowest Hb on CPB was 12 g l and she received 16 units PrBC 14 units ffP 58 units of cryoprecipitate 5 units platelets and 1800 ml washed red blood cells. this case report highlights several key points. the first is that excision and removal of pacing leads should only be attempted by experienced cardiologists and in institutions that allow full and rapid conversion and handover to a cardiothoracic team. Cardiothoracic teams should routinely be on standby in the event that extractions do not go as expected as rapid sternotomy and the ability to institute CPB is critical to treat major complications. Perfusion departments should also have wet-primed CPB circuits to facilitate timely institution of CPB and where possible two perfusionsists are always a benefit to the rapid institution of CPB and optimization of perfusion for the patient in the context of massive blood loss and potential for serious neurologic insult. Profound anemia in the short term though rare is survivable and having a massive transfusion protocol and involving blood bank in the early stages of the emergency allows appropriate levels of critical blood products to be sourced. Additionally studies have shown that having access to both roteM and multiplate to guide specific blood non-red cell transfusion products is also a significant benefit over standard coagulation tests in achieving rapid hemostasis 3 especially after long CPB that involves deep hypothermia and circulatory arrest a situation that has previously been associated with significant coagulation disturbances.4 References 1. 2. 3. 4. gaca Jg lima B Milano CA et al. laser-assisted extraction of pacemaker and defibrillator leads the role of the cardiac surgeon. Ann thorac surg 2009 87 1446-50. snow Js Parekh s. update on laser lead extraction. J invasive Cardiol 2009 21 230-2. schochl H Maegele M solomon C gorlinger K Voelckel w. early and individualized goal-directed therapy for trauma-induced coagulopathy. scand J trauma resusc emerg Med 2012 20 15. Mossad eB Machado s Apostolakis J. Bleeding following deep hypothermia and circulatory arrest in children. semin Cardiothorac Vasc Anesth 2007 11 34-46. APril 2013 www.anzcp.org 33 Case Presentation trAnsesoPHAgeAl eCHoCArdiogrAPHY And neAr-infrAred sPeCtrosCoPY ProVide MetHods of MiCroeMBoli deteCtion during CArdioPulMonArY BYPAss david P. webb Ms CCP LCP Adam Blakey Bs CP Abstract Microemboli during cardiopulmonary bypass (CPB) has been investigated for several decades and has lead to changes in the conduct of perfusion equipment design and the methods to monitor and detect microemboli 1 2 3. through this evolution microemboli arising from the bypass circuit during the application of CPB remain critical due to the associated neurocognitive deficit 4 5. while there are a many devices that can be applied either directly to the CPB circuit or to the patient many employ similar ultrasound technology as utilized by transesophageal echocardiography (tee) 1 3 5. with appropriate tee probe placement microemboli can be observed during all facets of CPB with great vessel cannulation 3 6. this information along with other technologies now common to cardiac operating rooms such as near-infrared spectroscopy (nirs) can help direct cardiac teams to perform modifications to blunt microembolisation during extracorporeal circulation and identify maneuvers which promote microemboli. the following is an illustration of how tee can be used to detect microemboli during CPB support for routine mitral valve repair (MVr) and aortic valve replacement (AVr) surgery. further these data provide quality assessment of corrective measures. of microemboli provides a quality improvement assessment tool. Microemboli reduction modifications can be evaluated and recorded for there effectiveness. detection modifications and assessment is multi-faceted and requires input from the surgeon anesthesiologist and perfusionist. As tee has nearly become staple in many cardiac surgical theaters microemboli detection provides another method for quality improvement. near infrared spectroscopy (nirs) is a non-invasive method that can be used to continuously measure regional tissue oxyhemoglobin saturation (rso2). nirs relies on the Beerlambert law for measurement of the concentration of a substance according to its absorption of light biologically that substance is oxyhemoglobin and its location of penetration being the cerebral cortex of the brain. nirs has been shown in numerous studies to provide an ideal means to evaluate cerebral oxygen delivery improve cardiac surgical outcomes and may also provide evidence associated with micro-embolisation 13 14 15. Case description A 36-year-old male presented to the emergency room due to sudden onset of shortness of breath. in the emergency room he was started on a dieresis milieu and followed up with a cardiac catheterization and echocardiogram. the cardiac catheterization demonstrated no coronary artery disease however the echocardiogram demonstrated severe aortic insufficiency moderate mitral insufficiency and a dilated left ventricle. the patient was subsequently worked up for an aortic valve replacement and mitral valve repair. the preoperative laboratory values were unremarkable and all within normal limits. introduction neurocognitive decline following CPB and cardiac surgery continues to provoke much interest in the compulsory pursuit to improve outcomes and reduce cost 1 5 7. despite advancements in the conduct of perfusion and equipment design microemboli continue to be associated with CPB supported cardiac surgery 8.9.10 11. there are numerous studies evaluating various perfusion techniques during CPB to identify sources of microemboli and perspective corrective measures (table 1). while perfusion conduct improvements may blunt sequelae associated with microemboli detection monitoring and alteration requires a multi-modality team approach. tee is an invaluable diagnostic tool often used to identify cardiac structure and function but can also be used for microemboli detection 3 6 12. ultrasound technology provides the basis of tee application as whole blood properties provide an ideal medium for intravascular assessment. ultrasound waves penetrate tissue and reflect light at relational angles of tissue structure. ultrasound reflection varies with tissue density allowing visual discrimination. while tee microemboli quantification remains a challenge visualization Case Management following transfer to the surgical suite the patient had 2 nirs sensors (somanetics troy Mi.) placed on their forehead where they remained for the duration of the procedure (figure 1). Positioning of the nirs sensors was followed by the placement of an intravenous line a radial arterial line and pulmonary arterial catheter. once satisfactory general anesthesia was obtained the patient underwent a median sternotomy. CPB was initiated with ascending aortic cannulation for arterial flow and bicaval venous cannulation for drainage. Prior to CPB initiation a retrograde cardioplegia catheter was placed in the coronary sinus. After bypass was initiated the heart was 34 APril 2013 www.anzcp.org filled for the placement of a left ventricular vent through the right superior pulmonary vein. the left ventricular vent was attached to a Y connector to allow for gravity venting into the venous line and mechanical venting with a roller pump. the transition from gravity venting into the venous line and mechanical venting with a roller pump is easily performed with the movement of a tubing clamp. the tubing clamp was placed on the mechanical line resulting in significant venous air following insertion of the left ventricular vent. As the heart was being evaluated by tee for the placement of the left ventricular vent a significant amount of microemboli was noted arising from the outflow of the arterial cannula (figure 2). subsequently the perfusionist requested the gravity vent line to be clamped. once the gravity vent line was clamped and the venous air was corrected tee was used to evaluate that the maneuver had corrected the microemboli delivery (figure 3). the patient was then gradually cooled to a target temperature of 28 degrees Celsius and an aortic cross clamp was applied. the heart was arrested with approximately 600 ml. of cold high potassium microplegia delivered retrograde via the coronary sinus and approximately 250 ml. cold high potassium microplegia delivered antegrade into each coronary ostia. the remainder of the case was un-eventful with a total bypass time of 189 mins. and a total cross clamp time of 134 mins. Post-operative recovery was also uneventful as the patient was discharged on day 6 and showed no signs of neurocognitive deficit. neurological outcome following cardiac surgery and cardiopulmonary bypass is certainly multi-factorial. some studies have found that the incidence of cognitive impairment post-bypass is as high as 50% while frank stroke considerably lower 18 19. the incidence of morbidity mortality post-bypass is heavily dependent upon the surgical technique perfusion technique equipment patient co-morbidities and age. in a study performed by Alexander et al. patients receiving cardiopulmonary bypass that are at greater than 80 years of age have a mortality rate 3.8 times higher than younger patients 20 . friedrich drew similar conclusions to include the fact that patients greater than 85 years old are 5.85 times more likely to expire as a result of cardiac surgery and cardiopulmonary bypass 21. this is most likely due to poor protoplasm associated with the aging process. while the patient in this study was only 36 years old one could speculate that had the patient been older and introduced to the same amount of microemboli the outcome may have been different. Conclusion Microemboli detection and modification remains a significant area of development to improve outcomes and reduce costs associated with cardiac surgery and cardiopulmonary bypass. evidence based practices of the future will certainly include perfusion techniques and equipment that lend to enhanced neurological protection. Currently tee is common to cardiac operating suites and has the ability to not only identify micro-emboli but also evaluate maneuvers that blunt microembolization. further nirs coupled with cerebral oximetry is another technology that provides a method to identify gross embolic events and may also provide a method to observe the subtleties associated with mircoemboli. As the cardiac surgical population continues to advance in age and co-morbidities neurological success will certainly require a multi-modality team approach. increase gaseous Microemboli delivery excessive Blood Venting rapid bolus through sampling manifold surgical field air excessive venous augmentation Purging manifold with air High flow with low reservoir volume pH stat increased rewarming rate Corrective Measures Venting at min. flow rates 22 limit air with medication administration23 24 Co2 insufflation25 26 Judicious venous augmentation27 28 run manifold off of arterial filter23 24 Maintain level above manuf. recommendations23 29 Alpha stat30 Maintain temperature gradients31 discussion this particular case study provides an example of the ease at which the tee can be used to identify microemboli during all facets of cardiac surgery. As there are certainly more elegant methods to not only detect but also quantify microemboli during CPB such as transcranial doppler (tCd) and emboli detection and classification (edAC) many of these devices are not common to cardiac theaters16. further this case study also demonstrates the response of nirs through cerebral oximetry during a microemboli episode of the ascending aorta. while gross emboli can be observed during rs02 monitoring with divergent right and left graphical trends micro-emboli may not be as easily identifiable. fischer and stone presented a case in which a rapid drop in cerebral oximetry values lead to an investigation with tee which indicated microemboli being delivered to the cerebral circulation due to poor arterial cannulation12. in the pediatric population Yeh et al. demonstrated an acute deterioration in cerebral oximetry transcranial doppler readings as well as eeg due to air embolism during the fenestration phase of a fontan 17. figure 1 may demonstrate the subtleties of microembolization during rs02 monitoring with the separation of left and right graphs. following the micro-emboli episode there is an increase in the distance between the left and right graph that represents a change in saturation between the left and right hemispheres of the brain. As the left and right graphs track together and the distance between the graphs narrows over time there is typically no obvious associated sequela in-particular with the age and co-morbidties of the patient presented. Table 1 techniques which potentiate microemboli and practical corrective measures. APril 2013 www.anzcp.org 35 References 1. groom rC Quinn rd lennon P donegan dJ Braxton JH Kramer rs weldner Pw russo l Blank sd Christie AA taenzer AH forest rJ Clark C welch J ross Cs o Connor gt likosky ds. detection and elimination of Microemboli related to Cardiopulmonary Bypass. Circulation 2009 2 191-198. 2. dickinson tA riley JB Crowley JC Zabetakis PM. in Vitro evaluation of the Air separation Ability of four Cardiovascular Manufacturers extracorporeal Circuit designs. JeCt 2006 38 206-213. 3. Zanatta P Bosco e salandin V salvador l Valfre C sorbara C. Microbubbles detection during cardiopulmonary bypass with transesophageal echocardiography a case report. Cases Journal 2008 1 141-145. 4. stump dA rogers At Hammon Jw newman sP. Cerebral emboli and Cognitive outcome After Cardiac surgery. J Cardiothorac and Vasc Anes 1996 10 113-119. 5. de somer fMJJ Vetrano Mr Van Beeck JPAJ Van nooten gJ. extracorporeal bubbles a word of caution. interactive Cardiovasc and thorac surgery 2010 10 995-1002. 6. tingleff J Joyce fs Pettersson g. intraoperative echocardiographic study of Air embolism during Cardiac operations. Ann thorac surg 1995 60 673-677. 7. likosky ds Marrin CAs Caplan lr Baribeau Yr Morton Jr weintraub rM Hartman gs Hernandez Jr. f Braff sP Charlesworth dC Malenka dJ ross Cs o Connor gt. determination of etiologic Mechanisms of strokes secondary to Coronary Artery Bypass graft surgery. stroke 2003 34 2830-2834. 8. Mitchell sJ wilcox t gorman df. Bubble generation and venous air fi ltration by hardshell venous reservoirs a comparative study. Perfusion 1997 12 325-333. 9. Figure 1 inVos graph during procedure. 10. riley JB. Arterial line filters ranked for gaseous Micro-emboli separation Performance An in Vitro study. JeCt 2008 40 21-26. 11. Borger M Peniston C weisel r Vasiliou M green r feindel C. neuropsychologic impairment after coronary bypass surgery effect of gaseous microemboli during perfusionist interventions. J thorac Cardiovasc surg 2001 121 743-9. 12. fischer gw stone Me. Cerebral Air embolism recognized by Cerebral oximetry. sem in Cardiothorac and Vasc Anesthesia 2009 13 1 56-59. 13. goldman s sutter f ferdinand f trace C. optimizing intraoperative Cerebral oxygen delivery using noninvasive Cerebral oximetry decreases the incidence of stroke for Cardiac surgical Patients. the Heart surg forum 2004 7 5. 14. Murkin JM Adams sJ novick rJ Quantz M Bainbridge d iglesias i Cleland A schaefer B irwin B fox s. Monitoring Brain oxygen saturation during Coronary Bypass surgery A randomized Prospective study. Anesthesia & Analgesia 2007 104 (1) 51-58. 15. Yao fs tseng CC Ho CY levin sK illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2004 18(5) 552-8. 16. Barbut d Yao fs Hager dn Kavanaugh P trifi letti rr gold JP. Comparison of transcranial doppler ultrasonography and transesophageal echocardiography to Monitor emboli during Coronary Artery Bypass surgery. stroke 1996 27 87-90. 17. Yeh t Jr Austin eH 3rd sehic A edmonds Hl Jr. rapid recognition and treatment of cerebral air embolism the role of neuromonitoring. J thorac Cardiovasc surg 2003 126(2) 589-91. 18. newman Mf Kirchner Jl Phillips-Bute B gaver V grocott H Jones rH Mark dB reves Jg Blumenthal JA. longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. n engl J Med 2001 344(6) 395-402. 19. M rie C K ber l olsen Ps Andersson C Jensen Js torp-Pedersen C. risk of stroke After Coronary Artery Bypass grafting effect of Age and Comorbidities. stroke 2011 oct 27. [epub ahead of print] 20. Alexander KP Anstrom KJ Muhlbaier lH grosswald rd smith PK Jones rH Peterson ed. outcomes of cardiac surgery in patients or 80 years results from the national Cardiovascular network. J Am Coll Cardiol 2000 35(3) 731-8. 21. friedrich i simm A K tting J th len f fischer B silber re. Cardiac surgery in the elderly patient. dtsch Arztebl int 2009 106(25) 416-22. 22. svitek V lonsky V Anjum f. Pathophysiological aspects of cardiotomy suction usage. Perfusion 2010 25(3) 147-52. 23. rodriguez r A williams K A Babaev A rubens f nathan HJ. effect of perfusionist technique on cerebral embolization during cardiopulmonary bypass. Perfusion 2005 20(1) 3-10. 24. taylor rl Borger MA weisel rd fedorko l feindel CM. Cerebral microemboli during cardiopulmonary bypass increased emboli during perfusionist interventions. Ann thorac surg 1999 68(1) 89-93. 25. webb wr Harrison lH Jr Helmcke fr Camino-lopez A Munfakh nA Heck HA Jr Moulder PV. Carbon dioxide field flooding minimizes residual intracardiac air after open heart operations. Ann thorac surg 1997 64(5) 1489-91. 26. svenarud P Persson M van der linden J. effect of Co2 insufflation on the number and behavior of air microemboli in open-heart surgery a randomized clinical trial. Circulation 2004 9 109(9) 1127-32. 27. Jones tJ deal dd Vernon JC Blackburn n stump dA. does vacuum-assisted venous drainage increase gaseous microemboli during cardiopulmonary bypass Ann thorac surg 2002 74(6) 2132-7. 28. willcox tw Mitchell sJ gorman df. Venous air in the bypass circuit a source of arterial line emboli exacerbated by vacuum-assisted drainage. Ann thorac surg 1999 68(4) 1285-9. Jones tJ deal dd Vernon JC Blackburn n stump dA. How effective Are Cardiopulmonary Bypass Circuits at removing gaseous Microemboli JeCt 2002 34 34-39. Figure 2 Microemboli observed with tee. Figure 3 tee observation following microemboli corrective measures. 29. nielsen Pf funder JA Jensen M nygaard H. influence of venous reservoir level on microbubbles in cardiopulmonary bypass. Perfusion 2008 23(6) 347-53. 30. Patel rl turtle Mr Chambers dJ James dn newman s Venn ge. Alpha-stat acid-base regulation during cardiopulmonary bypass improves neuropsychologic outcome in patients undergoing coronary artery bypass grafting. J thorac Cardiovasc surg 1996 111(6) 1267-79. 31. Borger MA rao V. temperature Management during Cardiopulmonary Bypass effect of rewarming rate on Cognitive dysfunction. sem in Cardiothorac and Vasc Anesthesia 2002 6(1) 17-20. 36 APril 2013 www.anzcp.org original Article sHould Air BuBBle deteCtors Be used to QuAntifY MiCroBuBBle ACtiVitY during CPB richard f newland Bsc CCP robert A Baker PhD CCP Annette l Mazzone Bsc (Hons) CCP Vijaykumar n Valiyapurayil Bsc DipPT. Cardiac and Thoracic surgical Unit Department of Medicine Flinders Medical Centre and Flinders University of south Australia Adelaide south Australia Australia. Air bubble detectors (ABd) are utilized during cardiopulmonary bypass (CPB) to alert Perfusionists to the presence of air in the arterial line and help protect against massive air embolism. Although modern techniques equipment and technology of CPB have minimized the incidence of fatalities from massive air embolism arterial gaseous microemboli (gMe) still represent a problem during conventional CPB (Kurusz 2004). gMe may arise from a number of different sources during cardiac surgery such as the ejection of residual air from the heart chambers or pulmonary veins after aortic declamping aortic cannulation bubble generation by venous reservoirs entrainment of air into the CPB venous line (Mitchell 2002) as well as drug injec tion aortic cannula type and placement levels of vacuum ( 40 mmHg) high blood flow rates (6 l min) tempera-ture gradient and long CPB duration (doganci 2013). Cognitive decline after cardiac surgery known as postoperative cognitive dysfunction (PoCd) is a common complication and has been reported in approximately 50% of patients at discharge 36% at 6 weeks 26% to 33% at 1 year and 42% at 5 years postop-eratively (Martin 2009). Although there has been some controversy as to the size and number of gMe that are associated with PoCd the body of evidence linking embolization to clinical outcome is increasing (Mitchell 2002 doganci 2013). doganci et al demonstrated significantly greater PoCd in patients exposed to 500 gMe during CPB compared to those that were exposed to 250 gMe at 1 week postoperatively which was not significantly different at 1 month. these results highlight the importance of minimising the number of gMe in reducing the incidence of CPB associated PoCd. Air bubble detectors utilized with the siii and s5 heart lung machines (stockert Munich germany) are purported by the manufacturer to quantify microbubbles 300 m (stockert siii and s5 operating Manuals) from which data may be generated and stored using the data Management system (stockert Munich germany). given the implication of gMe in PoCd data that is generated for reporting purposes must be reliable and accurate. the aim of this study was to assess the reliability and accuracy of the microbubble counts to determine suitability for inclusion in the CPB report. Microbubble detection Microbubble counts from the stockert 3 8 ABd with the siii heart lung machine (siiiABd) and stockert 3 8 ABd with the s5 heart lung machine (s5ABd) were compared against the emboli detection and classification (edAC) (luna innovations roanoke usA) quantifier during CPB. data was generated from the heart lung machine at 20 second intervals and collected using the data Management system (stockert). Measurements were obtained simultaneously using 2 edAC transducers and 2 ABd in series in the arterial line between the oxygenator and the arterial line filter throughout 6 CPB procedures for each ABd to allow simultaneous measurement for each detector type (figure 1). the siiiABd s and one s5ABd had been utilised clinically and an additional ABd was provided for the study by the distributor (Cellplex pty ltd.) to be utilised on the s5. edAC transducers s5 air bubble detectors Clinical Management general anaesthesia was induced with fentanyl (10 30 g kg) and supplemented with sevoflurane and or propofol. All patients underwent cardiac surgery with CPB using a siii roller pump (stockert). the arterial pressure was monitored via a radial artery catheter. CPB was instituted after positioning of either a single 36 51 fr two-stage atrial cannula (sarnstM terumo Corporation tokyo Japan) or 32 36 fr bicaval cannula tion (sarnstM) and a 22 fr ascending aortic cannula (dlP Medtronic Minneapolis Mn) or a 20 fr femflex used in the ascending aortic position (edwards lifesciences irvine CA). the CPB circuit included a hard-shell membrane oxygenator (Capiox sX25rX) biopassive tubing (sMArxt Cobe Cardiovascular Arvada Co) a 40-micron arterial-line filter (d703 dideco Mirandola italy) and a 0.2-micron pre-bypass filter (Prebypass Plus Pall Corporation Port washington nY). the circuit was primed with 375 ml of Plasmalyte solution 500 ml of gelofusine (isolated APril 2013 www.anzcp.org Methods study approval (344.12) was given and the requirement for written informed consent was waived by the southern Adelaide Clinical Human research ethics Committee. data was collected for 12 patients undergoing routine CPB. 37 CABg procedures) or 4% albumin (other procedures) 50 ml 8.4% sodium bicarbonate solution 375 ml Hartmann s solution and 10 000 iu heparin. Packed red blood cells were added if required to provide a predicted haemoglobin level of 7 g dl on initiation of CPB (deter mined by the algorithm of the dMs software). the CPB protocol included an arterial non-pulsatile target flow rate of 1.8-2.4 l min m2 alpha-stat pH management with a target po2 of 100-250 mmHg gravity venous drainage and tepid systemic temperature management (nasopharyngeal temperature 3435 C) with no active cooling. After placement of the aortic crossclamp car dioplegic arrest was induced with blood cardioplegia (32-34 C) 30 mmol l at induction and intermittent boluses (16 mmol l) as required. Mean CPB arterial pres sure was controlled using metaraminol phentolamine or isoflurane to achieve a target of 40-80 mmHg the target nasopharyngeal temperature for separation from bypass was 36 C with a maximum arterial outlet temperature of 37 C and rewarming rate 1 C per min. transfusion of red blood cells during CPB was trig gered when the haemoglobin level was measured to be 7 g dl. Figure 3. Microbubble counts from one of the siii ABd plotted against the other at simultaneous time points during cardiopulmonary bypass (n 4592 spearman correlation coefficient r 0.008). data Analysis reliability was assessed by the spearman correlation co-efficient (r) between simultaneous measurements for each detector type. Accuracy of the ABd microbubble counts was assessed using Bland-Altman analysis of difference between edAC counts 300 m and ABd counts (sPss V20.0). A weak negative correlation was found with the two s5ABd (r -0.16 p 0.001) (figure 4). results reliability correlation of simultaneous air bubble detector microbubble counts 4592 measurements at 20-second intervals were obtained for the ABd in 6 procedures using the siii heart lung machine and 5924 measurements using the s5. Average microbubble counts for each air bubble detector and average edAC counts 300 m are shown in figure 2. Figure 4. Microbubble counts from one of the s5 ABd plotted against the other at simultaneous time points during cardiopulmonary bypass (n 5924) spearman correlation coefficient r -0.16). Accuracy comparison of simultaneous air bubble detector microbubble counts with EdAC counts Figure 2. Mean microbubble counts for the air bubble detectors and the edAC transducers (error bars indicate standard error of the mean). for the s3 the counts for ABd2 were greater than ABd1 and edAC for the s5 both ABd were greater than the edAC and also greater than the siiiABd. Bland-Altman plots of the difference between edAC microbubble counts 300 m and ABd counts against the difference between edAC and ABd microbubble counts for each siiiABd are shown in figure 5 and for the s5ABd in figure 6. the comparison of microbubble counts recorded for each siii ABd is shown in figure 3. no correlation was found between microbubble counts recorded using the two siiiABd (r 0.008 p 0.793). 38 APril 2013 www.anzcp.org Figure 5. Bland-Altman plots of the difference between edAC microbubble counts 300 m and ABd counts against the difference between edAC and ABd microbubble counts for each siiiABd. the s3ABd1 counts were within the limits of agreement (2 standard deviations from the mean) for counts 2. the difference between edAC and siiiABd2 counts increased as the average of the counts from the 2 different devices increased. Figure 6. Bland-Altman plots of the difference between edAC microbubble counts 300 m and ABd counts against the difference between edAC and ABd microbubble counts for each s5ABd. for both s5ABd the difference between edAC and s5ABd counts increased as the average of the counts from the 2 different devices increased. industrial reference including the edAC and gampt BC200 (gAMPt mbH Zappendorf germany) (desomer 2010). the edAC transducer emits ultrasonic pulses every 1 ms which are reflected by emboli in the blood as they pass through the edAC connector. the amplitude of the reflected signals is then analysed to determine bubble size count and calculated volume (total embolic load). the manufacturer states that the device is capable of counting emboli with diameters from 10 m up to the diameter of the connector at a rate of up to 1000 emboli per second at flow rates between 0.2 and 6 l min (desomer 2010). the BC200 uses a pulsed ultrasonic doppler system to generate an amplitude-modulated low frequency signal depending on the size of the bubble and the time that the bubble is present in the detection signal. signal transformations allow calculation of the bubble size from the maximum amplitude of the corrected signal. the manufacturer states that the device is capable of counting emboli with diameters between 5 and 500 m at a rate of up to 1000 emboli per second at flow rates between 0.5 and 8 l min (desomer 2010). even using commercially available devices designed specifically to quantify microbubbles during CPB there are some limitations. desomer et al s study reported that both devices underestimate the number of microbubbles at 3 l min the edAC counts 38% the gampt 18% of total counts and at 6 l min both the edAC and gampt only count 3% of total counts. the authors concluded that both the edAC and gampt can be used in a clinical setting for monitoring basal gMe production however both devices have limitations when used for studying worst case scenarios. these findings highlight the limitations associated with microbubble measurement and reinforce the finding that air bubble detectors should not be used for this purpose. in our study we observed a significant correlation between edAC detectors for simultaneous measurements (r 0.096 p 0.001) demonstrating reliability in measurement and considerable contrast to the air bubble detectors reliability. the stockert air bubble detectors transmit an ultrasonic pulse through the CPB circuit tubing that is received by a piezo-element detector. since sound travels 5 times faster through fluid than air the presence of air bubbles will result in a drop in the signal amplitude that is received by the detector as the blood travels past the detector. According to the manufacturer the smallest single -bubble that the sensor can detect is 300 m in diameter. the sensor can detect conglomerates of much smaller -bubbles if the drop in signal amplitude is equal to or greater than that of a 300 m diameter single -bubble. since the system detects a total drop in receive signal amplitude the device cannot count -bubbles or determine how large the individual bubbles are. in our study we not only observed differences in measurements between air bubble detectors on the same heart lung machine but also between heart lung machines. Although the air bubble detectors are interchangeable between heart lung machines the modules used to process the signals from the detectors are not which may account for the differences in measurements between the siii and the s5. in a recent survey (Kelting 2012) 96.8% of respondents routinely utilised an air bubble detector during CPB a figure comparable to the 2006 Australian and new Zealand Perfusion equipment and monitoring survey of 54 centres with 100% utilisation (Baker 2006) both these regions considerably higher that the 32% of respondents in a french survey of 57 centres (Charri re 2006). the reported incidence of air embolism during CPB is relatively infrequent the Charri re et al 2006 survey reported a rate of 1 3757 procedures and 1 13 426 in an American survey discussion this study demonstrated that during our evaluation both s3ABd and s5ABd were unreliable for quantification of microbubble activity during CPB and inaccurate in comparison to the edAC. we were unable to demonstrate correlation of the microbubble data obtained with simultaneous measurements using the air bubble detectors on either the siii or s5 heart lung machines. the Bland-Altman plots illustrate that as the number of microbubble measurements increase the difference between the edAC counts of microbubbles 300 m and the air bubble detectors measurements also increase. this may be explained by the relatively few microbubbles detected by the edAC 300 m therefore the majority of the data in the Bland-Altman plots for the s5ABd and the siiiABd2 represent the over-reading of the ABd. in addition comparatively much greater numbers of microbubbles were detected using the s5 than with the siii. Although the differences between the siiiABd1 detector and the edAC (figure 5) may not be clinically significant it would not be practicable in clinical practice to utilise data from one of the siiiABd and not the other. A major limitation in the microbubble data from the air bubble detectors is that they do not provide detail of bubble sizes this renders the data meaningless as it is impossible to quantify bubble volume to define embolic load. these results highlights the importance of ensuring that all data that is intended to be included in the CPB report is accurate and clinically relevant and furthermore quantification of microbubbles during CPB should be achieved using a device specifically designed for this purpose. desomer et al reported a comparison of commercially available microbubble detection devices used during CPB against an APril 2013 www.anzcp.org 39 in 2000 (Mejack 2000). it is unclear as to the number of procedures in which the air bubble detector has resulted in the avoidance of air embolus being delivered to the patient although the 2010 dutch incident survey indicated 13% of respondents had experienced air embolus after the venous reservoir. therefore from a safety perspective air bubble detectors have an important role (Charri re 2006). the stockert air bubble detectors will alarm if a bubble is detected with a diameter of 5.5mm or greater in 3 8 tubing (stockert manual) therefore the issues with regard to microbubble quantification relate to clinical informatics and medico-legal concerns in the reporting of the microbubble data. Although our study was not designed to assess the use of air bubble detectors as a safety device for detection of microemboli our results suggest that air bubble detectors should be relied upon for detection of gross air only. the limitations of our study were that we measured emboli at one position within the CPB circuit and since not all of our data was obtained in open cardiac chamber procedures we may not have had the opportunity to measure as many emboli as possible. we compared the air bubble detectors against the edAC rather than an industrial reference therefore our comparison of accuracy is limited by the underestimation of the edAC. given the lack of correlation between the air bubble detector measurements from a practical outcome perspective the data from the air bubble detectors is not reliable therefore an assessment of the accuracy of this data was of academic interest only. in addition the age of the air bubble detectors was different the s5ABd were both 1 year old and the age of the siiiABd were 2 - 3 years old. All air bubble detectors had passed routine maintenance testing. despite these limitations the data from this study represents what would be detected during routine procedures in our centre and therefore our findings are representative of our clinical practice. Boots on the ground Perfusion visit... www.circuitsurfers.com Conclusions Both s3ABd and s5ABd were found to be unreliable for quantification of microbubble activity during CPB and inaccurate in comparison to the edAC. these results highlight the importance of ensuring that all data that is intended to be included in the CPB report is accurate and clinically relevant and furthermore quantification of microbubbles during CPB should be achieved using a device specifically designed for this purpose. references Baker r A willcox tw. Australian and new Zealand Perfusion survey equipment and Monitoring. JeCt. 2006 38 220 229. Charri re JM P lissi J Verd C et al. survey retrospective survey of Monitoring safety devices and incidents of Cardiopulmonary Bypass for Cardiac surgery in france. JeCt. 2007 39 142 157 filip M.J.J. de somer Maria r. Vetrano Jeroen P.A.J. Van Beeck and guido J. Van nooten. extracorporeal bubbles a word of caution. interact CardioVasc thorac surg 2010 10 995-1001. s doganci s gunaydin o Murat Kocak s Yilmaz and u demirkilic. impact of the intensity of microemboli on neurocognitive outcome following cardiopulmonary bypass. Perfusion. feb 2013. epub ahead of print Kelting t searles B darling e. A survey on air bubble detector placement in the CPB circuit a 2011 crosssectional analysis of the practice of Certified Clinical Perfusionists. Perfusion 27(4) 345 351 Kurusz M Butler Bd. Bubbles and bypass an update. Perfusion 2004 19 s49 Martin KK wigginton JB Babikian Vl Pochayd Ve Crittenden Md rudolph Jl. intraoperative cerebral high-intensity transient signals and postoperative cogni tive function a systematic review. Am J surg 2009 197 55 63. Mejak B stammers A rauch e Vang s Viessman t. A retrospective study on perfusion incidents and safety devices. Perfusion. 2000 15 51 61. Mitchell s gorman d. the Pathophysiology of Cerebral Arterial gas embolism. JeCt. 2002 34 18 23 siii operating Manual. stockert instrumente Munich germany. s5 operating Manual. stockert instrumente Munich germany. 40 APril 2013 www.anzcp.org APril 2013 www.anzcp.org 41 operation oPen HeArt from the small island nation of tonga Ana was incredibly sick with heart failure imminent as a result of rheumatic fever. A cardiologist diagnosed that Ana had severe damage to the mitral valve the aortic valve and some irregularities with the tricuspid valve. she was too sick for surgery and it was reluctantly concluded that she had only a fi nite time to live. whilst operation open Heart was providing surgery to other patients Ana s condition however improved somewhat. the improvement gave the team hope that she would be able to cope with complex and difficult surgery and a decision was made to push forward. surgery commenced at 3 00pm on sunday afternoon and she was wheeled into iCu just before midnight. Her marathon case left Ana with her mitral and aortic valves replaced and now working properly and it was decided that since the tricuspid function appeared to have improved as shown by toe it did not need replacing. two years on Ana returned to the same hospital a different person and for a different reason. Her family wanted to say thank you the only way they knew how they prepared a meal for the entire operation open Heart team. it was an extravagant feast of some 30 dishes that covered both tables in the tearoom and took the family 36 hours to cook up. now completing high school the difference in Ana is remarkable. she s not sure what she would like to do after school but is considering a career in nursing. in an emotional speech to the team she broke down in tears trying to express how thankful she was and there weren t many dry eyes in the room. if you would like to fi rst hand experience how humbling and rewarding working in developing countries can be volunteering opportunities exist with operation open Heart. A return visit to tonga in september is one of six surgical visits planned during 2013. further information including the calendar of scheduled visits can be obtained at www.ooh.org.au or alternatively contact Hayden dando or speak to Michael were at operation open Heart. name changed for privacy. 42 APril 2013 www.anzcp.org ConferenCe Corner by Clarke thuys CCP. we are delighted to confi rm that the AnZCP 30th Annual scientific Meeting will be held at the langham Hotel southbank Melbourne on november 7-9 2013. the program as is now becoming the norm will run from thursday afternoon until saturday afternoon with a mix of formal and informal sessions as well as the AnZCP Annual general Meeting. the gala dinner on the saturday night is in the swanston room at the Melbourne town Hall with a guest speaker and of course plenty of dancing. the friday night event will be far less formal including a beer education session (for those interested) conducted by a local craft brewer. the venues are both within easy walking distance of the hotel ( 800m). the program is fast being fi lled but we can announce that at this stage international speakers include dr. Matthias Arlt director department of Anesthesiology and intensive Care Kerckhoff Heart and lung Centre Bad nauheim gerMAnY. Mr Alois Philipp Perfusionist eCMo specialist Kerckhoff Heart and lung Centre Bad nauheim gerMAnY. invited papers include presentations on rotem thromboelestography eCMo coagulation nirs ischaemic Preconditioning neuromonitoring beyond eeg At this time in Melbourne spring racing Carnival is in full swing so accommodation will be very tight so please consider booking early to ensure your fi rst choice of hotel. At present the anticipated registration fee will be approx 750 - 800. 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FreseniusFortoAustralia Pty Limitedplease contact For Kabi more 1 For more information contact please aims to improve clinical outcomesimprove clinical nnecessary avoiding nnecessaryexposure information please components1 aims to improve clinical outcomes by exposure to blood 964 exposure blood components1contact Pacific Highway to aims to by avoiding outcomes by avoiding nnecessarycomponentsto blood Fresenius Kabi Australia Pty LimitedFresenius Kabi blood components1 aims to improve clinical outcomes by avoiding nnecessary exposureKabito Australia Pty Limited Fresenius Australia Pty Pymble NSW 2073 Australia Limited 964 Pacific Highway References 1.National Blood Authority. Patient Blood Management Guidelines Module 2 Perioperative. 2012 [cited 2013 Feb 5]. Available from http www.nba.gov.au guidelines module2 po-mod2.pdf References 1.National Blood Authority. Patient Blood Management Guidelines Module 2 Perioperative. 2012 [cited 2013 Feb 5]. Available from http www.nba.gov.au guidelines module2 po-mod2.pdf PM2013.050 2. Florio G et al. Int J Artif Organs 1996 19(7) 431-434 3. Shulman G et al. JECT 2000 32(1) 11-19 JECT 2000 32(1) 11-19 2. Florio Perioperative. Organs [cited 2013 Feb 5]. Available G et al. References 1.National Blood Authority. Patient Blood Management Guidelines Authority. PatientInt J Artif 2012 1996 19(7) 431-434 3. Shulman from http www.nba.gov.au guidelines module2 po-mod2.pdf References 1.National Blood Module 2 G et al. Blood Management Guidelines Module 2 Perioperative. 2012 [cited 2013 Feb 5]. Available from http www.nba.gov.au guidelines module2 po-mod2.pdf 2. Florio G et al. Int J Artif Organs 1996 19(7) 431-434 G et al. Int J Artif al. JECT 1996 19(7) 431-434 3. Shulman G et al. JECT 2000 32(1) 11-19 2. Florio 3. Shulman G et Organs 2000 32(1) 11-19 Think Think Think Think Thinkplusplus C.A.T.S plus C.A.T.S C.A.T.Splus plus C.A.T.S C.A.T.S 964Service 1300 732 Pacific Highway Customer964 Pacific Highway 001 Limited Fresenius Kabi Australia Pty Pymble NSW 2073 Australia Pymble NSW NSW 2073 Australia Pymble 2073 Australia www.fresenius-kabi.com.au 732 964 Pacific Service 1300 732 Customer Service 1300 Customer Service 1300 732 001 CustomerHighway 001 001 PM2013.050 www.fresenius-kabi.com.au www.fresenius-kabi.com.au Pymble NSW 2073 Australia www.fresenius-kabi.com.au PM2013.050 PM2013.050 PM2013.050 Customer Service 1300 732 001 www.fresenius-kabi.com.au APril 2013 www.anzcp.org 43 The following pages contain the abstracts from the AnZCP 29th Annual scientific Meeting Uluru. is eVerYtHing oKAY (i M not sure) A CAse PresentAtion Martin gill CCP The Heart Centre for Children sydney Australia. near-infrared spectroscopy (nirs) is rapidly being embraced as an adjunct to standard monitoring for patients undergoing cardiopulmonary bypass. whilst not yet widely accepted as a gold standard of care this form of monitoring is being factored into clinical care decision making and influencing medical interventions. A boy with a history of pulmonary atresia had a glen shunt performed at 7 months of age. this initial operation was complicated by post-operative strokes believed to be of embolic origin. the child now 7 years of age presented for completion of fontan circulation and was placed on cardiopulmonary bypass (CPB) with a standard terumo x-coated circuit and Medtronic Pixie oxygenator. due to a high pre-operative haematocrit this patient did not require a blood prime. throughout the bypass procedure standard markers of adequacy of perfusion- venous saturations urine output and lactate were all acceptable. following commencement of CPB both cerebral and somatic nirs had a precipitous fall that was largely unresponsive to intervention. during the bypass run the mean arterial pressure (MAP) measured on the right radial artery was also largely unresponsive to interventions tasked with raising this value. Prior to cessation of bypass following rewarming from mild hypothermia both the nirs value and MAP rose to baseline. the patient was separated from bypass without incident and had an uneventful post-operative course. this case raises many interesting questions that remain yet to be answered- was the level of intervention appropriate in the face of acceptable standard makers of perfusion adequacy Can technology become a distraction when not in keeping with other monitoring modalities does nirs provide valuable information on a regional scale that other markers of perfusion cannot assess Could nirs be affected by circuit component coatings does the post-operative review of data reflect the perception of intra operative intervention eCMo retrieVAl froM dArwin Keith Adkins Trainee Perfusionist. st Vincent s Hopsital Victoria street Darlinghurst nsW Australia nsw eCMo retrieval service has been operational since May 2009 retrieving around 50 cases to date. the service is provided by st Vincent s hospital and royal Prince Alfred hospital. the service covers the whole of new south wales although they have also retrieved cases from Queensland Alice springs and noumea. the retrieval service is funded by new south wales Health. the service retrieves both Veno-Venous and VenoArterial eCMo. on the 9th february 2012 the retrieval service was referred a patient in royal darwin Hospital s iCu. the patient was a 36 year old female with a two month history of dilated Cardiomyopathy and atrial fibrillation. she was being managed as an out-patient in darwin until she presented to ed with sudden decompensation. she was admitted to the iCu and had a near arrest and was commenced on an intra-aortic balloon pump multiple inotropes and CVVHdf. An eCMo retrieval from darwin would have been the longest retrieval performed by the service. it was 3150 kms and a 41 2 hour flight. the distance was the range of the learjet. the long distance meant the time from getting the referral to commencing eCMo was 10 hours. Also the long distance meant staff would be extremely fatigued. As well as this attempting to fix technical problems in the plane were difficult due to the planes size. despite this the patient was safely retrieved back to st Vincent s hospital. 44 APril 2013 www.anzcp.org AsPirin iMProVes oXYgenAtor longeVitY An eCMo CAse rePort Viji Vincent Clinical Perfusionist Royal Perth Hospital WA. A 19 year old female with cystic fibrosis (Cf) was admitted to iCu with type 2 respiratory failure secondary to infective exacerbation. rapid clinical deterioration after 10 days required institution of veno-venous extra corporeal membrane oxygenation (VV eCMo) as bridge to transplant. the patient was extubated on the 3rd day after instigating eCMo and kept awake through out. the main issue during this eCMo run apart from sepsis and bleeding was frequent oxygenator failure. 6 eCMo circuits were used for a total run of 48-days. the first two eCMo circuits were changed on 5th and 10th day due to deteriorating oxygenator function. there were fibrin strands clearly visible each time the oxygenator failed in spite of adequate anticoagulation. three days after the second circuit change-out the oxygenator started deteriorating again. the pulmonary manifestation of Cf is characterized by the production of viscous mucous that obstructs the airways underlying the subsequent inflammatory reactions and infections. it appeared that there may be a link between Cf platelets coagulation and inflammation which called for a slightly altered anticoagulation management. After much consideration1 2 3 and several conversations with other eCMo specialists a low dose (100mg day) of Acetyl salicylic Acid (Aspirin) was commenced soon followed by another circuit change out the following day. After instituting aspirin the 4th and 5th circuits were used for 15 and 17 days respectively. the patient received bilateral lung transplant two days after the 6th change-out. the post-op period was pretty smooth and devoid of any complications. references Bein et al. Addition of Acetylsalicylic Acid to Heparin for Anticoagulation Management during Pumpless extracorporeal lung Assist AsAio Journal 2011 57 164 168. Phillip et al. inhibition of thrombocyte aggregation during extracorporeal lung assist a case report Perfusion 2007 22 293 297. d. tondelier et al. Aspirin and some other nonsteroidal anti-inflammatory drugs inhibit cystic fibrosis transmembrane conductance regulator protein gene expression in t-84 cells Mediators of inflammation 8 219 227 (1999) Assessing tHe AdeQuACY of Perfusion And inflAMMAtorY MediAtion steven w. sutton l.P. C.C.P. V.P. Cardiovascular support services Inc. Texas Health Heart & Vascular Hospital the introduction of cardiopulmonary bypass on the world scene in the early 1950 s is one of many quantum leaps of the twentieth century for the benefit of humanity. it took around 300 years of medical and scientific discovery to make this dream a reality. we observed a global effort to eradicate and treat cardiac disease as a result when this goal throughout our history seemed unattainable. John gibbon recognized from day one the activation of complement antibodies and the morphological changes undergone by neutrophils which was poorly understood. Cardiopulmonary bypass since its inception has been incriminated for exacerbating the inflammatory response known by the acronym sirs. this adverse effect ranging from minimal to life-threatening systemically manifests itself in virtually all of the major organ systems of the body postoperatively as is evidenced in the medical literature. for 25 years a direct air-blood interface dominated our technology in the form of the bubble oxygenator and suction systems. today semipermeable membrane oxygenators have been utilized now for around 26 years predominantly with the introduction of changes in bioactive coated surfaces and reduced or eliminated air-blood interface. in spite of this we continue to observe undesired sequalae directly attributed to the artificial blood contact surfaces. Perfusion scientist have made many advances as we will explore in this lecture and reveal the good-the Badthe ugly in our past and present endeavors and attempt to peak into the future for potential methods to eliminate organ failure post bypass. this lecture examines complement biology and the microbiology of inflammatory mediation with emphasis on the published medical literature and original investigative work by the author. Attendees will achieve a greater knowledge in their daily practices which will hopefully enable them to engage in self-examination modification and implementation of simple technique changes as they endeavor to improve the product of their microbiological work. Additionally fellow practitioners will share ideas methods and techniques in open dialogue with one another as a positive outcome to reach out to others in our small community of professionals. APril 2013 www.anzcp.org 45 CliniCAl nirs MeAsureMents of CereBr Al oXYgenAtion HAeModYnAMiCs And MetABolisM eCMo And BeYond Clare elwell Biomedical optics Research Laboratory Department of Medical Physics and Bioengineering University College London London UK. near infrared spectroscopy (nirs) has found widespread application as an optical monitoring technology for the assessment of cerebral oxygenation haemodynamics and metabolism (1). the continuous non invasive and bedside nature of the measurement has led to its application in intensive care settings particularly for monitoring infants and children (2). to date nirs systems used clinically are single or dual channel systems which do not allow evaluation of the status of cerebral circulation in the extended cerebral regions. typically these systems rely on the provision of a single oxygenation marker an absolute haemoglobin oxygen saturation percentage. our group at uCl have developed a multichannel nirs system for use in paediatric cardiothoracic intensive care with specific application on patients supported on eCMo. A novel flexible neonatal cap was designed and constructed to accommodate an array of sources and detectors that provide measurements of multisite cerebral oxygenation from 12 channels. Multimodal data collection (systemic and eCMo circuit parameters) simultaneous with multichannel nirs was established to allow monitoring of multisite cerebral oxygenation and haemodynamics. A novel method of analysis wavelet cross-correlation was generated to study the concordance between multisite oxyhaemoglobin concentration (Hbo2) and mean arterial pressure (MAP) as a means to investigate regional variations in cerebral circulation and assess cerebral autoregulation during eCMo (3). this work will be discussed in addition to methods we have developed for the measurement of oxidation status of cytochrome c oxidase as a marker of cerebral cellular oxygen metabolism (4) and the use of a mathematical model for data interpretation of nirs signals (5). references elwell C. e. & Cooper C. e. (2011). Making light work illuminating the future of biomedical optics. Philosophical transactions. series A Mathematical Physical and engineering sciences 369(1955) 4358-79. greisen g. leung t. & wolf M. (2011). Has the time come to use nearinfrared spectroscopy as a routine clinical tool in preterm infants undergoing intensive care Philosophical transactions. series A Mathematical Physical and engineering sciences 369(1955) 4440-51. Papademetriou M. tachtsidis i. elliot M. Hoskote A. elwell C. (2012) Multichannel near infrared spectroscopy indicates regional variations in cerebral autoregulation in infants supported on extracorporeal membrane oxygenation. Journal of Biomedical optics 17(6) 067008 tisdall M. tachtsidis i. leung t. elwell C. smith M. (2008) increase in cerebral aerobic metabolism by normobaric hyperoxia after traumatic brain injury. J neurosurg 109 424-32 Jelfs B. Banaji M. tachtsidis i. Cooper C. elwell C. (2012) Modelling noninvasively measured cerebral signals during a hypoxemia challenge steps towards individualised modelling. Plos one 7(6) e38297 eCMo & VAd A Bridge to trAnsPlAntAtion Yishay orr transplant wait list times continue to be lengthy due to an inadequate supply of donor organs on a global perspective. the result is a substantial risk of clinical deterioration end organ dysfunction and death while awaiting heart and or lung transplantation. the last decade has seen an increasing use of mechanical circulatory support as a bridge to transplantation. Moreover device technology has continued to evolve resulting in improved survival post-VAd implantation. outcomes in the current era of VAd implantation the consequences of requiring biventricular support and future perspectives will be discussed. the evolving field of paediatric mechanical circulatory support will also be reviewed particularly in regards to recent and emerging trials. in the field of lung transplantation pre-transplant support with eCMo has been considered a contraindication to transplantation. However many units internationally are increasingly transplanting patients who deteriorate to the point of requiring eCMo prior to a donor organ becoming available. the experience at st Vincent s Hospital in sydney with lung transplantation during support with eCMo will be reviewed in addition to the international perspective. this is an exciting and evolving time for mechanical circulatory support as a bridge to transplantation and it is anticipated that this field will continue to grow and develop over the next decade. 46 APril 2013 www.anzcp.org CliniCAl interPretAtion Justin skowno Monitoring global and regional markers of tissue perfusion under cardiopulmonary bypass is crucial to patient wellbeing but standard measurements of arterial pressure haemoglobin saturation and pump flows do not measure the adequacy of tissue perfusion and additional monitors are required. nirs provides a non invasive optical technique for assessing tissue haemoglobin saturation under bypass in both global and regional circulations. the clinical use of nirs will be discussed in various settings and cover appropriate technical use sources of error and interpretation of tissue oximetry information. CoMPArison of tHe ePoC Point of CAre Blood gAs AnAlYZer And tHe lABor AtorY Blood gAs AnAlYZer for tHe MeAsureMent of All VAriABles sara tayeh B.BMed sc G.D.sc James McMillan CCP (AUs UsA) sreenivasulu galaeti B.sc CCP(India) Jessica underwood B.Bnsc M.sc Adam wells B.BMed sc M.sc smita gavande B.sc CCP(India) M.sc 1. Perfusion services Pty Ltd Victoria Australia the use of point of care blood gas analyzers in cardiac surgery has increased in the past decade. the availability of such devices in cardiac theatre intensive care unit and all wards throughout the hospital will eliminate the time delay in blood analysis. Point of care systems are designed to provide safe precise and consistent results for patients in need of rapid blood gas management in a clinical setting. Perfusionists rely profoundly on the values yielded from the blood gas analyzers for decision making regarding flow rates gas management blood transfusion and haemostasis of the patient. in this comparative study electrolytes pH gases glucose lactate hemoglobin bicarbonate and acid base deficit are measured by both ePoC point of care blood gas analyzer and the laboratory blood gas analyzer. it is essential that the results yielded from both blood gas analyzer are accurate and reliable as incorrect measurement can lead to unnecessary treatment or untreated situations that can be detrimental to the patients well being. norMotHerMiC eXtrACorPoreAl Perfusion for isolAted PorCine liVer rinaldo Bellomo1 Bruno Marino1 graeme starkey1 glenn eastwood1 Brenton Chambers2. 1. Department of Intensive Care Department of Perfusion. Department of Liver Transplantation surgery. Austin Hospital Heidelberg Melbourne Victoria 2. school of Veterinary science Melbourne University Werribee Melbourne Victoria liver transplantation is a major life-saving procedure. However demand for liver transplantation continues to exceed organ supply. donation after cardiac death (dCd) has increased the pool of potential liver donors but dCd livers are at increased risk of ischemic injury and primary graft dysfunction. dCd therefore remains a limited source of transplantable livers. we investigated techniques of organ preservations which might increase the ability to preserve dCd livers. we conducted a proof-of-concept experiment using eCMo to perfuse a dCd pig liver to assess the short term viability and function of a dCd liver over a 4 hour period. we achieved ex-vivo liver perfusion and function for four hours and our experiment opens the door to further investigations of dCd liver preservation. APril 2013 www.anzcp.org 47 trAnslAtionAl reseArCH on neonAtAl PediAtriC eCls 2012 uPdAte Akif ndar PhD shigang Wang MD Feng Qiu MD Yulong Guan MD Linda Pauliks MD Allen R. Kunselman MA David Palanzo CCP Larry Baer CCP Karl Woitas CCP Robert Wise CCP Robert McCoach Rn CCP Bonnie Weaver Rn Msn CCRn Joseph Brian Clark MD John L. Myers MD. Pediatric Cardiovascular research Center departments of surgery Pediatrics Bioengineering Comparative Medicine and Public Health sciences Penn state Hershey College of Medicine Penn state Hershey Children s Hospital Hershey Pennsylvania usA. Cardiovascular centers around the globe consider many factors when selecting components of the extracorporeal life support systems (eCls). ideally they should have access to scientific data to guide evidence based choices in order to optimize patient safety and minimize circuit related morbidity. translational research is rarely done to evaluate different pump systems (roller vs. centrifugal) oxygenators and cannulae (1). three of the major focuses of Penn state Hershey Pediatric Cardiovascular research Center are A) to do translational research for selecting the best combination of pumps oxygenators cannulae and tubing length on clinical elCs B) to train clinicians (including clinicians from other centers) with our newest circuits in-vitro-and in-vivo and C) to share our clinical protocols with other pediatric centers around the globe. the main objective of this presentation is to share our most recent research results on custom-made eCls circuitry. Based on the results of the translational research and input from the entire clinical team including perfusionists nurses surgeons and engineers we built our Penn state Hershey Pediatric eCls circuit (figure 1) which is composed of a rotaflow centrifugal pump a Quadrox-id Pediatric PMP HfMo two Bio-Medicus eCls cannulae (arterial and venous) and 3 feet of inch tubing for both the arterial and venous line. All of the components in the circuit have been tested in our center before being used in piglet experiments including the impact of different lengths and diameters of tubing on the hemodynamics of the circuit (1-5). the priming volume of the circuit is 190 ml and the inner surface has tip to tip biocompatible coating. it not only enables rapid priming (less than 10 minutes) but provides superior safety and portability as well (2). when we compared this new circuit with the conventional eCls circuit the results showed much lower pressure drops and a greater retention of total hemodynamic energy through the new circuit and there was no retrograde flow using the centrifugal pump at flow rates as low as 250 ml min (6 7). we have fi nished the training of the clinical eCls team including 150 clinicians from ten centers and we are now using this new circuit in our clinical settings since 2010 (8). references Qiu f Clark JB Myers Jl ndar A et al. translational research in Pediatric extracorporeal life support system and Cardiopulmonary Bypass Procedure 2011 update. world Journal for Pediatric and Congenital Heart surgery 2011 2(3) 476-481. Palanzo d Qiu f Baer l Clark JB Myers Jl ndar A. evolution of the eCls circuitry [guest editorial]. Artif organs 2010 34 869-873. Qiu f uluer MC Kunselman A Clark JB Myers Jl ndar A. impact of the length of the tubing on hemodynamics in a simulated neonatal eCls circuit. Artif organs 2010 34 1003-1009. Qiu f Clark JB Kunselman Ar ndar A Myers Jl. Hemodynamic evaluation of arterial and venous cannulae in a simulated neonatal eCls circuit. Perfusion 2011 26 (4) 276 283. Qiu f lu CK Palanzo d Baer l Myers Jl ndar A. Hemodynamic evaluation of the Avalon elite Bi-Caval lumen Cannulae. Artificial organs 2011 nov 35(11) 1048-51. Khan s Vasavada r Qiu f Kunselman Ar ndar A. extracorporeal life support systems Alternate vs. Conventional Circuits. Perfusion. 2011 May 26(3) 191-8. Clark JB guan Y McCoach r Kunselman Ar Myers Jl ndar A. An investigational study of minimum rotational pump speed to avoid retrograde flow in three centrifugal blood pumps in a pediatric extracorporeal life support model. Perfusion. 2011 May 26(3) 185-90. McCoach r weaver B Carney e et al. Pediatric extracorporeal life support systems education and training at Penn state Hershey Childrens Hospital. Artificial organs 2010 34 1023-1026. 48 APril 2013 www.anzcp.org CirCuit fAilure during eCMo tHerAPY At st VinCents HosPitAl sYdneY A reView Jonathan Cropper A dinale C soto K Adkins f Junius A Jackson. st Vincent s Hopsital Victoria street Darlinghurst nsW Australia introduction failure of the eCMo circuit is a significant risk associated with eCMo therapy. we investigated incidences of eCMo circuit failure at our institution. of all eCMo cases) were acute failures requiring emergent intervention. of the 24 failures 2 resulted directly in death (in the operating theatre) 2 were successfully weaned a parallel circuit was used in 1 and the circuit was successfully changed in 19 without incident. Causes included impaired gas exchange increased transmembrane pressure and haemolysis. of the 19 patients involved 9 survived to hospital discharge 9 died while on eCMo and 1 died in iCu after eCMo. 181 patients (90.5%) were treated with eCMo without circuit failure. Method we reviewed the first 200 cases of eCMo at st Vincent s Hospital sydney from 11th of March 2004 to the 25th of January 2012. Circuit failure was defined as a complication arising from any part of the circuit (tip-to-tip) that required either a change out of the circuit or urgent weaning of the patient from eCMo. results there were 24 incidences (12%) of circuit failure (14 VV 9 VA and 1 V-PA) involving 19 patients. of the 24 failures 7 (3.5% Conclusion the associated risk of circuit failure in eCMo requires diligent patient management and circuit management by all involved in order to prevent further complication. eCMo And oXidAtiVe stress Charles i Mcdonald Yl fung K shekar s diab K dunster and Jf fraser. Critical Care research Group The Prince Charles Hospital Chermside Queensland Background Acute oxidative stress occurs during critical illness and contributes to increased. the addition of extra-corporeal membrane oxygenation (eCMo) in this patient group is likely to overwhelm anti-oxidant mechanisms and exacerbate this oxidative stress. Findings eCMo was associated with significant reductions (p 0.05) in selenium and increases in MdA in all sheep. Ali-sheep experienced greater reductions in selenium and higher levels of MdA than healthy sheep on eCMo. selenium levels were inversely associated (p 0.001) with MdA levels on eCMo. Aims to investigated the effect of eCMo on oxidative stress selenium levels and antioxidant function. Methods 48 sheep with healthy lungs or acute lung injury (Ali) were subjected to 2hrs or 24hrs of VV-eCMo. Alisheep in 24-hrs group were further divided to receive fresh (n 8) or aged packed cell transfusion (n 8). Blood samples were taken at anaesthetic induction after Ali then 15 minutes 1 2 6 12 and 24-hours on eCMo and analysed for selenium glutathione peroxidase and malondialdehyde (MdA). discussion eCMo causes an increase in oxidative stress independent of preexisting injury. However the oxidative stress was notably worse in sheep with Ali. this was undoubtedly exacerbated by the clinically significant reductions in selenium in the Ali sheep. further studies are needed to confirm these results in humans. APril 2013 www.anzcp.org 49 sHould Air BuBBle deteCtors Be used to QuAntifY MiCroBuBBle ACtiVitY during CPB richard f newland Bsc CCP (Aust) robert A Baker PhD CCP (Aust). Cardiac and Thoracic surgical Unit Department of Medicine Flinders Medical Centre and Flinders University of south Australia Adelaide south Australia Australia. Background Air bubble detectors (ABd) are a component of the heart lung machine commonly utilized during cardiopulmonary bypass (CPB) to alert Perfusionists to the presence of air in the arterial line and protect against massive air embolism. the stockert ABd are purported by the manufacturer to have the capability to quantify microbubbles greater than 300um in size however the reliability and accuracy of these readings has not been reported. the aim of this study was to assess the reliability and accuracy of the microbubble counts from the ABd to determine suitability for inclusion in the CPB report. oxygenator outlet and the arterial line filter throughout 6 CPB procedures for both ABd. reliability was assessed by calculating the spearman correlation co-efficient (r) between simultaneous measurements for each detector type. if the devices were found to be reliable accuracy of the ABd microbubble counts was assessed by calculating the spearman correlation co-efficient (r) between the average edAC counts 300um and average ABd counts for simultaneous measurements. results there was a strong correlation between microbubble counts recorded using the edAC detectors throughout CPB (r 0.958 p 0.001). no correlation was observed between microbubble counts recorded using the s3ABd (r 0.008 p 0.793). Methods Microbubble counts from the stockert 3 8 ABd with the s3 heart lung machine (s3ABd) and 3 8 1 2 ABd with the s5 heart lung machine (s5ABd) were compared against the emboli detection and classification (edAC) quantifier during CPB. Measurements were obtained simultaneously using 2 edAC transducers and 2 ABd in series in the arterial line between the Conclusions the microbubble counts using the s3ABd were not comparable between the 2 devices tested. we conclude that these ABd should not be used to report microbubble activity during CPB. tHe PAst Present And future of our Perfusion steven w. sutton L.P. C.C.P. V.P. Cardiovascular support services Inc. Texas Health Heart & Vascular Hospital the word wonder traces its origin to before 900 A.d. used as a noun in Middle english old english wundor cognate with dutch wonder german wunder old norse undr as a verb in Middle english wonderen old english wundrian a derivative of the noun. this word describes the amazing accomplishments in the years since the birth of our profession. we will explore the many wonders of this saga. it is an amazing tale. the attendees will be enlightened greatly on the history of our vocation evolve an understanding as to where we actually are today regarding scientific progress or regress and where we think we are headed in the future. Many agree that cardiac surgery in the adult sector and to some extent in pediatrics is presently redefining itself and perhaps re-engineering its role as a specialty in the 21st century. with regard to perfusion we are mutually conjoined and interwoven with whatever outcome this journey yields. it is no time to slumber or despair. it is a remarkable opportunity to rethink tweak and sharpen the skillsets for an endearing profession which deserves to be protected. Attendees will enjoy the author s grasp of the history of the discovery of the circulatory system and cardiac surgery. As a very active collector of medical antiquities relevant to the history of circulation and heart surgery the author has much to share and offer the new entrant and more mature members of our profession. in many instances the names and faces are revealed who are luminaries to the career and profession. we will examine the technology practice and most importantly the current transition into a global economy and the potential benefits and barriers which may be confronted. A major goal of this lecture is to instill pride commitment joy as we encounter the daily requirements and demands of this career choice and to motivate all demographics in personnel with special emphasis in the practice of the teAM APProACH. our patients deserve no less than a well-trained and highly committed clinical team working in tandem cohesively to achieve a positive outcome for those who entrust their life literally in our hands and we must be prepared it is a privileged and courageous task for those who undauntedly confront the challenge. this is an excellent opportunity for clinical managers team members new entrants and students along with other disciplines to self-assess their current role and distinguish themself apart from any notion of an adverse member and be a strong contributor to the success of the respective program and institution most importantly the patient community we each serve. 50 APril 2013 www.anzcp.org A stePPing stone to dePtH-of-AnAestHesiA Monitoring using nirs thushura Perera1 4 6 P.lewis2 A.davidson3 4 P.Junor1 s.Bottrell5 1. La Trobe University Department of electronic engineering Melbourne Australia. 2. The Alfred Hospital neurosurgery Melbourne Australia. 3. The Royal Children s Hospital Anaesthesia and Pain Management Melbourne Australia. 4. The Murdoch Children s Research Institute Critical Care & neurosciences Melbourne Australia. 5. The Royal Children s Hospital Perfusion Department Melbourne Australia 6. The Bionics Institute neurobionics Melbourne Australia. the electroencephalogram (eeg) is the conventional tool used in cortical activation studies particularly during surgical procedures involving general anaesthesia. near-infrared spectroscopy (nirs) may be advantageous for activation studies because flowmetabolism coupling is age invariant. However there is a paucity of data on the nature of visually evoked nirs responses during general anaesthesia. we conducted a pilot study to validate the use of nirs as a tool for measuring cortical activity in anaesthetised children. After obtaining written informed consent from their parents 23 children (aged between two and five years) undergoing routine surgery requiring general anaesthesia were enrolled into the study. Visually-evoked haemodynamic responses measured using nirs were recorded for 30 minutes during the surgical procedure. nirs data - consisting of oxygenated deoxygenated and total haemoglobin concentrations - were segmented into epochs for evoked-response analysis after filtering motion artefact and baseline drift. A modified gaussian model was used to describe each evoked-response. goodness-of-fit statistics and classification rules were used to determine the existence of evoked-responses. nirs data were recorded in 20 children of whom nine showed a visually-evoked haemodynamic response. none showed a response in the baseline control data. it became apparent that in eight of ten children who had been administered intraoperative or premedication fentanyl a visually-evoked response could not be detected we assume that the pupillary-constrictive properties of fentanyl rendered visual stimulation ineffective. the results suggest that nirs can be used to measure cortical activation in anaesthetised children. sHedding ligHt on funCtionAl BrAin ACtiVAtion using nirs Clare elwell Biomedical optics Research Laboratory Department of Medical Physics and Bioengineering University College London London UK. functional nirs (fnirs) describes the optical measurement of the changes in haemodynamics specifically associated with brain activation in response to a given stimulus. there has been significant interest in the use of fnirs to perform studies where other scanner based neuroimaging technologies are difficult to use e.g. neurodevelopment psychiatry and intensive care. for example nirs studies of functional activation connectivity and resting state are being used to literally watch the brain develop (1 2) the Japanese health ministry has approved nirs as an advanced medical technology to assist the diagnosis of psychiatric disorders in adults (3) and 3d optical tomography has been used to image the cerebral response of preterm infants to passive motor activation (4). in addition fnirs can be combined with other imaging modalities such as electroencephalography (eeg) and functional magnetic resonance imaging (fMri) to further elucidate neurovascular coupling mechanisms in the healthy diseased and injured brain. this talk will describe the advances in instrumentation data analysis and interpretation which have made these studies possible and will look towards the future prospects for this application of the technology in the clinical and life sciences. references lloyd-fox s. Blasi a & elwell C. e. (2010). illuminating the developing brain the past present and future of functional near infrared spectroscopy. neuroscience and Biobehavioral reviews 34(3) 269-84. taga g. watanabe H. & Homae f. (2011). spatiotemporal properties of cortical haemodynamic response to auditory stimuli in sleeping infants revealed by multi-channel near-infrared spectroscopy. Philosophical transactions. series A Mathematical Physical and engineering sciences 369(1955) 4495-511. Cyranoski d. 2011 thought experiment. nature 469 148 149. gibson A. Austin t. everdell n. schweiger M. Arridge s. Meek J. wyatt J. delpy d. Hebden J. (2006) three-dimensional whole-head optical tomography of passive motor evoked responses in the neonate neuroimage. 30(2) 521-8 APril 2013 www.anzcp.org 51 PulsAtile eXtrACorPoreAl life suPPort sYsteM using A non-oCClusiVe roller PuMP And A noVel diAgonAl PuMP Akif ndar PhD shigang Wang MD and Conrad Krawiec MD and Yves Durandy MD Pediatric Cardiovascular Research Center Departments of surgery Pediatrics Bioengineering and Penn state Hershey Pediatric Critical Care Unit Penn state Hershey College of Medicine Penn state Hershey Children s Hospital Hershey Pennsylvania UsA Institut Cardiovasculaire Paris sud Ave du noyer Lambert FR 91300 Massy France introduction extracorporeal life support (eCls) technology is and will continue to advance. each improvement made to the circuit must be scrutinized and perfected preferably prior to clinical use. Pulsatile flow has been expecting to be used in eCls system because it could preserve microcirculation reduce the inflammatory response and improve patient outcomes. Conclusions the non-occlusive pulsatile roller pump performed well during all of the experimental conditions and generates adequate quality of pulsatile pressure-flow waveforms using eCls circuitry. Although this novel concept was first introduced in 1990 (1 2) we believe that there is still need for this technology because of significant advantages including safety no back flow higher hemodynamic energy and significantly reduced cost (5) the new-generation Medos deltastream dP3 eCls system can provide adequate quality of pulsatility without backflow and generate more hemodynamic energy under pulsatile mode in our simulated pediatric eCls system (6). Two circuits have been evaluated in our research center non-occlusive Pulsatile Pump A simple inexpensive pediatric pulsatile roller blood pump has been utilized for routine CPB eCls and MCs for decades in france (1 2). this particular non-occlusive pulsatile system has many advantages including several safety features for patients as well as an extremely lower cost. this particular pump can only generate pulsatile mode of perfusion. references durandy Y Chevalier JY lecompte Y. single-cannula venovenous bypass for respiratory membrane lung support. J thorac Cardiovasc surg 1990 Mar 99(3) 404-9. Chevalier JY durandy Y Batisse A Mathe JC Costil J. Preliminary report extracorporeal lung support for neonatal acute respiratory failure. lancet 1990 Jun 9 335(8702) 1364-6. schmid C Philipp A Hilker M rupprecht l Arlt M Keyser A lubnow M M ller t. Venovenous extracorporeal membrane oxygenation for acute lung failure in adults. J Heart lung transplant. 2012 Jan 31(1) 9-15. epub 2011 sep 1. tiedge s and optenh fel J. first uses of a new diagonal pump in extracorporeal support systems for children and infants (german). Kardiotechnik 2011 20(3) 72-6. wang s durandy Y Kunselman Ar ndar A. A non-occlusive inexpensive pediatric pulsatile roller pump for CPB eCls and lVAs rVAs. Artificial organs 2013 37 (1) (in press). wang s Kunselman Ar ndar A. novel Pulsatile diagonal Pump for Pediatric extracorporeal life support system. Artificial organs 2013 37 (1) (in press). New generation diagonal Pulsatile Pump the Medos deltastream dP3 system uses a novel diagonal pump to provide non-pulsatile and pulsatile flows for pediatric and adult eCls. this system is small compact and user-friendly. it has been approved for extended clinical eCls use in children and adults in europe (3 4). Objective and methods the objective of this study is to evaluate the two particular systems for eCls in pulsatile mode in a simulated eCls model. the experimental eCls circuits consisted of the two pumps Medos Hilite 2400 lt hollow-fiber oxygenator arterial and venous cannula primed with human blood (HCt 35%). All trials were conducted at different flow rates and pulsatile flow setting. results our results showed that the two eCls systems can generate physiological quality of flow and pressure waveforms (figure 1 2). 1). the non-occlusive roller pump automatically created pulsatile flow at certain frequencies depending on flow rates. Higher flow rates generated higher hemodynamic energy output. 2). the new-generation diagonal dP3 pump was easily switched between nonpulsatile and pulsatile mode generated effective pulsatile flow without backflow and create surplus hemodynamic energy (sHe) and more total hemodynamic energy (tHe) than non-pulsatile flow at all pump flow rates. 52 APril 2013 www.anzcp.org Figure 1. Flow pressure waveforms in non-occlusive roller pump ECLS system. Figure 2. Flow pressure waveforms in Medos DP3 ECLS system. 2 APril 2013 www.anzcp.org 53 AnAlYsis of intrA-VAsCulAr CAnnulAs used during CArdioPulMonArY BYPAss sara tayeh B.BMed sc G.D.sc James McMillan CCP (AUs UsA) Jessica underwood B.Bnsc M.sc Adam wells B.BMed sc M.sc Michael Mcdonald CCP (AUs UsA) Professor robert shanks PhD Professor Margaret deighton PhD. 1. Perfusion services Pty Ltd Victoria Australia 2. Monash University Clayton Melbourne 3. Department of Biotechnology and environmental Biology RMIT University Melbourne 4. Leader in Polymer science Research school of Applied sciences RMIT University Melbourne Plastics are widely utilized in medical devices due to their properties flexibility biocompatibility inertia and the relatively inexpensive cost of production. good manufacturing practice (gMP) dictates that all medical devices are produced under the highest possible standards. this study investigates the observation that certain cannulas used during cardiopulmonary bypass denature after use. the chemical composition and biochemical interaction of the cannula was analyzed by the following methodologies drug test ( Various media) sheer force and pressure testing in vivo (visual observational) human and animal chemical composition of cannula complete polymer analysis gas chromatography mass spectrometry electro spray ionization mass spectrometry surface reflected infrared spectroscopy bacterial study interaction of staphylococcus aureus and staphylococcus epidermidis with the cannula and toxicology. the change of colour of the cannula is the result of the plasticizers namely phthalates migrating from the bulk of the polymer to the surface of the cannula. the type of plasticiser which is the structure of the alkyl groups of the phthalate determines miscibility and plasticiser efficiency. shorter alkyl groups disturb the optimum miscibility ratio and are less efficient and more volatile giving plasticiser loss. if too much plasticiser is added or not effectively mixed with poly(vinyl chloride) bleeding to the surface and surrounding media may result. the phthalates that are present in cannulas that are used in everyday cardiopulmonary bypass have been identified as toxicants and documented to be carcinogenic. HeArt trAnsPlAnt using orgAn CAre sYsteM trAnsMediCs - A CAse rePort Viji Vincent Clinical Perfusionist Royal Perth Hospital WA. A 42 year old male was diagnosed with restrictive (Amyloid) Cardiomyopathy. echocardiography showed severe concentric left ventricular hypertrophy with 21% ejection fraction. screening showed isolated cardiac amyloidosis with systemic myeloma. He was accepted for cardiac and bone marrow transplant after extensive evaluation and discussion. two months later he was admitted with loss of consciousness double incontinence and hypoxic seizures. the Mri brain and eeg were normal. this was felt to be consistent with intermittent insufficient cerebral perfusion. A month later following a pulseless electrical activity (PeA) arrest for 3 minutes CPr was administered with a return of spontaneous cardiac output. A dual chamber pacemaker was inserted. Clinically he remained nYHA iV in hospital and was not considered suitable for lVAd. He was listed for emergency heart transplant. He further deteriorated with PeA arrests on days 10 and 16. A marginal donor heart (with a downtime of 35 minutes and troponin of 1000) was available in Adelaide a day after his latest PeA episode. the rPH transplant team decided to accept the heart. recent implementation of the transmedics organ Care system (oCs) at rPH allowed for the opportunity to carry out the first long distance retrieval on the system reducing the ischaemic time1 and allowing assessment of the donor heart. After significant logistical delays the heart was transplanted successfully. despite a stormy intra-operative course necessitating an iABP and substantial inotropic support including levosimendan the post-op period was relatively smooth and devoid of complications. the recipient was extubated the next day and left iCu on day 4 post surgery transferred to the ward on day 10 and home on day 16. Life-Years Gained by Reducing Donor Heart Ischemic Times Goldsmith et al. Transplantation 2009 87 243 248 54 APril 2013 www.anzcp.org oPtiMising HAeMofiltrAtion of tHe residuAl PriMe VoluMe of tHe CArdioPulMonArY BYPAss CirCuit neil Casey CsCP ACP. Chief of Perfusion Children s Hospital of British Columbia. Vancouver BC. Canada. Modified ultra filtration (Muf) is an established practice in pediatric perfusion immediately post CardioPulmonary Bypass (CPB). it has been shown to reduce the requirement for allogenic blood transfusions improve lung compliance and reduce time to extubation. its application varies between clinical centres but invariably there is still a residual whole blood component left behind in the CPB circuit. we studied the application of a whole circuit rinsing and single pass method of haemoconcentration of this residual volume post Muf and looked at the quality of the product being passed onto anaesthesia PiCu to ensure use. Clotting factors plasma free hemoglobin factor Xa ACt pH Be and electrolytes were all measured and the technique fine tuned to deliver the best product possible. we were able to match haematocrit levels achieved by cell salvage without removing plasma constituents minimize heparin levels and balance the pH electrolyte levels encouraging post Protamine product utilization. iMPleMenting BenCHMArKing in Perfusion PrACtiCe results of A MultiCentre QuAlitY iMProVeMent initiAtiVe Richard F newland Bsc CCP (Aust) Robert A Baker Phd CCP (Aust) Carmel fenton Dip Perf CCP (Aust) eCCP (europe) Michael Mcdonald Dip Perf CCP (Aust) timothy w willcox Dip Perf CCP (Aust) and Alan f Merry FAnZCA Cardiac and Thoracic surgical Unit Department of Medicine Flinders Medical Centre and Flinders University of south Australia Adelaide south Australia Australia Cardiothoracic surgical Unit Royal Hobart Hospital Hobart Tasmania Australia Perfusion services Cabrini Health Melbourne Victoria Australia Green Lane Perfusion Auckland City Hospital Auckland new Zealand Professor and Head of Department of Anaesthesiology school of Medicine Auckland University Auckland new Zealand. Background the Perfusion downunder Collaboration (PduC) has established a multi-center perfusion focused database with the objectives of measuring and reporting clinical practice and to facilitate clinical improvement through the introduction of benchmarking of quantitative quality indicators. results seven thousand eight hundred and seventy-seven procedures were evaluated to compare the incidence of Qi before and after the introduction of benchmarking. the incidence of the blood glucose Qi improved from 67% to 75% of procedures with a benchmark value of 93.4%. the arterial outlet temperature Qi improved from 61% to 75% of procedures with the benchmark of 99.7% while the arterial pCo2 Qi improved from 57 to 60% with the benchmark value of 83.9%. Methods data were collected using the PduC database from procedures performed in 8 Australian and new Zealand cardiac centres between March 2007 and february 2012. Benchmarked quality indicator s (Qi) of cardiopulmonary bypass (CPB) management were blood glucose 4 mmol l and 10mmol l arterial outlet temperature 37oC and arterial blood gas pCo2 35 and 45 mmHg. the incidence of Qi in our baseline procedural cohort (2007-2011) was compared with procedures after the introduction of benchmarking. Conclusions Participation in a multicentre perfusion database that incorporates quantitative quality indicators facilitates clinical improvement through benchmarking. APril 2013 www.anzcp.org 55 infeCtion Control during CArdioPulMonArY BYPAss sara tayeh B.BMed sc G.D.sc James McMillan CCP (AUs UsA) smita gavande B.sc CCP(India) M.sc Jessica underwood B.Bnsc M.sc Adam wells B.BMed sc M.sc Michael Mcdonald CCP (AUs UsA) 1. Perfusion services Pty Ltd Victoria Australia 2. RMIT University Melbourne Australia despite the introduction of prophylactic antibiotics infection occurring in cardiopulmonary bypass cardiac surgery patients is still of concern. it is known that infection is the most common cause of late complications in cardiopulmonary bypass surgery patients. infections post cardiopulmonary bypass are associated with high morbidity and mortality. the purpose of this study is to determine the incidence and predisposing factors that affect the outcome of patients that become infecting during cardiopulmonary bypass. this study was conducted in two different cardiac units where random swabs were taken from elCs (extra corporal life support system) prime over 4 weeks cardiopulmonary (CPB) prime heart lung packs (pre post and 24 hours post assembly) and hardware and consumables. All swabs were taken in a sterile manner and tested by an independent microbiology laboratory. the results of this study showed no growth of foreign organisms after 7 day incubation. this confirmatory study provides evidence that the protocols that are endorsed in our practice are strictly adhered to demonstrating that infection occurring in cardiac surgery can be isolated from cardiopulmonary bypass. ACute lung inJurY And tHe ACute resPirAtorY distress sYndroMe (Ards) MeCHAnisMs outCoMes And PotentiAl tHerAPies dr dani-louise dixon Bsc PhD ICCU Flinders Medical Centre and Dept of Critical Care Medicine Flinders University. the acute respiratory distress syndrome (Ards) covers a spectrum of inflammatory conditions associated with substantial morbidity and mortality. A report on the Australian incidence of acute lung injury from a survey of 21 iCus in the late 1990 s found 34 cases per 100 000 year population aged 15 years which equates to 5340 cases per year in Australia. the Australian incidence of Ards was found to be 28 cases per 100 000 of population per annum with a 34% mortality rate. Ards can be triggered by direct or indirect injury to the thin (approx 0.1mm) alveolar epithelium. this epithelial surface is constantly susceptible to potential injury through both its exposure to environmental air containing pathogens toxins and particulate matter and its close proximity to the pulmonary microvasculature which carries potent stimulants in the form of toxins immunological mediators and activated leukocytes. in addition while mechanical ventilation is a well established therapy for patients with acute respiratory failure it is increasingly recognized as a major contributor to Ards also know as ventilation-induced lung injury (Vili). up to 35% of Ards mortality has been attributed to Vili which also appears to be an important aetiological factor for bronchopulmonary dysplasia in ventilated neonates. this presentation will touch on some of the major causes of Ards the mechanisms by which they each elicit and maintain the inflammatory response and the ultimate physiological effects on respiratory function. in addition some recent advances in potential treatments will be covered. 56 APril 2013 www.anzcp.org PHArMACologiCAl isCHAeMiC Pre-Conditioning david t Andrews MBBs fAnZCA Phd ddu. Cardiovascular therapeutics unit university of Melbourne Parkville Australia department of Anaesthesia and Pain Management royal Melbourne Hospital Parkville Australia this talk summarizes the data supporting the role of the mitochondrial permeability transition pore (mPtP) in ischaemiareperfusion injury. details of ischemic and pharmacological manipulation of this molecular channel and the relevance this holds for current cardiac surgical practice will be presented. in short both necrosis and apoptosis are the results of mPtP opening during cellular ischemia. necrosis results from ischaemic damage to the electron transport chain of enzymes which sets into play the assembly of a non-specific mitochondrial megachannel known as the mPtP. subsequently during reperfusion widespread and uncontrolled opening of the mPtP eventuates and causes in succession depolarization of the inner mitochondrial membrane hydrolysis of AtP mitochondrial rupture and necrotic cell death. in a similar fashion less substantial ischemia causes the same pore formation but consequently only transient mPtP opening during reperfusion. this results in differential swelling of the intermembrane space in comparison to the mitochondrial matrix and causes swelling-induced-rupture of the outer mitochondrial membrane release of pro-apoptotic factors into the cytosol and apoptotic cell death. recent data suggests that ischaemic preconditioning as well as pharmacological preconditioning with volatile anaesthetic agents result in similar downstream interactions with this molecular channel leading to cytoprotection. furthermore intravenous anaesthetic agents also interact with the mPtP during reperfusion and although by dissimilar mechanisms volatiles and propofol both separately promote cell survival by preventing uncontrolled opening of the mPtP. interestingly recent data suggests that the combination of volatiles and propofol may have unexpected effects on mPtP function not always leading to cellular survival. BrAins And BYPAss steven w. sutton L.P. C.C.P. V.P. Cardiovascular support services Inc. Texas Health Heart & Vascular Hospital Hominid brains evolved and grew from 400g 3-4 million years ago to the present size of approximately 1400g (1.4kg). the bodies of Homo erectus (1.7 million years ago) were not substantially smaller than humans of the last century yet their brains were nearly half the size. the cerebral cortex (or neocortex) is the newest evolutionary contribution. in contrast to comparative anatomical genera the oldest mammals such as opossums have only a thin layer of cerebral cortex while rabbits are slightly larger and felines in contrast are increased in size only by a fraction. Monkeys possess a substantial cerebral cortex. Humans--and only humans--have an enormous cerebral cortex. Around 2.5 million years ago our ancestors brains expanded. studies suggest it was no fluke this brain boom coincided with the onset of an ice age (Quaternary ice Age about 2.5 million years ago). it is speculated that the larger brain would have generated heat faster improving survival. the modern human brain is a huge energy glutton accounting for nearly half of our resting metabolic rate. regarding the architecture of the skull and cerebral contents it is made up of brain tissue (80%) blood (12%) and cerebrospinal fluid (8%) with a total volume of 1600 milliliters (about the size of a cantaloupe). Adverse neurologic sequalae post cardiopulmonary bypass has evolved and given rise to such terms as Pump Head and it is a devastating morbidity to any cardiovascular program. in this lecture we will examine the current techniques employed to protect the brain and monitor for enhanced results. this particular issue was quoted to be in its infancy by robert litwak in 1978 today we remain suspended in this state and for what purpose Many of the professional multi-disciplines in cardiac surgery fail to remain current on cardiopulmonary bypass science and outsource this technology to a few who may or may not be authoritative and unbiased. we battle many obstacles when change is proposed for implementation of new technology this is appropriate since change must be for all the safe and right reasons. we will explore the variants which influence the adequacy of cerebral perfusion and factors which may positively or negatively impact our ability to protect the brain from injury. Attendees will engage a process of review and practice trends with emphasis upon modification where possible. furthermore the scientific evidence will be examined along with profound economic considerations to treat undesired clinical outcomes. APril 2013 www.anzcp.org 57 MiCroeMBoli HAndling And AssessMent in PediAtriC CirCuitrY Akif ndar PhD shigang wang MD Yulong guan MD feng Qiu MD ryan K. Mathis Bs natalie M. dogal Bs Judith lin Bs Ashton strother Allen r. Kunselman Ms J. Brian Clark MD John l. Myers MD Pediatric Cardiovascular Research Center Departments of surgery Pediatrics and Bioengineering Penn state Hershey College of Medicine Penn state Hershey Children s Hospital Hershey Pennsylvania UsA gaseous microemboli formed in the closed circuit during CPB may cause postoperative brain injury and complications through Akif ndar PhD Shigang Wang MD and neurological damage (1). to monitor blood vessel occlusion Yulong Guan MD Feng Qiu MD Ryan K. Mathis BS Natalie M. Dogal BS Judith Lin BS Ashton Strother Allen R. Kunselman MS J. Brian Clark MD the amount of microemboli generated during CPB transcranial John L.doppler (tCd) ultrasound is used to detect microemboli larger Myers MD than 40m in Research Center Departments of Surgery Pediatrics and Pediatric Cardiovascular the middle cerebral artery of the patient (figure 1) Bioengineering Penn State Hershey College and Classification Hershey Children s Hospital (2) and emboli detection of Medicine Penn State (edAC) is used to Hershey Pennsylvania USA detect microemboli larger than 10m and classify them by size in the circuit (figure 2) (2-4). oxygenators cardiotomy reservoirs and arterial filters in the circuit are designed with membrane Gaseous microemboli formed in the closed circuit during CPB may cause postoperative brain fi lters to trap microemboli by size in order to reduce the amount injury and complications through blood vessel occlusion and neurological damage (1). To of microemboli reaching the patient. Microemboli handling and assessment in pediatric circuitry references su Xw ndar A. Brain protection during pediatric cardiopulmonary bypass. Artificial organs 2010 34 91-102 rogerson A guan Y Kimatian s Kunselman A Clark JB Myers Jl ndar A. transcranial doppler ultrasonography A reliable method of monitoring pulsatile flow during cardiopulmonary bypass in infants and young children. J thorac Cardiovasc surg 2010 139 e80-2. Clark J Qui f guan Y woitas Kr Myers Jl ndar A. Microemboli detection and classification during pediatric cardiopulmonary bypass. world Journal for Pediatric and Congenital Heart surgery 2010 2(1) 111-114. wang s woitas K Clark JB Myers Jl ndar A. Clinical real-time Monitoring of gaseous Microemboli in Pediatric Cardiopulmonary Bypass. Artificial organs 2009 33(11) 1026-1030. Mathis r lin J dogal n Qiu f Kunselman A wang s ndar A. evaluation of four pediatric cardiopulmonary bypass circuits in terms of perfusion quality and capturing gaseous microemboli. Perfusion. 2012 Jun 29. [epub ahead of print] lin J dogal nM Mathis rK Qiu f Kunselman A ndar A. evaluation of Quadrox-i and Capiox fX neonatal oxygenators with integrated arterial fi lters in eliminating gaseous microemboli and retaining hemodynamic properties during simulated cardiopulmonary bypass. Perfusion. 2012 May 27(3) 235-43. epub 2012 feb 15. dogal nM Mathis rK lin J Qiu f Kunselman A ndar A. evaluation of three hollow-fiber membrane oxygenators without integrated arterial fi lters for neonatal cardiopulmonary bypass. Perfusion. 2012 Mar 27(2) 132-40. epub 2011 nov 24. ndar A Palanzo d wang s. using a secondary reservoir for pump suckers to avoid the generation of foam during CPB procedures in pediatric patients [invited commentary]. Perfusion 2012 Jun 20. [epub ahead of print] monitor the amount of microemboli generated during CPB transcranial Doppler (TCD) ultrasound is used to detect microemboli larger than 40 m in the middle cerebral artery of the in order to reduce the priming volume and eliminate a separate patient (Figure 1) (2) and Emboli Detection and Classification (EDAC) is used to detect arterial filter in the circuit manufacturers recently developed new microemboli larger than 10 m and classify them by size in the circuit (Figure 2) (2-4). hollow-fiber membrane oxygenators with integrated arterial filters. Oxygenators cardiotomy reservoirs and arterial filters in the circuit are designed with we have evaluated the Quadrox-i neonatal pediatric oxygenators membrane filters to trap microemboli by size in order to reduce the amount of microemboli (Maquet Herrlingen germany) and Capiox Baby fX05 reaching the patient. In order to reduce the priming but we are also interestedarterial filter in the circuit energy levels(5-8) volume and eliminate a separate in comparing the manufacturers recently of these neonatal pediatric oxygenators in the flow effectiveness developed new hollow-fiber membrane oxygenators with integrated arterial filters. We have evaluated the Quadrox-i neonatal pediatric oxygenators (Maquet range of neonatal patients in terms of reducing microemboli load Herrlingen Germany) and Capiox Baby FX05 (Terumo Corporation Tokyo Japan) in terms of delivered to the patient. in this lecture we would like to compare hemodynamic energy levels(5-8) but we are also interested in comparing the effectiveness of the performance of circuit components (oxygenators with and these neonatal pediatric oxygenators in the flow range of neonatal patients in terms of without iAf arterial filters venous and cardiotomy) in terms of reducing microemboli load delivered to the patient. In this lecture we would like to compare microemboli delivery to the neonatal pediatric patient. the performance of circuit components (oxygenators with and without IAF arterial filters venous and cardiotomy) in terms of microemboli delivery to the neonatal pediatric patient. Figure 1. Transcranial Doppler (TCD). (terumo Corporation tokyo Japan) in terms of hemodynamic Figure 2. Emboli Detection and Classification Device (EDAC). 1 References 1. Su XW ndar A. Brain protection during pediatric cardiopulmonary bypass. Artificial Organs 2010 34 91-102 2. Rogerson A Guan Y Kimatian S Kunselman A Clark JB Myers JL ndar A. Transcranial Doppler ultrasonography A reliable method of monitoring pulsatile flow during cardiopulmonary bypass in infants and young children. J Thorac Cardiovasc Surg 2010 139 e80-2. 3. Clark J Qui F Guan Y Woitas KR Myers JL ndar A. Microemboli detection and classification during pediatric cardiopulmonary bypass. World Journal for Pediatric and Congenital Heart Surgery 2010 2(1) 111-114. 4. Wang S Woitas K Clark JB Myers JL ndar A. Clinical Real-Time Monitoring of Gaseous Microemboli in Pediatric Cardiopulmonary Bypass. Artificial Organs 2009 33(11) 10261030. 5. Mathis R Lin J Dogal N Qiu F Kunselman A Wang S ndar A. Evaluation of four pediatric cardiopulmonary bypass circuits in terms of perfusion quality and capturing gaseous 58 APril 2013 www.anzcp.org tHe lung in CHroniC HeArt fAilure (CHf) dr dani-louise dixon Bsc PhD ICCU. Flinders Medical Centre and Dept of Critical Care Medicine Flinders University. Chronic heart failure (CHf) is common and costly with both a high mortality rate and prolonged morbidity. it has been estimated that between 3% and 9% of the adult population in Australia suffer from CHf depending upon definition and noteworthy that it is the only cardiovascular condition whose incidence is rising. the ageing population and improved survival following large myocardial infarcts is further contributing to a substantial increase in both the financial and social health burden due to CHf. shortness of breath and exercise intolerance are cardinal manifestations of CHf and the major cause of morbidity. while their mechanisms are complex with contributions from inadequate cardiac output skeletal muscle weakness and altered central respiratory drive the lung is the major contributor. in addition to the well recognized immediate effects of pulmonary oedema on lung function CHf leads to lung remodelling and pulmonary hypertension a frequent therapeutic target. this presentation will explore recent advances in the understanding of the lung in CHf including pulmonary remodeling and subsequent effects on respiratory function biomarkers of symptom severity and recent studies into the effect of cardiac surgery on mediators of inflammation in the lung. ischaemic and Pharmacological Preconditioning. Remember to book early for the AnZCP 30th Annual scientific Meeting For Details visit www.anzcp.org APril 2013 www.anzcp.org 59 9 th International Conference on Pediatric Mechanical Circulatory Support Systems & Pediatric Cardiopulmonary Perfusion http pennstatehershey.org web pedscpb home The Ninth International Conference Is Dedicated In Honor Of John A. Waldhausen MD For His Life-Long Contributions As The Founding Chair Of The Department Of Surgery At Penn State Hershey And As A Pioneering Surgeon And Educator Of The Development Of Pediatric Cardiac Surgery In The United States. 1 60 APril 2013 www.anzcp.org The toP ten by the editorial team. After flicking through the Perfusion literature and beyond over the last 6 months or so we came up with ten articles that we thought you might be interested in hearing about. whilst you might not personally agree that these are the ten best articles of recent months we are confident that you will find them interesting. if you don t find them particularly stimulating then why not send us one of your favorites and tell us why you liked it- we will gladly include it in the next edition. 1. Alkan-Bozkaya t Ak evin A t rkog lu H and ndar A. impact of Pulsatile Perfusion on Clinical outcomes of neonates and infants with Complex Pathologies undergoing Cardiopulmonary Bypass Procedures. Artificial organs. 2013 37(1) 82 86. so to the researcher. i believe that one is expected to be familiar with the authors other work on this subject in order to be able to reproduce this study for oneself. that said my interest has been tweaked sufficiently in order to take a long hard look at pulsatile perfusion in my practice. 2. lansdowne w Machin d and grant dJ. development of the orpheus Perfusion simulator for use in Highfidelity extracorporeal Membrane oxygenation simulation. JeCt. 2012 44 250 255. positive thing. our College already owns an orpheus simulator that is available for use by College members i for one look forward to hearing if any AnZ centers manage to effectively reproduce this model. 3. sievert A and sistino J. A MetaAnalysis of renal Benefits to Pulsatile Perfusion in Cardiac surgery. JeCt. 2012 44 10 14. this study aimed to assess whether pulsatile perfusion in paediatric patients with complex congenital heart defects impacted upon patient morbidity. the study randomized patients presenting for repair of transpostion of the great arteries with a ventricular septal defect to receive either Pulsatile or non-pulsatile flow. there existed no statistically significant differences between the two groups with regard to pre and operative parameters. the study parameters addressed were intubation time duration of iCu and hospital stay inotrope requirement pre and post operative enzymes (Alt Ast) creatinine CrP lactate albumin fBC urine output and chest drain losses. this study found that pulsatile perfusion resulted in reduced postoperative inotrope requirement lower intubation time lower lactate levels higher urine output and shorter hospital stay. Having personally never having used pulsatile perfusion clinically yet having the equipment capable of doing so it is quite difficult to ignore the findings of this study. it would appear that in the group of patients in this randomized study the use of pulsatile perfusion had real benefits to the patient and i am certain the hospitals purse. the study is an easy and enjoyable read without reams of statistical analysis and extremely complex methodology. this is great for the reader but probably less this paper describes how eCMo is in essence a modification of standard CPB. Many centers may not have particularly large volumes of eCMo or lack the capabilities to have effective simulation based learning. it is recommended that in order to improve patient safety a model must be in place that can facilitate the prevention and management of adverse events while reflecting a genuine team environment inclusive of human factors. in order to make this possible slight modifications to the orpheus were necessary due to this simulation device being designed for use with a open CPB system. the primary modification required was the addition of a bladder to the arterial line in order to reproduce the lowering of venous pressure. during simulation based learning it was possible to effectively reproduce circulating volume loss tamponade oxygenator failure kinked arterial line obstructed venous line and air entrainment. it is felt that the employment of this method of simulation-based learning has enhanced the learning process and been complicit in the maintenance of standards. the virtues of simulation-based learning have been well established in many industries including perfusion over the years. the orpheus simulator has a proven track record with standard CPB and its virtues have been widely reported. this is the first time i have read about its standard functionality being modified to enable effective eCMo training. for this the authors must be applauded. these devices do not come absent cost and if their usage can be broadened resulting in improvement in standards in a field closely aligned with CPB that must be a this meta-analysis set out to compare the previously published literature pertaining to pulsatile perfusion in order to determine if a difference existed in poet operative renal function. following the identification of 298 articles only 10 met the inclusion criteria within this ten 708 patients underwent pulsatile perfusion whilst 477 underwent non-pulsatile perfusion. the results showed that onbypass MAP was slightly lower in the pulsatile group no significant difference existed for post operative creatinine Bun or sVr. Post operative creatinine clearance was significantly different with pulsatile perfusion as was the serum lactate in that group. the intra-aortic balloon pump usage in order to generate pulsatile perfusion had more favorable results than other methods employed. thus the authors concluded that pulsatile perfusion resulted in lower lactate levels in the post operative period and greater creatinine clearance. this was felt to be sufficiently evident of improved renal preservation and increased oxygen delivery to the tissues due to the nature of the delivered pulsatility. it would appear that over the last year or so there has been resurgence in the interest with pulsatile perfusion. in no small part this may be down to avid researcher and friend of the College Akif undar. Akif is a great proponent of this technology and has published widely on the subject- as evidenced by the reference list in this article. Another reason for this resurgence may also be the ability of the new generation of centrifugal pumps to generate effective pulsatility. looking at this meta-analysis and several of the articles in the references list it would appear that tangible benefits do exist. that said whilst this study made every attempt to have homogenous samples differences (that were declared) were evident. these differences related to APril 2013 www.anzcp.org 61 the inclusion of paediatric studies being grouped with adult studies differing perfusion protocols being used and differing modalities being employed to generate the pulsatility. whilst i probably would not make a decision to use pulsatile perfusion based solely upon this metaanalysis i do think that i would have a look at the studies referenced within this article and be open to the possibility that pulsatility is something that may augment my practice. 4. demma l and levy JH. A Case series of recombinant Platelet factor 4 for Heparin reversal After Cardiopulmonary Bypass. Anesth Analg. 2012 115 1273-8. heparin for post operative dVt prophylaxis thus potentially not receiving a post immunisation trigger for Hit. they also speculate that exogenous administration of rPf4 bypasses the internal release and exteriorization of Pf4 which may be required in developing antigenicity. finally the clinical arm of this study was ceased prior to analysis of blood samples to detect anti-Pf4 heparin antibodies which are responsible for Hit. Personally i would be very excited to see further work in this area- i am just not sure i would be willing to carry it out. 5. fernandes P Cleland A Adams C et al. Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery. Perfusion. 2012 27(6) 493 501. my way to adapting our bypass circuit for independent pump control of lower body perfusion as oppose to simply perfusing lower and upper body through a Y up at the table and consequently having no control over the degree of perfusate to the separate vascular beds. 6. tully PJ. Psychological depression and Cardiac surgery A Comprehensive review. JeCt. 2012 44 224 232. recombinant platelet factor 4 (rPf4) has previously been considered for use in the reversal of heparin as an alternative to protamine. Concern however exists due to the Pf4 heparin moiety being seen as integral in the condition heparin induced thrombocytopenia. this study retrospectively compared a case series of 16 patients who received rPf4 and 5 patients who received protamine in order to address heparin reversal activity. it was found that 10 minutes following rPf4 administration heparin was adequately reversed in all patients. it was further found that a dose of 5mg kg was adequate 5 minutes after administration in 10 of 10 patients. in both groups no bleeding thrombotic complications or thrombocytopenia existed. the study concluded that although further work was required to assess the safety of this method it was demonstrated that rPf4 administration was effective in reversing heparin without serious complications. this paper sets out to test the efficacy of rPf4 as an alternative to protamine. whilst protamine is tremendously effective in its duties being solely reliant upon one drug for a particular job especially one with such profound side effects is not an enviable position to be in. Conversely the administration of rPf4 to post cardiac surgical patients is not risk free either. My first thought when reading this paper was how did they get approval for that study Perhaps the reason is due to the actual clinical arm of the study taking place in 1995 with the authors not being able to analyse the data till far more recently. it must also be said that this is not the first time that rPf4 has been looked at in the reversal of heparin. this study cites a randomised blinded trial in cardiac catheter patients that demonstrated the safety and effectiveness of rPf4 in heparin reversal- so perhaps it is i that am overreacting. that said the authors of this study quite rightly point to caution before applying these findings to a larger group. they point to the study group not being exposed to Circulatory arrest hypothermia and antegrade cerebral perfusion are all often required in order to permit effective repair of transverse aortic arch aneurysms. these strategies are reported to result in significant morbidity due to mesenteric and lower limb ischemia. this study describes lower body and mesenteric perfusion 1-3l min at 30c in conjunction with cerebral and myocardial perfusion in 5 such patients. it was found that post circulatory arrest lactate levels declined rapidly from a peak of 9.9 down to around 3.4 back in iCu. the pH levels rose from 7.25 to 7.43 upon return to iCu. the authors suggest that this study shows early lactate clearance normilisation of acidosis and metabolic recovery when simultaneous cerebral and warm body perfusion is employed for this group of patients. furthermore this strategy may attenuate visceral and lower body ischemia that is commonly seen when deep hypothermic circulatory arrest on its own is utilised. i particularly enjoyed this novel study as it addresses a problem that i have spent a reasonable amount of time considering namely effective whole body perfusion for aortic cases in which the simple approach is always to go on cool down and come off. i acknowledge that this approach is beautiful in its simplicity and many surgeons obtain a less littered operative filed many surgeons also believe that they can do the operation quicker. i may even accept that the actual procedure may be quicker but are they factoring in all the standing around awaiting haemostasis due to the coagulopathy associated with profound hypothermia- probably not. Admittedly this study had a very small sample size and lacked a control- although the authors maintain that their work is backed up by other larger studies. that said since reading this paper i am well on the association between cardiac surgery and psychological and neurological dysfunction has been studied for many years. the assessment of pre-procedural depression and its potential effects on postoperative recovery has not been researched as adequately as other preoperative risk factors. this review paper looks at existing literature pertaining to the impact of depression on cardiac and neuropsychological morbidity and mortality. it is apparent that depression and major depressive episodes increase major cardiovascular morbidity post cardiac surgery. Clinicians should consider thorough assessment of depressive tendencies and where appropriate pharmacological and non-pharmacological treatments. i must first admit to being moderately amazed that depression in terms of the prognosis of coronary artery disease has been studied for more than two decades. Having reflected on why i was so amazed i believe that this is due to my perception of very little being done to address the neuropsychosocial needs of cardiac surgical patients. As this review points out this area of concern has been known about for some time yet the weight of research into the problem lags far behind other more tangible prognostic indicators. Perhaps this is reflective of mental health research in general i m not sure. what does become clear whilst reading this review is the extremely strong association between depression and postoperative morbidity. i particularly enjoyed how this review also went to the trouble of explaining the mechanisms of this association. it would appear that pharmacological treatments can carry their own independent risk factors in this group of patients yet at times and in conjunction with non-pharmacological treatments can yield positive results. i would agree completely with the author that this area is fruitful ground for future research. 7. Albal Pg Menon Pg Kowalski w et al. novel fenestration for controlled Venous flow shunting in failing fontans with systemic Venous Hypertension. Artificial organs. 2013 37(1) 66-75. 62 APril 2013 www.anzcp.org the fontan procedure is carried out to complete single ventricle palliation. once complete the patient will have completely passive pulmonary blood flow. this group of patients is prone to systemic venous hypertension pleural effusions and protein losing enteropathy. in order to relieve venous pressure and improve post operative haemodynamics a circular fenestration can be made which creates a shunt to the common atrium. this fenestration comes at the cost of lower systemic saturations. this study seeks to discover if different fenestration designs can limit shunt flow at lower venous pressures and permit increased flow at higher venous pressures. such designs consisted of a plus or s shaped orifice. steady leakage flow tests leaflet opening kinematics fluid structure interaction analysis and a lumped parameter model of the single ventricle for pulsatility tests were all carried out to assess the novel designs. for the plus shaped fenestration it was found that the leaflets activated passively after a critical systemic venous pressure threshold this would minimize excessive venous shunting. Altering the shape thickness size and material of the fenestration could change the shunting flow rate to reflect patient specific characteristics. in the immediate post operative period children with a fontan circulation are often prone to elevated pulmonary pressures especially if early extubation is not possible. Creation of a fenestration permits alleviation of this. this study correctly states all of the limitations of the commonly used circular fenestration. it would appear that in this in vitro study many of these limitations can be ameliorated or even avoided with the use of a modified s or plus shaped fenestrations. My early thought was that these designs would not overcome one of the major shortcomings of the fenestration namely closure of the fenestration. the authors however claim that potential exists for spontaneous closure by neointimal formation at the leaflet boundaries when systemic pressures are consistently low. the authors do acknowledge the need for further blood studies to test how prone these new designs are to thrombus formation and longer term flow dynamics. i look forward to seeing this future work. 8. goodnough lt and shander A. Current status of Pharmacologic therapies in Patient Blood Management. Anesth Analg. 2013 116 15-34. comprehensive review of the pharmacologic and haemostatic agents that are used in PBM with a view to informing clinicians and patients alike of the relative risks and benefits of these alternatives to allogeneic blood. they present sections on erthyropoises stimulating agents iV iron therapy heamostatic agents antifibrinolytics desmopressin factor concentrates recombinant activated factor vii and artificial oxygen carriers. each section presents the available evidence both good and bad of the use of each of the therapies mentioned. of particular note was the mention of the reintroduction of Aprotinin for cardiac surgery in europe and Canada after a review of the BArt data. the paper provides an excellent review of each of the strategies but we seem a long way from the use of these therapies when the anaemia is often noted in the anaesthetic room just prior to surgery. As is often the case the paper makes a sound case for particular strategies but offers little on the actual implementation of them. i accept that this was not the focus of this particular paper but the gap between research and practice for the majority of us is a chasm that is difficult to cross. 9. Muthiah K robson d Macdonald Ps et al. thrombolysis for suspected intrapump thrombosis in Patients with Continuous flow Centrifugal left Ventricular Assist device. Artificial organs. 2013 37(3) 313322. 10. Holsworth Jr. re shecterle lM st. Cyr JA et al. importance of Monitoring Blood Viscosity during Cardiopulmonary Bypass. Perfusion. 2013 28(1) 91-92. this letter to the editor describes how post CPB focus on causes of morbidity and mortality rarely stray from cerebral complications as the primary cause. the letter then goes on to detail how CPB interventions alter the viscosity of blood. Haemodilaution for example whilst lowering viscosity it will also increase cerebral blood flow alter cerebral metabolism and may result in an increase in embolic load being delivered to the brain. Hypothermia on the other hand will lower metabolic demands whilst elevating the bloods viscosity up to 300 times with a reduction in temperature to 22 C. the author postulates that the existence of microvascular shunts throughout the body including the brain would result in blood being diverted away from capillary beds congested with hyperviscous blood with resultant hypoperfusion and local ischemia. numerous studies are highlighted that show a strong association between the degree of viscosity and cerebral and cardiovascular risk factors. the letter ends with the suggestion of knowledge of the blood viscosity profile leading to improvement in perfusion management. since commencing my career in perfusion manipulation of blood viscosity has been a subject that has confounded me on a daily basis. i as i am sure we all have done have read the historical section in gravlee detailing the advancements in perfusion when the benefit of haemodilution was discovered. Also in gravlee we have all probably seen the graph showing that the optimum haematocrit for oxygen delivery to the microvasculature is around 30%. Certainly at our institution we target the magic 30%- and due to me working in paediatrics this requires the addition of bank blood to the majority of cases. this is where the issue of viscosity starts to confound me- i add blood to my pump in order to offset the induced haemodilution in order to optimise oxygen delivery. Yet i add to my pump bank blood that contains cells far less deformable than native cells i then subject this to varying degrees of hypothermia thus increasing viscosity further... in order to improve oxygen delivery. whilst this letter to the editor does not highlight any strategies to gain understanding of individual blood viscosity profiles i agree with the authors wholeheartedly when they state that an improvement in perfusion management would come about with an increased understanding of blood viscosity profiles. in this paper the authors report 5 cases from their series of 51 implants of the centrifugal Heart-ware lVAd who were treated with thrombolyis for thrombus formation in the pump avoiding pump replacement. thrombus formation was detected due to increasing power requirements and changes in blood flow. they show a significant correlation with the known risk factors of anticoagulation interruption inadequate antiplatelet therapy and sepsis. they recommend temporary increased anticoagulaiton with heparin in the setting of systemic sepsis and ultimately conclude that pump exchange can be avoided with repetitive thrombolysis in some patients. this is an intriguing study yet it would be of interest to know what monitoring of the antiplatelet therapy was used. resistance to aspirin and Clopidigrel therapy is well described. it is also not clear if there were patient risk factors in the patient group that did not form thrombus in their pumps or if the risk factors mentioned can be correlated with this outcome. ref Variable Platelet response to Aspirin and Clopidogrel in Atherothrombotic disease. Andrew o. Maree and desmond J. fitzgerald Circulation. 2007 115 2196-2207. dr goodnough and dr shander are well known and respected advocates of the Patient Blood Management (PBM) approach to reduction of allogeneic blood exposure. in this paper they present a APril 2013 www.anzcp.org 63 CAlendAr of eVents APriL 2013 13 Mid-Atlantic VAd and eCMo symposium (MAVes) 2013 inoVA fairfax Hosptial falls Church VA usA http www.mdperfusion.com 18-20 the 10th interCePt (international Course on extracorporeal technologies) and outcome Meetings Milan italy www.intercepteurope.org MAY 2013 8-11 eCMo and Advanced intensive Care 2nd euro-elso Annual Meeting stockholm sweeden www.euroelso.com 31 - June 2 Autologous Blood therapy Course ABtC Holiday inn - trustMart Park Pearl (Jackson) Mississippi usA http autologousbloodtherapycourse PrfuZn bellsouth.net 601-824-3915 JuNE 2013 12th to 15th 15th european Congress on extracorporeal Circulation technology Hotel Biatriz toledo spain http www.fecect.org email office fecect. 12 - 15 AsAio 59th Annual Conference Chicago il www.asaio.com 20-21 international Course on eCMo international Course on eCMo & short term Circulatory support respiratory support uiCP Paris france www.paris-ecmo.org SEPTEMBEr 2013 5-7 AMseCt 21st Annual symposium on new Advances in Blood Management loews Annapolis Hotel Annapolis Md http amsect.societyhq.com meetings upcoming.iphtml OCTOBEr 2013 5 13th european Conference of Perfusion education and training-2013 Vienna Austria judy.horisberger gmail.com 9-12 Best Practices in Perfusion Mariott riverwalk san Antonio tX http amsect.societyhq.com meetings upcoming.iphtml 23 - 25 latin American Perfusion Congress Margarita island Venezuela http www.clateven.com NOvEMBEr 2013 13-17 AMseCt Pediatric Perfusion grand Hyatt denver denver Co www.amsect.org The Pumpers Quiz Answers 1. C 6. D 2. B 7. B 3. A 8. D 4. A 9. A 5. D 10. C 64 APril 2013 www.anzcp.org AutoCAT 2 WAVE ProActive Counterpulsation TheAutoCAT2WAVE isthefirstIABP Systemwhichproactivelyanticipates anddeterminesAVclosure Improvedtimingaccuracywithregardto IABinflationanddeflation Optimumtriggeringduringsevere arrhythmiasprovidedbytheAutoCAT2 WaveSystemandFiberOptixSensor TheAutoPilotmodeconsistently maintainstimingandtriggering CanbeusedwithARROW FiberOptix&fluid-filledIAB catheters Further information 1300 360 226 Mayo Healthcare Customer Service www.mayohealthcare.com.au APril 2013 www.anzcp.org 65 WINTER MEETING PERFUSION DOWNUNDER September 1st - 3rd 2013 Hayman Island Queensland Australia www.perfusiondownunder.com Perfusion Downunder is an exciting annual meeting designed to promote original prospective research into the effects of perfusion management on patient outcomes. KEYNOTES Donald Likosky Associate Professor University of Michigan Medical School Ann Arbor MI USA FACULTY Alan Merry Auckland New Zealand Sara Jane Allen Auckland New Zealand Rob Baker Adelaide Australia Michael McDonald Melbourne Australia Richard Newland Adelaide Australia Mike Poullis Liverpool UK Tim Willcox Auckland New Zealand Rob Young Adelaide Australia THEMES Quality Improvement Outcomes Cardiac Surgery Blood Management Collaboration Teamwork Patient Specific Bypass Cognitive Outcomes The Professor Merry Lecture David Scott Associate Professor St. Vincents Hospital Melbourne Australia PROFESSOR MERRY LECTURER Paul Myles Melbourne Australia REGISTRATION To find out more details regarding the Conference including registration accommodation options booking contacts and registration please visit www.perfusiondownunder.com SPONSORED BY