This Digital Edition requires Flash 9.0.115 or above to activate some rich media components.

Please click the following link to download and install: Get Adobe Flash player
When you are finished installing, please return to this window and PRESS F5 to view this edition.

Description: The Australian and New Zealand College of Perfusionists Gazette

The AUSTRALIAN AND NEW ZEALAND COLLEGE of PERFUSIONISTS GAZETTE DECEMBER 2014 Gazette Issue 12 14 TABLE OF CONTENTS Page 2 Page 3 Page 4 Page 4 Page 5 Page 8 Page 9 Page 10 Page 12 Page 14 Page 15 A Message from the Editor Molly Oldeen A Message from the President Jane Ottens. Registration Committee Report Alison Horton. The ABCP Board Report Clarke Thuys. PIRS Report Tim Willcox. Around the Pump Room Craig McDougal. A Busy Year for the Queensland Paediatric Cardiac Service Carla Zazulak. National Blood Authority Guidelines Summary Chris Morley. NASRHP Submission to National Registration and Accreditation Scheme Review Conference Corner Intraoperative Management of Blood 2014 Conference Corner AmSECT Quality and Outcomes Conference Page 27 Page 20 Page 18 Page 19 Friends of Fiji Heart Foundation Paediatric Trip Mark Greaves. Open Heart International Papua New Guinea Jessica Ozdirik. Air Transmission Comparison of the Affinity Fusion Oxygenator with Integrated Arterial Filter to the Affinity NT Oxygenator with Separate Arterial Filter An In Vitro Pilot Study Kieron C. Potger. An In House Audit on the Use of Cardiotomy Suction During Protamine Administration at TTH Helen Scarrott. Abstract Cardiac Catheter Procedures During Extracorporeal Life Support A Risk-Benefit Analysis Novel Equipment for Safer ECLS Transport Molly Oldeen. Abstracts from the IMOB Conference Sydney 2014 Calendar of Events Page 28 Page 28 Page 30 Page 35 aemodilution Terumo Australia Pty Ltd Macquarie Park NSW 2113 Australia T 1800 837 866 Mount Albert 1025 New Zealand T 0800 66 77 57 E cs_australia Prescriptive OxygenationTM is a Trademark of Terumo Corporation Registered Trademark The AUSTRALIAN AND NEW ZEALAND COLLEGE of PERFUSIONISTS GAZETTE EDITOR Molly Oldeen CCP Perfusion Department Mater Children s Hospital Level 6 Raymond Terrace South Brisbane QLD 4101 Tel 07 3163 5325 Email gazette EDITORIAL CORRESPONDENCE Editorial correspondence should be addressed to the Gazette Editor gazette (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. ASSOCIATE EDITORS Carla Zazulak CCP Mater Children s Hospital Brisbane QLD Email carla.zazulak Jane Ottens CCP Ashford Hospital Ashford SA Email jane.ottens 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 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. ADVERTISING To advertise in the Australian and New Zealand College of Perfusionists Gazette contact the Gazette Editor. Tel. 07 3163 5325 email. gazette This edition of the Gazette has been proudly supported by Cellplex. DECEMBER 2014 1 A MESSAGE FROM THE EDITOR by Molly Oldeen CCP. We have some big changes happening in Queensland...This November our team at the Mater Children s Hospital will be transitioning into the new Lady Cilento Children s Hospital. A 1.5 billion project we will have 359 beds to provide statewide care for children in Queensland. We will be combining the services of both the Royal Children s Hospital and the Mater Children s Hospital to create one of Australia s largest and most advanced paediatric facilities. As anyone that has moved hospitals before knows it will be an exciting yet challenging time ahead for our team. Change on a smaller scale is happening within the Gazette It is with pleasure that I announce the addition of abstracts from the latest Intraoperative Management of Blood (IMOB) meeting held in Sydney this past April. Thank you to the authors as well as Darryl McMillan and Chris Morley for permission to include them in this edition. They will continue to appear in future publications alternating with abstracts from the Annual Scientific Meeting. The next IMOB meeting will be held in Sydney at the Amora Hotel on 27-28 March 2015. Furthermore this issue includes some great original research articles such as an in vitro pilot study from Kieron Potger regarding air transmission comparisons between two oxygenators. In addition it includes an article from Helen Scarrott regarding an internal audit of their practices concerning sucker usage. These serve as a reminder to always strive to improve and advance our techniques. Current literature may offer a guideline for protocols however at times internal audits may provide the best practical evidence. I hope you enjoy this issue of the ANZCP Gazette. Thank you to everyone that has contributed content. And thank you especially to Carla and Jane for all of their support and resources. Kindest regards Molly Oldeen The Gazette Editor Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood & management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to 2-3 high haematocrit blood components1 Patient blood management aims to improve clinical outcomes by avoiding nnecessary exposure to blood components1 Patient blood management aims to improve clinical outcomes by avoiding nnecessary exposure to blood components1 Patient blood management For more information please contact aims to improve clinical outcomes by avoiding nnecessary exposure to blood components1 Consistently operation Simple set up Think C.A.T.Splus Fresenius Kabi Australia Pty Limited 964 Pacific Highway Pymble NSW 2073 Australia Customer Service 1300 732 001 PM2013.050 References 1.National Blood Authority. Patient Blood Management Guidelines Module 2 Perioperative. 2012 [cited 2013 Feb 5]. Available from http guidelines module2 po-mod2.pdf DECEMBER 2014 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 2 A MESSAGE FROM THE PRESIDENT by Jane Ottens CCP. In writing this President s message I spent many hours going through previous editions of the Perfusion News and The Gazette. And yes I still have every edition on my bookshelf in the pump room- albeit yellowing and slightly tatty. (Obviously I knew that one day I would read them again). One common theme throughout the history of the two publications for the society college has been the importance of the communication that they provide and sharing what we do. While we have progressed over the past 22 years all of the editorial committees seem to have to beg and grovel for input for the publication...I guess at least we have been consistent no matter who is the Editor . I discovered that this boxed set of these editions provides us with a concise archival history of the college which is not documented elsewhere other than maybe searching through the many boxes of paperwork folders trash emails on computers from previous executives all over Australia and New Zealand. What I did enjoy as I was re-living my past was the memories of the ASM meetings and seeing the stages of our growth especially in the late 90 s when there were units being set up all over Australia and New Zealand and our continual quest to improve what we do with the development of PIRS simulation and our education and recertification. But back to reality the real reason for trawling through the archives was to jolt my memory and remind us all of the leaders and visionaries that have provided the foundation for the college of what it is today. We have previously honoured three of those such leaders with Life Membership Paul Bernhardt in 1999 Don Pastoriza Pinol in 2001 Sid Yarrow in 2006 And this year for the first time as the ANZCP we will award two more members Life Membership Mr Timothy Wilcox and Mr Darryl McMillan who were unanimously voted by the membership to receive this award. Perfusion News was first published in 1992 during Tim Wilcox s Presidency (1991-94) of the ASCVP. For those of you who may not be aware this was the first communication of its type to be circulated by the society to all Australian and New Zealand members. The internet did not yet exist and it enabled us to all keep in touch with what was happening outside of the ASM AGM. It told us of news around the pump rooms and made important announcements. So back in 1992 it notified us of the first draft of the Standards and Guidelines which were to be sent to all for comment. There were also other items of importance -the Society had scarves and ties for everyone the ASM was to be held at a fun park (Seaworld) and the going rate for a perfusion job in Perth was 26- 32 000 per year. In 1998 the Perfusion News morphed into the The Gazette with Tim this time taking the reins as Editor (1998-2001). The Gazette was glossy and contained for the first time advertising for perfusion products and included scientific content. In 2001 Tim passed his editorship to Darryl McMillan and took over running PIRS which he continues to do. Darryl took on the dual role of both Editor and President (1999-2006) something I definitely don t envy as every edition he had to write two of these but he continued to do so until 2006. In these later editions reports from the executive committees were added as well as abstracts from the presentations given at the Annual Scientific Meetings. These two individuals were the driving force of this publication for many years which is relevant to mention in this message prior to them receiving their Life Membership in Auckland at the ASM 2014. On behalf of the membership I thank them both for their insight and dedication. Jane Ottens President ANZCP ANZCP STRUCTURE The Executive Jane Ottens - President Jonathon Cropper - Vice President Matt Sheminant - Secretary Carla Zazulak Treasurer Jon Van de Berg - NZ Representative Tim Willcox Registrar The Board Mark Mennen Chairmain Chris Morley - Member Andrew Lahanas - Member Vincent Rajkumar Member Sub-Committees Alison Horton - Registration Committee Jane Ottens - Simulation Committee Tim Willcox - PIRS Editor DECEMBER 2014 3 REGISTRATION COMMITTEE REPORT by Alison Horton CCP. Dear Colleagues The last six months working with the National Association of Self- Regulating Health Professionals (NASRHP) the sub group of the Allied Health Professionals Association (AHPA) has accomplished the following. Monthly meetings have helped us finalise the details for the governance accreditation scope of practice etc. to present to each of the Associations Board s. The aim is to form a united group and over-reaching umbrella company to regulate the Self-Regulating Professionals . Have sent letters and met with health department officials to discuss the Government appetite to support and endorse the venture. Louise Robinson the senior project manager of the NR AS review was invited to The AHPA meeting in Oct to discuss and answer any questions we might have for her. This was a great opportunity to hear how the Government views National Registration its pros and cons and what needs to change. The Government has been considering ways of reducing its costs and is considering the Canadian and UK models of regulating the health professions. This may give ANZCP the chance be recognized but still remain self-regulating. We sent in a submission regarding the National Code of Conduct. We responded to the National Registration and Accreditation Scheme (NR AS) review firstly as a member with NASRHP and secondly the ANZCP Executive Committee sent a separate submission highlighting the unintended consequences of being excluded from legislated registration. The BOARD REPORT OCTOBER 2014 by Clarke Thuys Chairman ABCP Work is progressing with the annual review of the Diploma of Perfusion modules and the Board has decided to make some more alterations concentrating on the relevant material including new material and culling material considered no longer relevant. Certification exams will be held in Melbourne in late February currently there are four candidates. There is now interest in the course from Japan where there is only on the job training available Saudi Arabia and Oman where they currently send trainees to Germany but there is a 2-3 year wait for places. I anticipate that we will have one or two more Singaporean trainees starting next year. The Autotransfusion course has taken off and we have had to limit the numbers to 50 per course. We have already started a waiting list for the next course. The increase is fuelled by anaesthetists CME requirements so we could be very busy for a few years. Chis Morley recently attended the AMSECT Blood Management meeting and will be reviewing the course material to include new developments. Registering as a training organisation to enable the Diploma to be accredited and recognised has slowed to some extent as I discovered that we need qualified trainers and assessors before we can even begin the application. We also need more than one qualified trainer ideally we need one in NZ and 4 in Australia to be able to cover all the states. It is needed because one of the requirements of any registered course is to be able to assess competency. Currently we rely on supervisors to do this but in a registered course competency can only be assessed by a qualified assessor. The qualification being the outcome of successful completion of a registered training and assessment course. I envisage that for the future course there will be an annual visit to the trainees hospital to observe at least one case from start to finish. If you think you can do this the ANZCP will pay the course fees for your qualification. There are a number of different ways the course can be complete ranging from online to face to face one night per week for one or two terms or an intense 6 day course. I am currently doing the course and although a little difficult in some areas I am learning a good deal about how we need to structure the course and what is required to be a registered training organisation. I am also learning about how to teach and assess with one subject being dedicated to online and distance education. We must have these qualified people in place to be able to proceed with registering as a training organisation and having our course recognised. I would like to thank Carla and Jane for helping me prepare some of the submissions over the last few months. 4 DECEMBER 2014 PERFUSION INCIDENT REPORTING SYSTEM (PIRS) NOVEMBER 2014 by Tim Willcox PIRS Editor The PIRS is currently undergoing change with a view to making it more accessible and interactive and hopefully garnering a renewed interest by perfusionists to submit any incident be it a near miss or accident. At the November 2014 ANZCP Annual Scientific Meeting (ASM) in Auckland feedback on PIRS was sought during the fireside chat PIRS session and this is discussed below. However in the interchange on barriers to reporting the comment was made that determining if the incident was a near miss or an accident was confusing. On the submission form we have defined this as Near miss an event that could have had bad consequences but did not Accident a failure causing damage or disruption to system or patient. In any event a submitted PIRS report is reviewed by the PIRS editors and any confusion can be resolved at that point. So the message is ascribe your own interpretation of the nature of the incident and submit then this can be clarified in the review process. As we reinvigorate PIRS it is appropriate to summarise the background to the benefits of changing the culture of our profession to have a natural expectation that near misses and accidents can and will be reported without fear or favour. To get a good understanding of the management of error there are two essential reference books that perfusion units should have on their shelf. Both are authored by James Reason who is a world expert in this field and they are Managing the Risks of Organisational Accidents - Aldershot UK Ashgate and Human Error - Cambridge University Press UK. The theory of accidents and human performance that govern our actions is explained in detail. Accidents in perfusion are more prevalent that in related fields such as anaesthesia[1]. The first successful bypass performed by John Gibbon was almost not successful due to inadequate anticoagulation where clots began to form on the oxygenator screens. This is a far less well known aspect of this historic operation. In looking to leaders in accident prevention the airline industry is held up as the gold standard. And yet despite the sophistication of the checks and balances in aviation as well as the reporting culture this industry is not without near misses and accidents. The latter can be of spectacular impact such as the ill-fated Canary Islands crash on the Tenerife runway resulting in the death of 538 passengers. While we learn valuable from these accidents more innocuous near miss data may give us a heads up and indeed prevent an impending catastrophe. Reason discusses how human behaviours control our actions by automatic and conscious mechanisms[2]. The automatic mode controls routine skill-based actions and the conscious mode controls deliberative knowledge-based actions. The former is very fast and can operate in parallel the latter is for solving novel problems is very smart but linear and very slow. Resolving a novel problem during cardiopulmonary bypass may be necessary to avoid an accident but time is a critical factor. A mixture of automatic and conscious modes of action is rule-based actions that are trained for problem solving learnings. Using such rulebased training enables complex and infrequent problems to be managed quickly and effectively. Errors are skill-based slip-lapse errors rule-based mistakes or violations. Violations are where the action is intended but the outcome is not and may fall into the categories of routine violations (corner cutting) optimising violations (violating for the thrill of it) or necessary violations (resulting from organisation failings). Of interest analysis of the PIRS data shows rule-based mistakes to be the most prevalent (Fig 1). Figure 1. Percent Reports to PIRS by Error Type 2005-2014 In this context we should consider whether we are as proficient as we should be in managing rule-based actions (and hence errors) that are best controlled or governed by effective and regular training. Simulation training in medicine and more especially in perfusion lags far behind aviation. Annual simulation in aviation is required for credentialing commercial pilots to continue to fly. There is a growing awareness that multidisciplinary simulation human factors training in cardiac surgery is something requiring institutional buy-in and the concept of closing the operation rooms for one day a year devoted to planned team human factors training is a realistic objective. A greater focus on accident theory in perfusion training programmes requires attention. Figure 2. PIRS incidents by Year The frequency of reporting to PIRS has varied over the years (fig 2) and is not a reflection of the frequency of incidents. It more likely reflects the exposure or marketing of PIRS through the Gazette or at various symposia. DECEMBER 2014 5 In 2013 PIRS was given open access having previously been restricted to ANZCP members. The American Society expressed interest in encapsulating PIRS in AMSECT but was overcome in legal quagmire. The Canadian Society has endorsed PIRS although there has been scant activity from that country. In response to a question and answer session at the 2014 ASM PIRS fireside chat session only 25% of the audience had accessed PIRS in the past year for any reason. Under reporting of incidents in a voluntary reporting system is common. The PDUC database asks the perfusionist at the end of each procedure Did a perfusion incident occur and Was the incident reported to PIRS While the total number of near misses and accidents reported to have occurred in this prospective database is almost certainly a gross under representation[3] only 40% of these were reported to PIRS. respect as it may be influenced by one or two centres that have a low threshold for reporting. Until the number reports substantively increases reviewing data over the whole reporting period is more representative of regional areas of risk. All the incidents bar one in the database are from Australia or New Zealand and so it can be seen (fig4) that regionally circuit disruption (not surprisingly) is the leading incident category however drug and medication error is a consistently reported incident type as is air in circuit. These three category leaders consist primarily of accidents rather than near miss. It is certain that many more near miss incidents of these type occur that would heighten our attention had they been reported and almost certainly prevented accidents of a similar nature. Figure 4. Figure 3. Percent incidents in PDUC Database Reported to PIRS. It is understandable that only 11 percent of PIRS incidents from 200514 were reported to external agencies such as the TGA and Medsafe (Australia and New Zealand s equivalent to the FDA) as these were infrequent significant device failures. Not surprisingly almost all incidents (90%) in the PIRS database are discussed by the team. However by comparison to PIRS hospital incident reporting systems in Australia and New Zealand received only 22% of the (under) reported incidents posted to the PIRS website. One could speculate on the reason for hospital reporting systems to be widely shunned but it is plausible a significant disincentive is the fact that these are not anonymous and potentially punitive. Disincentives to incident reporting are various. Responses to the reasons at the ANZCP ASM were somewhat muted with only a few offering reasons. To change the culture and increase incident reporting perfusionists need to feel secure that anonymity is guaranteed. The PIRS database is de-identified after the PIRS reviewer has clarified any aspects of the report with the submitter. If the submitter answers no to the question Permission to publish edited description in ANZCP Gazette & or website then no detail or description of the incident is posted on the website. Data of error type such as equipment management or rule-based skill-based is included in statistical analysis and graphs. As part of the editing process should a submitter unwittingly include detail that could identify the centre then that detail is edited out. For additional transparency the PIRS editor is having a confidentiality agreement drawn up that will be signed by the PIRS team members such that they are bound to keep incident detail absolutely confidential. These will appear on the website. The best incentive to increase reporting is for perfusionist to understand and realise the benefits gained by the free lessons we learn especially from near misses. These may seem innocuous but they occur far more frequently than accidents and provide a qualitative insight on how small defence failures can combine to create disasters. Such information needs to be distributed widely and be readily available. PIRS identifies incidents as either equipment or management grouping incidents into categories. Periodic review of the most frequent occurring categories can identify areas of highest risk to which our attention to preventive measures is most warranted. Given the current low numbers of near miss and accidents reported to PIRS on an annual basis the current year data may be misleading in this To achieve this aim PIRS needs to provide feedback more effectively. In the first instance we have revised the PIRS website http www. pirs pirs_entry.htm such that as soon as a report with permission to publish has been de-identified and entered into the database a summary report including what happened and how it was managed with some detail of error type is posted and accessible via the PIRS Reports tab. There is a tab for all reports with permission to publish for the current year and another for archived reports from the previous years. There are additional tabs with data that is periodically updated from the database. However as only a small number of perfusionists regularly access the PIRS website we have come up with a plan to make PIRS more dynamic. We have had a positive response to constructing a PIRS mailing list that will operate in in a similar manner to PERFLIST. Perfusionists will be invited to subscribe to a group electronic mailing list. Once on the mailing list members will receive an email when a new incident (that has permission to publish) is posted with the incident category and near-miss accident and with the link to the PIRS page. The recipient can then choose to open the link and review the incident. We believe that this will keep perfusionists up to date with incidents as they occur and encourage perfusionists to access PIRS to review what is being reported and indeed encourage contributions. We very much welcome your feedback and invite you to email us at any time at pirs Without a detailed analysis of mishaps incidents near misses and free lessons we have no way of uncovering recurrent error traps or of knowing where the edge is until we fall over it. James Reason 2000. Tim Willcox Dip Perf FANZCP PIRS Editor for the PIRS TEAM Dani Blackie Andrew Sanderson Jane Ottens Tim Willcox. 1. 2. 3. Jenkins O.F. R. Morris and J.M. Simpson Australasian perfusion incident survey. Perfusion 1997. 12(5) p. 279-88. Reason J. The human in contribution in Managingthe Risks of Organisational Accidents J. Reason Editor. 2000 Ashgate Aldershot UK. p. 61 83. Svenmarker S. et al. Quality assurance in clinical perfusion. Eur J Cardiothorac Surg 1998. 14(4) p. 409-14. 6 DECEMBER 2014 ER ... B M TO E M IT RE BM SU Perfusion Incident Reporting System What is PIRS PIRS further information see 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 ...and hit the PIRS tab. DECEMBER 2014 7 Perfusion News AROUND THE PUMP ROOM WHAT WE DO IN THE SHADOWS by Craig McDougal There have been some changes within the Perfusion Department over the last twelve months. Jim Grant retired in September 2013 due to progressive motor neurone disease. Jim remains positive even though his motor skills are degrading. His replacement Rob Koch takes up his position in October. Susan Arnold-Barron finished up at the beginning of the year. Currently Len Cooper is at the helm with Amber Blakey Glaswegian locum Rosie Dickson and myself returning to Perfusion after a two year hiatus in Paediatric Echocardiography rounding out the team. Surgeon Glenn McKay has recently moved to Canberra and John Riordan is now Clinical Director. We welcome locum Surgeon Indra Nordstrand from Melbourne and welcome back Surgeon Sean Galvin who spent time at Wellington Hospital on the surgical training programme. The workload has been sporadic during the winter spring transition due to the Ward ICU bottleneck punctuated with out of hours aortic surgery. The Cardiothoracic Unit is on track to do 550 bypass procedures this year in the two operating theatres. Non-clinical work over winter has seen extensive circuit modifications to reduce priming volume and accommodate integrated arterial filtration. If you re going to live for eternity you may as well do it in a happening place Viago from What We Do In The Shadows For those not in the know this is the recently released mockumentary tale of four vampire flatmates (not) living in modern day Wellington. There are four Perfusionists at Wellington Hospital and we have been doing a bit of night work of late but all similarities stop there. Rosie had the pleasure of talking with Taika Waititi (Viago) whilst in Queenstown recently for the Perfusion Down Under Meeting. Needless to say Taika is now versant in the dark art of Perfusion. Wellington is a happening place. It s the centre of New Zealand s film production industry the burgeoning craft beer industry (showcased at Beervana in August) and there is a vibrant cafe culture arts and local music scene. Boots on the Ground Perfusion visit... 8 DECEMBER 2014 Perfusion News A BUSY YEAR FOR THE QUEENSLAND PAEDIATRIC CARDIAC SERVICE by Carla Zazulak After 6 years of Paediatric Cardiac Surgery at The Mater Children s Hospital the time has come to transition our service to the brand new Lady Cilento Children s Hospital next door. The first cardiac cases will commence following the move on November 29th 2014. Located in South Brisbane the Lady Cilento Children s Hospital brings together the staff and services of the Royal Children s Hospital and Mater Children s Hospital to provide specialist paediatric care for children from birth to 16 years of age (up to 18 years for established patients). The new hospital will be the single specialist children s hospital for the state owned and operated by Children s Health Queensland. It will provide the very highest level of care to children from all over Queensland as well as general health services to those living in the local inner-Brisbane community. A statewide service The Lady Cilento Children s Hospital will support regional hospitals through telemedicine and outreach services and new and expanded children s health services in the greater Brisbane metropolitan area. Lady Cilento Children s Hospital vital statistics Public hospital owned and operated by Children s Health Queensland All highly specialised children s health services in one location 359 beds - 25 per cent more that the Royal Children s and Mater Children s hospitals combined All existing services of the Royal Children s Hospital and Mater Children s Hospital plus new clinics to treat obesity pain and allergies a specialised adolescent service and paediatric renal treatment Carla Anthony Mahesh and Molly will be doing our next Around The Pump Room from our brand new environment here is a last photo from our current pump room. DECEMBER 2014 9 Perfusion News NATIONAL BLOOD AUTHORITY GUIDANCE FOR THE PROVISION OF INTRAOPERATIVE CELL SALVAGE SUMMARY by Chris Morley After some 13 months of meetings conference calls and emails between the member s of the ICS Clinical Writing Group the National Blood Authority released their Guidance for the Provision of Intraoperative Cell Salvage document on 26th March. This document is intended to inform health-care practitioners health educators health service managers and policy makers about Intraoperative Cell Salvage (ICS) use for patients undergoing surgery or invasive procedures particularly those in which blood loss is anticipated. It is aimed at supporting hospitals to develop and implement an intraoperative cell salvage program. The guidance and accompanying resources in the appendixes such as patient education materials business case study and education competency workbook have been designed with the intention that they can easily be adapted to accommodate the local policies and practice of individual hospitals. They are available as generic baseline material to download alter and adapt as applicable to their local requirements. The National Safety and Quality Health Service Standard 7 Blood and Blood Products require blood and blood product policies and procedures to be consistent with national evidence based guidelines for pre-transfusion practices prescribing and clinical use of blood and blood products. The ICS Guidance aims to improve clinical practice and patient outcomes through alignment with the Patient Blood Management (PBM) Guidelines. Implementation of an intraoperative cell salvage program by health providers is not mandatory as a patient quality improvement measure. The aim of the ICS guidance is to provide information that will allow clinicians to 1. Appropriately identify suitable patients undergoing elective and or emergency surgical procedures where ICS could be of benefit. Safely utilise ICS in an effective manner. GUIDANCE FOR THE PROVISION OF INTRAOPERATIVE CELL SALVAGE 2. The ICS guidance has been developed in accordance with the Patient Blood Management Guidelines and in line with National Safety and Quality in Health Service Standard 7 Blood and Blood Products. The ICS Guidance is part of the National Reference Set. The ICS guidance was written in consultation with a clinical writing group comprising an anaesthetist an orthopaedic surgeon and a perfusionist and was reviewed by a clinical cross-jurisdictional group before being available for a six-week public consultation period. APPENDIXES Guidance for Australian Health Providers MARCH 2014 Guidance for the provision of Intraoperative Cell Salvage Appendices AUS ICS Version No 1 March 2014 Page 0 Enter Organisation details here Traditional barriers to implementation of ICS have included not having access to or knowledge of cell salvage documentation which is now required for accreditation. The NBA has eliminated this barrier by providing the resources in this documents. Documents are available to view download at ics GUIDANCE FOR THE PROVISION OF INTRAOPERATIVE CELL SALVAGE Guidance for Australian Health Providers Guidance for Australian Health Providers MARCH 2014 MARCH 2014 Guidance for the provision of Intraoperative Cell Salvage Ref No Enter Organisation Ref Page 0 AUS ICS Version No 1 March 2014 10 DECEMBER 2014 ARROW AUTOCAT 2 WAVE Cardiac Assist ProActive CounterPulsation The AutoCAT 2 WAVE is the first IABP System which proactively anticipates and determines AV closure Improved timing accuracy with regard to IAB inflation and deflation Optimum triggering during severe arrhythmias provided by the AutoCAT 2 Wave System and FiberOptix Sensor The AutoPilot mode consistently maintains timing and triggering Can be used with ARROW FiberOptix & fluid-filled IAB catheters Teleflex Medical Australia Pty Ltd 4 Secombe Place Moorebank NSW 2170 Customer Service 1300 360 226 DECEMBER 2014 11 NATIONAL ALLIANCE OF SELF-REGULATING HEALTH PROFESSIONS SUBMISSION TO THE NATIONAL REGISTRATION AND ACCREDITATION SCHEME REVIEW 9 October 2014 Executive Summary Since its implementation the National Regulation and Accreditation Scheme (NRAS) has made significant steps in establishing a nationally consistent framework to protect the health and safety of those who access health services. Through these achievements the NRAS commencing under National Law in July 2010 has raised the community expectation that all Australian healthcare delivery meets a governed standard with established public protection processes in place. Notably this expectation is currently only met for a quarter of recognised health professions through NRAS. The remainder of Australian health practitioners operate outside of a formalised framework with public protection offered only through a mix of practitioner voluntary membership of a self-regulating professional association employer workplace arrangements and individual state legislation. The primary concern of a robust health regulatory system is public safety through the assurance of quality service provision. Unfortunately self-regulation in its current form is not sufficiently far-reaching because it cannot mandate standards beyond entry level nor ensure that all practitioners submit to a code of ethics conduct and a complaints management system. Existing self-regulatory arrangements only regulate members or those who seek voluntary accreditation. Most self-regulated professions have examples of serious public complaints where the practitioner was either not a member or chose to resign membership providing no avenue to pursue the complaint and ensure public safety. This highlights the gaps in the current health practitioner regulatory system where there is a high level of regulation for the professions partnering with AHPRA in NRAS but no enforceable public protection for the other three-quarters of Australia s health professions These current arrangements run contrary to public expectation that a formal regulation structure exists which provides recognition of qualifications minimum entry standards assurance of practice standards a code of conduct and ethics and a single avenue for complaints. The National Alliance of Self Regulating Health Professions (NASRHP) operating under the Auspice of the Allied Health Professions Australia (AHPA) is composed of nine allied health professions which are not described under the NRAS and is representative of the broader collective of self-regulating health professions in Australia. The core objectives of NASRHP are to seek clarity regarding regulation for their respective professions benchmark their self-regulatory environment advocate on behalf of the public for an improved health regulatory environment address the challenges and consequences for the professions and health agencies of the current fragmentation in health practitioner regulation. In 2012 the NASRHP developed a detailed cost effective model for the inclusion of self-regulating health profession under the NRAS. This Harnessing self-regulation to support safety and quality in healthcare delivery A comprehensive model for regulating all health practitioners (the Submission) is included at attachment 1. The NASRHP contends that to protect the interests and safety of the public a single national authority such as the Australian Health Practitioner Regulation Agency (AHPRA) should be responsible for managing the regulation of all health practitioners. This requires an integrated framework covering the registered professions authorised self-regulating professions and negative licensing of those practitioners who do not otherwise fit within the regulation processes as described in the Submission. Recommendation The national law be amended to include a description of selfregulating health professions for inclusion under the NRAS. Authorised self-regulation with reserved protected title legislation will require practitioners utilising the protected title to meet standards for practice set by the professional association. All regulation will be managed by AHPRA and the framework will be fluid such that on AHPRA s recommendation a profession may move out of or into the NRAS should its demonstrated risk profile change. Unintended consequences as a result of a confined application of the NRA Examples 1. Health Workforce Australia s decision to only include registered professions in the Health Professionals Prescribing Project . It is understandable that when considering a policy to extend prescribing of pharmaceutical products governments needs to ensure there are appropriate standards and adequate complaints system in place for protecting the public. However this decision meant that selfregulated professions like Dietetics speech pathology and social workers who have a clear role in formal extension of prescribing rights (with some already engaged in such practices in Queensland) were not included in this project. This is a curious and awkward consequence and is contrary both to the intent of the project and the NRAS to the detriment of the effective delivery of healthcare. 12 DECEMBER 2014 2. Changes to Victorian legislation in August 2014 to improve safety and security measures for emergency workers in Victorian has been applied for the 14 AHPRA registered health practitioner groups (the letter from the Honourable David Davis MP Victorian Minister for Health is at Attachment 2). 3. AHPRA registration as a mandatory criteria for health professionals applying for Doctoral Scholarships offered by the Windermere Foundation to support the professional development of Victorian health practitioners who will become future leaders in their profession. 4. The online publication Australian Doctor states the contents of this site are available to Australian Registered Health Practitioners only . This gives the continual message particularly to doctors that everyone else is less worthy and should be excluded . The above three examples are indicative of the types of unintended consequences that have resulted from the establishment of a two tier regulatory system which has developed as a result of a confined application of the NRAS. More examples can be provided on request. The establishment of the NRAS has raised the expectations of the community health professionals and broader stakeholders that all health professions in the continuum of Australian healthcare delivery meets a governed standard with established public protection processes and regulation in place. The NASRHP and individual self-regulating health professionals do raise these issues as they are identified however often (as with legislation that has just been amended) there is limited opportunity effect timely change to the systems and opportunities that are established only recognising AHPRA registered professions. Amending the national law to include a description of selfregulating health and establishment of an integrated framework for authorised self-regulation as described in the submission not only responds to the national regulation expectations of people accessing health services it would also addressed many of the unintended consequences of the two tier regulatory system currently in place. Further to this the proposed model is proactive and seeks to identify and prevent risk through the promotion of quality standards. Other models such as legislated codes of conduct are reactive models reliant on an adverse event its reporting and the subsequent discipline procedure outcome. 7. Should the National Law be amended to recognise those professions that provide adequate public protection through other regulatory means NASRHP strongly supports this. Establishment of a legislatorial definition of self regulating health professions under the NRAS is required to achieve national consistency of the regulatory functions that assure the health and safety of those who access health services. The NASRHP argues that other regulatory means in place for self-regulating health professions (such as through workplaces or voluntary membership to professional bodies) do not provide adequate public protection. The NASRHP member professional associations vary from covering 98% to 50% of their profession. The public risk posed by so many practitioners working outside of a regulatory environment is unacceptable. The primary advantage of the proposed model is that it embraces a right-touch nationally consistent regulatory methodology focused on patient and consumer safety and quality healthcare which fills the gaps in the current regulatory environment that is silent on the quality and safety of healthcare provided by 75% of health professions. 11. Should there be a single entry point for complaints and notifications in each State and Territory 12. Should performance measures and prescribed timeframes for dealing with complaints and notifications be adopted nationally The NASRHP supports both of these on the provision that more importantly there is a single nationally consistent single entry point for complaints and notifications for all health professions. A key component of the proposed model for regulation ensures that all practitioners whether a NRAS described profession or authorised self-regulating profession are held accountable against enforceable profession specific standards of practice supported by a transparent complaints and notification handling process. A significant advantage of the proposed model is that it embraces a right-touch regulatory methodology focused on patient and consumer safety and quality healthcare. It fills the gap in the current regulatory environment that is silent on the quality and safety of healthcare provided by 75% of health professions. This model addresses the public need for safety and minimises risk with the least administrative impact. Through protection of title the public can be assured that their treating practitioner has the appropriate qualifications competency and meets other credentialing requirements. The proposed framework and model of authorised self-regulation outlined builds on current knowledge and structures satisfies community expectations of healthcare quality and safety and supports the growth of health professions in Australia. Responses to questions from the consultation paper 6. Should future proposals for professions to be included in the National Scheme continue to require achievement of a threshold based on risk to the public and an associated cost benefit analysis The NASRHP strongly supports this. The Submission outlines how practitioners in the self-regulated professions can be captured in a sensible regulatory framework. It provides for a more cost effective option for increased regulation rather than extending the current NRAS model to each individual profession and argues that the public risk whilst deemed medium to low can be further minimised and managed through authorised self-regulation. The proposed model addresses the public need for safety and minimises risk with the least administrative impact. Through this model s protection of title for self-regulating health professions the public can be assured that their treating practitioner has the appropriate qualifications competency and meets other credentialing requirements. DECEMBER 2014 13 CONFERENCE CORNER INTRAOPERATIVE MANAGEMENT OF BLOOD (IMOB 2014) by Darryl McMillan and Chris Morley This year saw the inaugural Intraoperative Management of Blood (IMOB) conference held on the 4th and 5th April 2014 at the Menzies hotel in Sydney. IMOB was intended to be a conference that would attract specialists from across the spectrum of surgical blood management disciplines. The backgrounds of the attendees reflected IMOB had met its aims with a great mix of Anesthetists Autotransfusionists Anaesthetic Theatre Nurses Blood Bank personnel Perfusionists and Transfusion nurses. A total of 73 registrants attended. The meeting started at 12 00 on the Friday afternoon with 2.5 sessions focusing of the use of intra operative blood salvage in a number of surgical specialties. In addition to this a presentation covered the current Australasian education process for Autotransfusionists and a review of the new guidelines of intra operative blood salvage from the Australian National Blood Authority was outlined. I would like to thank all the speakers who provided excellent and informative presentations. Dr. Michelle Roets Mr. Troy Tozer and Mr. Chris Morley The Saturday was divided into four sessions with two speakers per session plus 30 minutes of interactive discussion at the end of each session. This format proved to be very popular with the delegates. We were lucky enough to have Dr. Bruce Spiess from Virginia USA passing through Sydney and he agreed to set the scene for the meeting. He then followed on with an outstanding presentation on Transfusion Related Immune Modulation prior to leaving for the airport to return home to USA. The organizing committee and delegates were very grateful for the time Bruce gave to the meeting with his brief but informative attendance. The remaining Saturday speakers were also outstanding with their presentations and content What can Registries tell us about Critical Bleeding and Massive Transfusion Prof. James Isbister. Morbidity and Mortality associated with transfusion Dr. Peter Wood. Cost of blood Transfusion Prof. James Isbister. Rotem and its impact on Intra-operative blood management Ms. Bronwyn Pearse (RN). Changes to Transfusion Practices and the outcomes blood in management Dr. Bruce Cartwright. Role of Fibrinogen and Factor Concentrates in patient blood Management Dr. Bruce Cartwright. Iron Replacement and Anaemia Dr. Danny Stiel. The feedback from the delegates was extremely positive with special note given to the high quality of the speakers and the relevance of the information in their presentations. Both Chris and I would like to thank each speaker very much for taking time from their busy work and family schedules to present on a Saturday and for sharing their expertise. It would be remiss of me not to acknowledge and thank our corporate sector for their generous support and sponsorship of the meeting. CellPlex Fresenius Kabi Haemonetics HaemoView Diagnostics Medtronic and Terumo all had very impressive trade exhibitions relating to Autotransfusion devices and point of care coagulation monitors. The trade exhibits were a highlight for many of the delegates from the smaller and peripheral hospitals. Chris and I would like to take this opportunity to thank the College President Jane Ottens and the executive for their encouragement and support in making IMOB a reality. The meeting was underwritten by the ANZCP and run as a specialty interest meeting with all funding coming from and returning to the college. I am pleased to say the meeting made a small profit. In closing I can t help but to reflect on how much the College has grown over the years to where it now provides (what is hoped to be) an annual conference to a subspecialty of perfusion where the majority of delegates are not perfusionists but is seen as an important area for the College and Board to provide education and direction. Please consider attending IMOB 2015. Refer to the IMOB 2015 advert for further details. 14 DECEMBER 2014 CONFERENCE CORNER AMSECT QUALITY AND OUTCOMES CONFERENCE by Jane Ottens AmSECT decided to combine two of their meetings - Best Practices in Perfusion and New Advances in Blood Management hence the first annual Quality and Outcomes Conference was held in Baltimore USA on 1st -4th October 2014. The guest presentations were by Miriam A. Markowitz Chief Executive Officer of the American Association of Blood Banks (AABB). Ms. Markowitz currently guides the vision and mission of the AABB in advancing the practice and standards of transfusion medicine and cellular therapies to optimize patient care and outcomes. Her presentation included how the AABB could work with perfusionists AmSECT in achieving standards of practice. Pathologist Irwin Gross. Dr. Gross made a provocative case in support of the role for patient blood management programs and in his second presentation discussed an integrated approach toward taking care of cardiac surgical patients in order to minimize blood transfusions. Raising the patient s haemoglobin preoperatively was a major focus. Anesthetist Steven Frank. Dr. Frank who is the medical director of the Bloodless Medicine and Surgery Program at Johns Hopkins Hospital shared his view on the value of data in improving clinical practice and the role of evidence based transfusion practices. To marry with this session data from the USA Perform registry was presented as well at the Perfusion Down Under Collaboration registry data and the multicentre trial on transfusion. At previous Best Practice meetings break out workshops have been an integral part of the program. This year those workshops were also used in conjunction with AmSECT University to produce a flipped classroom . Delegates enrolled in a particular workshop were directed to readings videos and other online resources (in an AmSECT U course) in advance of the faceto-face workshop so that the delegate would have learned the fundamental concepts before they undertook the workshop. Extra CEU points were on offer if the AmSECT U course was undertaken. The topics included Stream 1 Red Cell Preservation (with hands on simulation on Haemoconcentration RAP and ANH) Stream 2 Coagulation Metrics and Blood Products Recommendations Stream 3 Communication This novel concept had never been tried at a conference setting before and was well received as a large number of attendees completed the course prior to the workshops (or have since done so since the meeting).(I helped run the RAP workshop) There were a number of interactive sessions (using an audience response system). The first was to gain comments to a number of proposed updates for the AmSECT Standards and Guidelines. The other session was to comment and further develop a consensus statement on how we report perfusion practices that impact on transfusion. Minimal Criteria for Reporting Perfusion-Related Contributions to Red Blood Cell Transfusions Associated with Adult Cardiac Surgery. This session also had perspectives presented by Clinical perfusion Corporate perfusion anesthesia and surgical viewpoint and then the ensuing discussion on how the consensus statement should read. One of the final sessions was a debate with AmSECT Board of Directors vs the Planning Committee. The two topics debated were Electronic Perfusion Records (EMR) are Important for Ensuring Safe Perfusion Practice and Post-graduate Patient Blood Management National Certification for Perfusionists is Needed in Our Current Healthcare Environment Debate Teams with both sides producing informative and entertaining arguments. AmSECT combining the Best Practices meeting with Blood Management to produce the Quality and Outcomes meeting I think was successful. The merging of the two meetings worked well but produced long scientific sessions (7am 6 30pm) which combined with jet lag was a times a struggle but the content was relevant and there was plenty of information to think about take home and question -how and why we do what we do every day . If you are thinking about attending an overseas meeting this is a good one. The Great Debate AmSECT Board of directors vs the Planning Committee. Retrograde autologous priming hands-on simulation workshop - using the Biomed simulator and Sorin HLM. (Interestingly enough from the 58 people that did this workshop I discovered there are almost that many different ways to RAP) DECEMBER 2014 15 FRIENDS OF FIJI HEART FOUNDATION 2014 PAEDIATRIC TRIP by Mark Greaves Snr Perfusionist Starship Auckland City Hospital Over the last 9 years Parma Nand and the Friends of Fiji heart foundation has established a yearly trip to Fiji to undertake adult cardiac surgery. The first trip visited Suva but from year 2 Lautoka became the base for operations. In 9 years over 200 patients have successfully received surgery. In 2013 Kirsten Finucane joined the adult team in Lautoka to assess whether a paediatric team could join the venture. After returning to Auckland a small task force comprising of Surgeon cardiologist perfusionist anaesthetist technicians and nurses met drank and ate pizza while putting a plan together for 2014. What became evident from the first meeting was how passionate the team were about making the trip happen. The main issues were money equipment and the size of the team. All the individual professions went away compiled a wish list and started asking suppliers for help. From my point of view I organised the perfusion side of things. I rang and emailed our suppliers asking for support knowing that most of them were already assisting the adult team. The response was amazing and within a couple of weeks the circuits oxygenators and cannula were ordered. At our next meeting the team discussed a potential case load of 6 bypass cases and 4 non bypass cases. A team of 25 people from across the professions would make the trip. However the case load was to change. On August 28th I flew over to Nadi with the technician to start the unpacking process. This was made easier because the adult team were already operating and only consumables needed unpacking. The following day the rest of the team arrived including my perfusion colleague all keen to start. The operating list was finalised and after a few sighs we set about wondering if 9 bypass cases and 2 non bypass cases could be completed in 3 days. The First case was approached with some in trepidation but it quickly became apparent how adaptable the team was. Our routine practice involves use of blood products such as FFP and PLATELETS. These were not available in Fiji and the quality of the whole blood questionable. From a perfusion point of few it was decided we would drift patient temperature rather than cool. We felt this may help with preventing coagulation disturbances. As with our routine practice all patients were muffed after completion of bypass. We completed the following cases 27 year old Pulmonary valvotomy RVOT muscle and AS 12 year old VSD via PA 8 week old TAPVD 8 year old Mitral valvotomy 2 year old Tet repair 1 month old VSD 11 month old Tet repair 18 month old Tet repair with monocusp 3 year old resection subaortic membrane 8 year old PDA 5 year old PDA 15 year old Pericardial window After 57 hours of operating an exhausted team retired to the bar for a well-earned beer and let our ICU and ward colleagues take charge. All patients did well with no major complications. Interestingly we had no issues with bleeding and now this has led to debate as whether we should review our everyday practice. After a quiet day sat around the pool we packed all the equipment up and headed back to Auckland with a feeling of a job well done. We have already started planning 2015 and look forward to another great trip. From a personal perspective I would like to acknowledge Obex cellplex Medtronic and Terumo for supporting this project. Without your generosity this trip wouldn t have succeeded. Last but not least my Auckland colleagues for their advice and support. DECEMBER 2014 17 18 DECEMBER 2014 Open HEART INTERNATIONAL by Jessica Ozdirik CCP This August saw Open Heart International s 22nd mission across the Torres Strait to Port Moresby General Hospital Papua New Guinea. The trip was slightly different to how they have been run in the past - we were heading there for two weeks of surgery paediatrics were to be in the first week and adults in the second. A team of 40 volunteers from all over the world signed up including surgeons Graham Nunn and Sylvio Provenzano who I have heard so much about from my colleagues at POWH having had a long history working along-side these talented men Dr Nunn has believe it or not been on every single OHI trip to PNG With a priceless amount of experience under his belt he is the perfect person to be teaching the surgeons of tomorrow. It wouldn t be an aid mission without a few political problems or delays this time it was quite controversial with our medical registrations being revoked the day before surgery was due to begin Nevertheless we arrived at the hospital and utilised the extra time we had to educate locals and our own staff on certain areas of our specialties that many people many not have been very familiar with. I had the pleasure of about 40 or so people attending an impromptu Perfusion tutorial in the pump room one morning. So many inquisitive eyes staring at me Many had never been into the operating theatre let alone understood what bypass involves. It was great to be able to enlighten the others as to what our role as a Perfusionist is all about After many meetings with hospital officials and the Medical Board combined with local media frenzy we were eventually given the green light to go ahead and start surgery two days late. All of that was put behind us and we carried out the work that was intended. With three cases on the list every day and being the only Perfusionist in the country I knew I d be BUSY While the mission of OHI is to train locals in our specialties so that a sustainable and successful cardiac surgery program will be possible in the future I actually had no local Perfusionists to train this time. They were attending a course in Singapore so little ol me was all by herself While under a lot of pressure to be ready to go and not keep the team waiting in theatre everyone was patient and helpful and willing to pitch in and do whatever they could to assist me. The camaraderie you experience on these trips is incredible. I definitely felt very supported and nurtured as one of the most junior members of the team. I m thanking my lucky stars for La our Biomedical Engineer who literally saved my life one day when one of the HLMs started to sizzle due to old corroded wiring With only 4 operating days while I was there and beds held up in our tiny 3-bedder ICU we completed 10 paediatric cases. On day 2 our first patient who had undergone a VSD repair earlier that day suddenly arrested in ICU. After a week or so he was transferred to the palliative ward and things weren t looking good for him due to prolonged resuscitation combined with ventilation problems. All of the hard work of the intensive care staff and the prayers from his family during the week must have paid off though a couple of weeks later he was up and walking and recovering nicely. With our second week of surgery looming and no Perfusionist signed on yet a call out on the Perfusion Without Borders website was placed. Canadian Perfusionist Peter Allan who has had extensive experience with various aid organisations all over the world put his hand up for the very long trip to Port Morseby. A mixture of paeds and adults underwent surgery in the second week and the team departed. With no real time to see much that the beautiful country of PNG has to offer I ll definitely be back and would love to incorporate a Kokoda trek & some diving to WW2 ruins next time. I have to say that this was such a maturing experience professionally and personally being part of an incredible team of dedicated professionals travelling to a developing country overcoming setbacks and difficult situations to achieve our goals. It is humbling to reflect back upon what we accomplished with the local team during our time in PNG the kinship between all involved is astounding. For anyone who has ever wanted to get involved in aid work and experience a rewarding and inspiring challenge you ll always be welcome on any OHI trip. Can t wait for my next one maybe after a real holiday DECEMBER 2014 19 Original Article AIR TRANSMISSION COMPARISON OF THE AFFINITY FUSION OXYGENATOR WITH INTEGRATED ARTERIAL FILTER TO THE AFFINITY NT OXYGENATOR WITH SEPARATE ARTERIAL FILTER AN IN VITRO PILOT STUDY by Kieron C. Potger CCP BSc Dip Perf MClinN Darryl McMillan CCP Dip Perf Perfusion and Autotransfusion Unit Dept. of Anaesthesia & Pain Management Royal North Shore Hospital Sydney Australia Presented at the ANZCP 30th Annual Scientific Meeting Melbourne 2013. A separate arterial filter is usually positioned in the arterial line after the oxygenator to capture potential emboli before the blood enters the patient. Clinically we use the Affinity NT oxygenator (CB511 Medtronic Inc. Minneapolis MN USA) with an Affinity adult arterial filter (CB351 Medtronic Inc.) installed distal to the oxygenator outlet. Some contemporary oxygenators are being designed with an integrated arterial filter partly to reduce haemodilution and improve haemocompatibility. The Affinity Fusion oxygenator (Medtronic Inc.) has an integrated 25- m filter that incorporates a pre-membrane bubble trap and uses progressively denser bundling of its microfibers to filter out gas and particulate matter (4). As part of our departmental consideration of a replacement oxygenator we wanted to determine if the Fusion oxygenator was as safe as the Affinity in terms of relative microbubble transmission of introduced air. This was investigated by comparing the Affinity NT oxygenator with a separate arterial filter to the Affinity Fusion oxygenator in terms of relative microbubble transmission during air introduction in vitro over a range of flow rates. Specifically we wanted to determine if these two systems transmit microbubbles when air is bolused or infused into their respective oxygenator inlets and if they do which of the oxygenator systems transmits more air Our aim was also - in this modestly sample sized exploratory study- to ascertain the effect size of differences in transmitted microbubble volumes and sizes between the two oxygenatorarterial filter systems to design an adequately powered future full trial with appropriate sample size. Additionally we wanted to review the in vitro circuit air introduction procedure and experimental design with regard to a full trial. ABSTRACT Arterial filters added to the extracorporeal circuit have been shown to minimise cerebral injury by capturing particulate matter and microbubbles. We clinically use the Affinity NT oxygenator with a separate Affinity arterial filter attached ( Affinity system ). The new Affinity Fusion oxygenator ( Fusion ) incorporates integrated arterial filtering potentially eliminating the need for a separate arterial filter. We wanted to determine if the Fusion oxygenator was as safe as the Affinity system in terms of relative microbubble transmission of introduced air. A recirculating in vitro circuit primed with 4% albumin was used to compare the two oxygenatorarterial filter systems (Fusion Affinity system). Microbubbles were detected using a GAMPT BC100 Doppler system in the outflow line of the oxygenator-arterial filter system. Measurements were taken during the first and third minutes after rapidly bolusing 50 mL air or infusing 20 mL of air over one minute while altering pump flow rates (3L min 5 L min). Both oxygenator-arterial filter systems transmitted microbubbles during air introduction. Microbubble air volume transmitted by the Fusion was less than the Affinity system at both pump flow rates whether during air bolus or air infusion. The Fusion cleared its air challenge at a faster rate than the Affinity system. Median bubble size transmitted by the Fusion oxygenator was consistently smaller than that of the Affinity system. Large effect sizes were seen for most differences in outcome. Under the parameters of this in vitro study the Affinity Fusion oxygenator with integrated arterial filter is as safe as the Affinity NT oxygenator with separated arterial filter in terms of microbubble handling. However more research is needed to confirm this study s findings and relevance to the clinical environment. MATERIALS AND METHODS Test circuit A recirculating test circuit was constructed of new components using heparin coated tubing (Carmeda Medtronic Inc.) (Figure 1). The patient was simulated by a hardshell venous reservoir (Affinity Fusion CVR Medtronic Inc.). This patient reservoir was filled to the 2000 mL level marker to facilitate the deairing the recirculating prime. To provide a constant siphonage drainage pressure the patient reservoir fluid level was kept at 100 cm above the outlet of the circuit reservoir this was accomplished by adjusting a variable clamp positioned on the venous line connecting the patient reservoir to the circuit reservoir. INTRODUCTION Microemboli are an important cause of postoperative cognitive impairment after cardiac surgery (1). However a significant source of microemboli during cardiopulmonary bypass (CPB) may be from the extracorporeal circuit (ECC) (2). Arterial filters have been shown to minimise cerebral injury by capturing particulate matter and microbubbles (3). 20 DECEMBER 2014 Emulating our institutions clinical ECC the circuit reservoir was a collapsible venous reservoir bag (CBMVR 1600 Medtronic Inc.) attached and open to a separated cardiotomy (Intersept CB1351 Medtronic Inc.). This reservoir bag was tested in a fully compressed (minimal volume) position by closing the reservoir holder cage onto its back plate. One litre of prime filled the circuit reservoir-cardiotomy system alone. The fluid that drained into the circuit reservoir was pumped out into the test oxygenator-filter system by a calibrated and properly occluded roller pump (Sarns 8000 Terumo Corporation Tokyo Japan). Oxygen at two litres per minute flowed into the test oxygenator s gas inlet port. The next component the prime entered was another Affinity NT oxygenator. This oxygenator helped remove microbubbles that had been introduced into the circuit a process that was facilitated by connecting the oxygenator s gas inlet port to suction (-200 mmHg) while sealing all its other gas openings. Circuit pressure was controlled by adjusting a variable clamp on the inlet to the deairing oxygenator. From the deairing oxygenator the prime was returned back to the patient reservoir. Test oxygenators-arterial filter systems Two oxygenator-arterial filter systems were assessed for their air handling performance the Affinity Fusion membrane oxygenator with integrated arterial filter of 25 m and the Affinity NT CB511 membrane oxygenator with attached 38 m arterial filter (Affinity CB351 Medtronic Inc.). See Table 1. Both the oxygenator and the arterial filter were Carmeda coated. The Fusion oxygenator had a hydrophilic polymer coating (Balance Medtronic Inc.). Two copies of each oxygenator-arterial filter model were used with the Affinity arterial filter permanently affixed to its respective oxygenator by 75 cm of 3 8 tubing with bypass loop. The purge lines on the Affinity arterial filter was kept open as were the purge lines on the oxygenators all purge lines returned prime to the cardiotomy. Prime The prime consisted of 4000 mL of 4% albumin (Albumex 4 CSL Bioplasma Australia) kept at ambient temperature (19-21 C). Top up prime was added pro re nata to maintain levels describe above due to small loses during oxygenator change outs. Air challenge Air bolusing and air infusing were used to assess the devices air handling abilities. In both situations the air injection site was a Luer lock connector with injection plug inserted between the circuit venous reservoir and the roller pump. A 38 mm 21-gauge hypodermic needle pierced this plug. For air infusion a syringe pump (Graseby 3500 Smiths Medical Australasia Pty. Ltd.) was used to pump air from a 50 mL syringe through a 150 cm extension line into the injection site. Air was injected at 20 mL min for 60 seconds. An air bolus entailed rapidly injecting 50 mL of air by hand using the syringe and extension line described above. Microbubble detection A GAMPT BC100 pulsed ultrasound Doppler system (GAMPT mbH Merseburg Germany) was used to detect microbubbles in the outflow line of the test oxygenator-arterial filter systems. The GAMPT Doppler was configured for microbubble detection in the 10 500 m range. The device cannot measure the size of bubbles larger than 500 m diameter. If any bubble larger than 500 m diameter occurred the instrument records the volume as 65.45 L with a count of one (i.e. the volume of a 500 m diameter bubble). In addition to a factory calibration during measurement the instrument automatically self-calibrated to account for the influences of fluid and tubing variations and flow rates. (5). A transluminal 3 8 ID microbubble detection probe was attached to the tubing approximately 80 cm distal to the outflow of the test oxygenator. This corresponds to five centimetres after the Affinity arterial filter or an equivalent distance from the Fusion oxygenator outlet. The detection probe was connected to the bubble counter BC100 itself connected to a laptop computer running BCView version 3.4.4 data acquisition software (GAMPT mbH Merseburg Germany). To maximise the reproducibility of all readings the same probe was used thereby avoiding issues of subtle differences in probe sensitivities. Ultrasonic gel was used to couple the probe to the tubing to exclude any air. The probe was reapplied for every trial. A second microbubble detection probe was positioned immediately proximal to the circuit reservoir to confirm that the circuit was effective at removing any introduced microbubbles by observing that the recirculation of microbubbles was minimal (3 counts sec). A baseline period consisted of the distal probe recording 12 counts sec for at least 30 seconds prior to air bolusing. A measurement was made for 60 seconds either starting immediately on bolusing or after 10 seconds upon commencement of air infusion (to allow time for the air infusion to actually inject air from starting up the syringe pump driver). In both air delivery scenarios the third minute after initiating air delivery was also recorded to observe any drop in microbubble transmission. Bubble volume and sizes were measured bubble counts were deemed less meaningful (6) as one moderately sized bubble of e.g. 100 m diameter may have significantly more clinical effect than 125 20 m bubbles of similar total volume. Test procedure The four test oxygenator-arterial filter systems were randomly subjected to two pump flows (3 L min 5 L min) and two air deliveries (bolus infusion). A variability of approximately 2.5% is given for flows (e.g. 5000 mL min 125 mL min) and 5% for reservoir volumes (e.g. 1000 mL 50 mL). Both flow rates were seen as being representative of adult pump flows. The sequencing of the oxygenator-arterial filter systems was also randomised. Thus two copies of the two oxygenator-arterial filter systems at both flow rates during air bolusing or infusion yielded a total of 16 scenarios. These 16 scenarios (tests) were randomly sequenced and performed in one trial three trials were run for a total of 48 tests. Line pressures were standardised at 180 mmHg at 3 L min pump flow and 200 mmHg at 5 L min pump flow by adjusting the variable clamp on the inlet to the deairing oxygenator. Preoxygenator pressures were recorded. Statistical Analysis Microbubble volumes and sizes in tables are presented as medians and interquartile range. Microbubble size was derived from the median bubble size transmitted during each test. A null hypothesis of no difference in median microbubble transmitted during infusion or bolus (volume and size) between the two oxygenatorarterial filter systems or within each oxygenator-arterial filter system at varying flows was rejected if p .05. To compare the differences between the two oxygenator-arterial filter systems microbubble transmission during air infusion or bolus at the two flow rates non-parametric comparisons (using Mann-Whitney U tests for two groups) were computed. Effect sizes of significant differences were also calculated. Effect sizes (r) of significant differences were calculated with r .1 as small r .3 as medium and r .5 as having a large effect (7). To compare each of the oxygenator-arterial filter system s [within] difference in microbubble transmission during air infusion or air bolus (volume DECEMBER 2014 21 and size) at varying flow rates the non-parametric Wilcoxon Signed-Rank Tests was used. Additionally effect sizes of significant differences were calculated (8). Statistical analyses were performed using StatView (StatView Abacus Concepts Berkeley CA) and Microsoft Excel. pump flow was significantly larger - with large effect sizes - than bubble size at a pump flow of 3 L min at both the first minute and the third minute and during air infusion or air bolus in both oxygenator-arterial filter systems (p .027-.028 r .64). See Table 3 Figures 4 and 5. RESULTS Part A) Microbubble transmission - volume 1) Microbubble transmission [volume] between oxygenatorarterial filter systems. Microbubble air volume transmitted by the Fusion system was significantly less - with large effect sizes - than the Affinity system at both pump flow rates of 3 L min and 5 L min at both measured time intervals of the first minute and the third minute whether during air bolus or air infusion (p .0039 with r .83 except when air infusing at 3 L min during the first minute where p .0065 and r .78). The magnitude of the reduction in air transmitted by the Fusion system was at least approximately onethird (Table 2 Figures 2 and 3). 2) Microbubble transmission [volume] within each oxygenator-arterial filter system at 3 L min versus 5 L min pump flow. Consistently microbubble air volume transmitted at 5 L min pump flow was significantly greater - with large effect sizes - than at a pump flow rate of 3 L min at both measured time intervals of the first minute and the third minute and during air infusion or air bolus in both oxygenator-arterial filter systems (p .0277 r .64). See Table 2 Figures 2 and 3. 3) Microbubble transmission [volume] within each oxygenator-arterial filter system during the first minute versus the third minute. Microbubble air volume transmitted during the initial minute was consistently more than during the third minute at both pump flow rates during air infusion or air bolus in both oxygenator-arterial filter systems (p .0277 r .64). Again large effect sizes were seen (Table 2 Figures 2 and 3). The Fusion system cleared its air challenge at a greater rate by the third minute a larger percentage of the bubbles introduced were cleared compared to the Affinity system. This was statistically significant with large effect sizes during bolusing air at 5 L min and during air infusion at both flow rates (p .004 r .84). See Table 2. 3) Microbubble transmission [size] within each oxygenatorarterial filter system during the first minute versus the third minute. Median microbubble size transmitted during the initial minute was consistently larger than during the third minute at both pump flow rates during air infusion or air bolus in both oxygenator-arterial filter systems (p .026-.028). Again large effect sizes were seen (r .64). See Table 3 Figures 4 and 5. Part C) Pressure gradient Pressure gradient between the pre-oxygenator and postoxygenator-arterial filter between oxygenator-arterial filter systems. Although the Fusion system had a slightly higher though significant transmembrane pressure gradient at 3 L min when compared with the Affinity system (p .025) no differences were seen at 5 L min (Table 4). DISCUSSION The results of this in vitro pilot study show that the transmission of introduced air by the Medtronic Fusion oxygenator with integrated arterial filter is not more than the Medtronic Affinity NT oxygenator with separate arterial filter over a range of pump flow rates suggesting that it is as safe in terms of air handling. More specifically this study shows that during air bolusing or air infusion into the ECC both oxygenator-arterial filter systems transmit microbubbles. However the Fusion oxygenator with integrated arterial filter transmits less volume of air and smaller sized microbubbles than the Affinity NT oxygenator with a separate arterial filter Injecting air into the inlet of the oxygenator was associated with an increase in bubble volume transmitted by both oxygenator-arterial filter systems. The oxygenator-arterial filter systems are designed to prevent the transmission of introduced air however as observed by other investigators some of the introduced air bypassed their bubble removal mechanisms (9-11). At higher pump flows microbubbles were less effectively removed by both the oxygenator-arterial filter systems a phenomenon noted by other investigators (12 13). Increasing the pump flow rate directly shortens the blood transit time within the oxygenator and decreases the time for any entrained bubbles to be eliminated. Furthermore higher preoxygenator and arterial filter pressures associated with increased pump flows may displace trapped bubbles within the oxygenator or arterial filter. Additionally by exceeding the bubble-point pressure (BPP) of the micropore bubbles may be squeezed through the screen filters. Indeed as more bubbles larger than the pore size accumulate on the filter screen and partially obstruct fluid flow there would be an increasing prescreen pressure contributing more force to exceed the BPP (14). Although both oxygenator-arterial filter systems transmitted more microbubbles during air introduction the magnitude of the effect was less with the Fusion oxygenator. Also the air handling Part B) Microbubble transmission - size. 1) Microbubble transmission [size] between oxygenatorarterial filter systems. Median microbubble size transmitted by the Fusion system was consistently smaller than that of the Affinity system at both pump flow rates of 3 L min and 5 L min at both measured time intervals of the first minute and the third minute whether during air bolus or air infusion (p .004). Large effect sizes were calculated (r .83). See Table 3 Figures 4 and 5. 2) Microbubble transmission [size] within each oxygenatorarterial filter system at 3 L min versus 5 L min pump flow. Consistently median microbubble size transmitted at 5 L min 22 DECEMBER 2014 discrepancy between the two systems was exacerbated at higher pump flows. Furthermore the Fusion cleared its air challenge at a greater rate between the first and third minute measured. We suggest that the Fusion has a superior design to capture bubbles. Firstly a vortex is used as a dynamic bubble trap to retain then expel bubbles via a purge line. Secondly any escaping microbubbles are then restrained within the progressively more tightly bundled oxygenator fibres acting as a depth filter. Thirdly the oxygenator fibres may aid in removing captured bubbles via the pressure differences between the blood and the gas compartments causing these bubbles to enter the inner lumen of the microporous hollow fibre to be eliminated through the gas outlet (15). Conversely the purge port on the Affinity NT oxygenator appeared to capture a smaller percentage of the introduced air. These uncaptured bubbles seem to more easily bypass the fibre bundles to be passed out into the arterial line and arterial filter. Another crucial difference between the two designs is that the Affinity NT oxygenator positions its heat exchanger in the blood path prior to entering the oxygenator proper while the Fusion integrates its heat exchanger within the oxygenator. Consequently the Affinity NT s heat exchanger inadvertently smashes entering bubbles into many smaller ones making them harder to eliminate. Additionally this proximally positioned heat-exchanger compartment also temporarily retain air only to release these bubbles later resulting in the prolonged bubble clearance rate. The Fusion design captures large bubbles by the dynamic bubble trap before entering the heat exchanger and oxygenator thus not atomising entering bubbles (16). The median size of transmitted bubbles during air injection of the Fusion oxygenator was consistently smaller than the Affinity NT oxygenator regardless of flow rate. Again the more efficient selective retention of larger bubbles by the Fusion s dynamic bubble trap may play a role Sch nburg and colleagues (17) were able to show that their dynamic bubble trap was more effective at removing larger sized bubbles. An additional contributing factor is the depth filters in the Fusion oxygenator filtering down to 25 m versus 38 m in the Affinity NT system generally there is better sieving with smaller filter pore size (18). The GAMPT bubble counter may underestimate microbubble counts and overestimate bubble size particularly at higher flow rates (19). This may be a contributing explanation for the transmission of bubbles measured larger than the rated filter pore size as the actual bubble may be smaller. Although caution is warranted in making clinical implications the findings are still valid as the purpose of the study was to quantitatively rank the oxygenator-arterial filter systems in terms of microbubble volumes and size transmitted. An albumin prime was used because it is more physiological than water or electrolyte solution without the complexities or expense of using blood. Studies investigating microbubble removal in in vitro ECC using water (9) or crystalloid solution (16) versus blood as primes showed a decreased ability of oxygenators to remove microbubbles using blood. The behaviour of our physiological protein prime might be expected to be within the range of that seen between blood and water i.e. less microbubble removal might be expected if the study was repeated with blood. Although a future in vitro study may use packed erythrocytes suspended in 4% albumin to emulate the non-Newtonian rheological properties of blood it would not be expected to upset our findings of relative differences in performance. Any future in vitro study could consider the recommendations of the US Center for Devices and Radiological Health in their guidance for cardiopulmonary bypass arterial line blood filter submissions (20). Here a quantification of gas volume introduced proximal to the filter and use of a bubble detector distal to the device to verify adequate air handling would be interpreted as determining the percentage of introduced air captured by the filter. This would entail repositioning a microbubble detection probe distal to the air introduction site yet proximal to the oxygenator and measuring the percentage drop in gas volume determined post arterial filter. The volume of introduced air may need to be reduced to account for the limitations of the GAMPT device in undercounting bubble counts and inability to precisely measure bubbles larger than 500 m. Unfortunately the GAMPT instrument s lack of a third probe means that confirmation of no microbubble recirculation in the in vitro circuit cannot also be made. However not needing to confirm a microbubble free prime with a probe could be made with confidence as our circuit design has been found to be efficient and reliable in removing microbubbles (minimising their recirculation) and as such remains a satisfactory contraption for any future study. Nonetheless in any future study we would modify the in vitro circuit to incorporate all the oxygenator-arterial filter systems in parallel to address the issues of prime loss and potential circuit air introduction when swapping tested components. The large effect sizes determined confirmed the power of our study theoretically increased trial numbers should not be needed. However by changing the prime to blood with a possible reduced oxygenator microbubble capture suggests that increasing the tests run number is prudent. Furthermore using a minimum of three specimens of each device would reduce the possibility of seeing the effects of non-representative oxygenators or arterial filters. There is a need for clinical trials confirming biocompatibility reduced priming volume satisfactory gas exchange and heat exchanger performance. Practical issues of perfusing a patient with no additional arterial filter need to be considered for example performing an oxygenator change-out. In summary we investigated the relative microbubble handling capabilities of two kinds of adult oxygenator-arterial filter systems the Affinity NT oxygenator with separate Affinity arterial filter and the Affinity Fusion oxygenator with integrated arterial filter. These oxygenator-arterial filter systems relative microbubble handling capabilities were examined under equal in vitro conditions of air bolus or infusion while varying pump flow rates. We conclude that under the parameters of this in vitro study the Affinity Fusion oxygenator is as safe as the Affinity NT oxygenator in terms of microbubble handling. However more research is needed to confirm this study s findings and relevance to the clinical environment. REFERENCES 1. Hammon JW Stump DA Kon ND et al. Risk factors and solutions for the development of neurobehavioural changes after coronary artery bypass grafting. Ann Thorac Surg. 1997 63 1613 8. Abu-Omar Y Balacumaraswami L Pigott DW Matthews PM Taggart DP. Solid and gaseous cerebral microembolisation during off-pump onpump and open cardiac surgery procedures. J Thorac Cardiovasc Surg. 2004 127 1759 65. Pugsley W Klinger L Paschalis C Treasure T Harrison M Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke. 1994 25 1393 9. Medtronic Inc. Affinity Fusion Oxygenation System 2013 [website]. http (accessed 4 June 2014). Gesellschaft fur Angewandte Medizinische Physik und Technik mbH. Bubble Counter BC100 A device for the detection of micro bubbles in streaming fluids. [User Manual]. Merseburg GAMPT mbH April 2010. Melchior R. (Presenter). Commentary on An in vitro comparison of the ability of three commonly used pediatric cardiopulmonary bypass circuits to filter gaseous microemboli. Perfusion. 2010 25 265-6. Yatani K. Statistics for HCI Research Mann-Whitney viewed 19 August 2013 http HCIstats MannWhitney. 2. 3. 4. 5. 6. 7. DECEMBER 2014 23 8. 9. Yatani K. Statistics for HCI Research Wilcoxon Signed viewed 19 August 2013 http HCIstats WilcoxonSigned. 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 2132 7. Nielsen PF Funder JA Jensen M Nygaard H. Influence of venous reservoir level on microbubbles in cardiopulmonary bypass. Perfusion.2008 23 347-53. Myers GJ Voorhees C Haynes R Eke B. Post-arterial filter gaseous microemboli activity of five integral cardiotomy reservoirs during venting An in vitro study. J Extra Corpor Technol. 2009 41 20 7. Liu S Newland RF Tully PJ Tuble SC Baker RA. In vitro evaluation of gaseous microemboli handling of cardiopulmonary bypass circuits with and without integrated arterial line filters. J Extra Corpor Technol.2011 43 107-14. Lin J Dogal NM Marthis RK Qui F Kunselman A ndar A. Evaluation of Quadrox-I and Capiox FX neonatal oxygenators with integrated arterial filters in eliminating gaseous microemboli and retaining hemodynamic properties during simulated bypass. Perfusion. 2012 27 235-43. Herbst DP Najm HK. Development of a new arterial-line filter design using computational fluid dynamics analysis. J Extra Corpor Technol.2012 44 139-44. De Somer F Dierickx P. Can an oxygenator design potentially contribute to air embolism in cardiopulmonary bypass A novel method for the determination of the air removal capabilities of neonatal membrane oxygenators. Perfusion. 1998 13 157-63. Weitkemper HH Oppermann B Spilker A Knobl HJ K rfer R. Gaseous microemboli and the influence of microporous membrane oxygenators. J Extra Corpor Technol. 2005 37 256-64. Sch nburg M Urbanek P Erhardt G et al. Significant reduction of air microbubbles with the dynamic bubble trap during cardiopulmonary bypass. Perfusion. 2001 16 19-25. Riley JB. Arterial line filters ranked for gaseous micro-emboli separation performance an in vitro study. J Extra Corpor Technol. 2008 40 21 6. De Somer FM Vetrano MR Van Beeck JP Van Nooten GJ. Extracorporeal bubbles A word of caution. Interact CardioVasc Thorac Surg. 2010 10 995 1001. U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health. Guidance for cardiopulmonary bypass arterial line filter 510(k) submissions final guidance for industry and FDA. Nov 29 2000. Affinity Fusion Affinity Fusion Table 2. Microbubble transmission [volume] median microbubbles volume (nL min) in the outflow of the two oxygenator-arterial filter systems during bolus air or air infusion and pump flows of 3 L min or 5 L min measured during the first and third minutes. Bolus 3 L min 1st Minute 3760 (3376.8) 984 (868) 3rd Minute 387 (212) 31.2 (28.2) 5 L min 1st Minute 3rd Minute 3 L min 1st Minute 3rd Minute 794 (366.7) 13.6 (1.8) Infusion 5 L min 1st Minute 3rd Minute 10. 11. 12. 64753 2860 3867 (8613) (919.0) (2133.7) 19518 (9366) 571 (222) 1090 (97.0) 48866 5499 (16689) (2217.3) 11568 (6110) 149 (101) 13. 14. Data are medians and (interquartile range). p .01 Affinity vs. Fusion p .05 Same oxygenator-arterial filter system 3 L min vs. 5 L min p .05 Same oxygenator-arterial filter system 1st min vs. 3rd min 0.8 % bubbles 500 m diameter 3.4% bubbles 500 m diameter 0.03% bubbles 500 m diameter. 15. 16. 17. Table 3. Microbubble transmission [size] median microbubbles size ( m) in the outflow of the two oxygenator-arterial filter systems during bolus air or air infusion and pump flows of 3 L min or 5 L min measured during the first and third minutes. Bolus 3 L min 1st Minute 83.5 (6.0) 53.0 (6.0) 3rd Minute 46.5 (3.0) 35.0 (3.5) 5 L min 1st Minute 174 (13.0) 89.0 (10.0) 3rd Minute 78.0 (9.0) 47.5 (4.0) 3 L min 1st Minute 91.5 (13.0) 58.5 (1.0) 3rd Minute 54.5 (7.0) 34.0 (2.5) Infusion 5 L min 1st Minute 207 (28.0) 129 (25.0) 3rd Minute 96.5 (13.0) 40.0 (2.0) 18. 19. 20. TABLES Table 1. Oxygenator and arterial filter specifications. Membrane oxygenators Fusion Recommended blood flow rate Static priming volume Filtration Surface gas transfer fibers Oxygenator material Coating Heat exchanger design Heat exchanger material 1-7 L min 260 mL 25 m (depth design) 2.5 m2 Microporous polypropylene hollow fibres Balance Capillary Polyethylene Terephthalate 2.5 m2 Microporous polypropylene hollow fibres Carmeda Bellows Stainless steel Carmeda NT CB511 1-7 L min 270 mL Arterial Filter CB351 Up to 7 L min 205-219 mL 38 m (screen design) Data are medians and (interquartile range). p .01 Affinity vs. Fusion p .05 Same oxygenator-arterial filter system 3 L min vs. 5 L min p .05 Same oxygenator-arterial filter system 1st min vs. 3rd min. Table 4. Pressure gradient (mmHg) between the pre-oxygenator and postoxygenator-arterial filter at pump flows of 3 L min or 5 L min. 3 L min Affinity Fusion 80.0 (0) 90.0 (20.0) 5 L min 160 (10.0) 150 (10.0) Data are medians and (interquartile range). p .025 Affinity vs. Fusion. postoxygenator-arterial filter pressure kept at 180 mmHg. post-oxygenator-arterial filter pressure kept at 200 mmHg. 24 DECEMBER 2014 FIGURES Figure 1. Diagram of in vitro circuit. Figure 4. Boxplots of microbubble transmission (size m) in the outflow of the two oxygenator-arterial filter systems during bolus air and pump flows of 3 L min and 5 L min measured during the first and third minutes. Figure 2. Boxplots of microbubble transmission (volume nL) in the outflow of the two oxygenator-arterial filter systems during bolus air and pump flows of 3 L min and 5 L min measured during the first and third minutes. Figure 5. Boxplots of microbubble transmission (size m) in the outflow of the two oxygenator-arterial filter systems during air infusion and pump flows of 3 L min and 5 L min measured during the first and third minutes. 240 220 200 180 160 140 m 120 100 80 60 Microbubble transmission size air infusion Affinity Fusion Figure 3. Boxplots of microbubble transmission (volume nL) in the outflow of the two oxygenator-arterial filter systems during air infusion and pump flows of 3 L min and 5 L min measured during the first and third minutes. 40 20 0 60000 Microbubble transmission volume air infusion Affinity Fusion 3 L min pump flow 1st minute 5 L min pump flow 3 L min pump flow 3rd minute 5 L min pump flow 50000 Figure 5. Boxplots of microbubble transmission (size m) in the outflow of the two oxygenator-arterial filter systems during air infusion and pump flows of 3 L min and 5 L min measured during the first and third minutes. 40000 nL 30000 20000 10000 0 3 L min pump flow 5 L min pump flow 3 L min pump flow 5 L min pump flow 1st minute 3rd minute Figure 3. Boxplots of microbubble transmission (volume nL) in the outflow of the two oxygenator-arterial filter systems during air infusion and pump flows of 3 L min and 5 L min measured during the first and third minutes. DECEMBER 2014 25 Tubing Packs & Packaging Solutions Intelligent Convenience Right out of the Box Fully preconnected customized tubing packs Maquet is dedicated to designing unique perfusion circuits in close cooperation with the perfusionists who depend on an optimum efficient set-up for extracorporeal circulation. After analysing and defining together the customer s needs Maquet develops a prototype tubing pack for clinical testing and then assembles an individually tailored tubing pack. The result is a sophisticated product that perfectly fits the customer s specific clinical needs. image Maquet The Gold Standard 26 DECEMBER 2014 Original Article AN IN HOUSE AUDIT ON THE USE OF CARDIOTOMY SUCTION DURING PROTAMINE ADMINISTRATION AT TTH by Helen Scarrot AIM To demonstrate that the cardiotomy sucker should be stopped prior to 1 3 protamine. Figure 1. Baseline 148 130 138 118 138 141 138 155 141 141 METHOD It was decided that all patients would be tested until approx 50 patients were in the study group. All procedures were as per standard protocols for this unit. ACT s were tested on the Medtronic ACT Plus with the lower of the two results recorded. The baseline ACT was recorded after induction. ACT s were performed approximately three minutes after heparin prior to bypass and at 20-30 min intervals during bypass. The lowest ACT while on bypass was recorded. Just prior to weaning another ACT was taken and recorded. Post bypass an ACT was taken by the Anaesthetist at 1 3 of the protamine and after all the protamine was given. Both of these ACTs were also recorded. The blood in the retransfusion bag was tested in the first few patients but this was discontinued as it was always the same as the ACT immediately prior to weaning from bypass. 136 158 Lowest on Just about bypass to wean 489 498 460 498 488 480 498 555 488 461 419 498 489 550 582 666 488 517 538 555 559 534 498 538 Patient Post at 1 3 Protamine Protamine 126 184 295 126 136 134 149 141 138 136 155 128 N A N A 121 116 138 135 130 147 128 131 153 116 BACKGROUND Some surgeons in this unit continued to use the cardiotomy sucker until 1 3 of the protamine was given to the patient. Occasionally though the call from the surgeon would be keep the sucker on I can t see any clot yet . As a result clot was sometimes found in the venous reservoir and the cardiotomy suction tubing. It was decided to test the ACT s at specified times to see how protamine affected the ACT. It was suggested by one surgeon that the clot was because our ACT on bypass had got low This needed to stand corrected. CONCLUSIONS It became immediately obvious that the patients were fully reversed by the time 1 3 of the protamine was given. One patient was a bit higher than the rest but this anaesthetists protocol is to put the protamine into a 100ml infusion bag so that 1 3 is harder to determine than when delivered from a syringe and by his own words He wasn t too sure if he had given 1 3 . The practice of the unit changed immediately. The test dose is now given. If the patient tolerates the test dose the cardiotomy sucker is turned off and the rest of the protamine given. The study was abandoned after 12 patients as we had achieved our goal. We had also proved that the ACT during bypass was maintained over 480 and so that wasn t the reason that the 1 3 ACT result was low. It was suggested that we would have to start putting up the cell saver for all cases to cover increased blood loss post bypass. This has not happened as there appears to be no significant change in blood lost to the outside sucker. There was talk about reducing the total amount of Protamine given but because of factors such as pump blood reinfusion and heparin rebound that practise has not changed. No cardiotomy suction lines or venous reservoirs have had clot in them since the study. Results The results are displayed in Figure 1. The average baseline ACT was 140secs and post protamine 132sec. The mean ACT on bypass was 486secs and the just prior to weaning was 542secs. The mean ACT at 1 3 protamine was 154secs. The standard protocol for protamine administration was used. At 1 3 protamine the average ACT was 154sec. The post protamine ACT was 132secs. DECEMBER 2014 27 Original Article CARDIAC CATHETER PROCEDURES DURING EXTRACORPOREAL LIFE SUPPORT A RISK BENEFIT ANALYSIS Biswa R. Panda MCh1 Nelson Alphonso FRCS C-Th1 Maheshkumar Govindasamy CCP1 Benjamin Anderson MD2 Christian Stocker MD3 4 and Tom R. Karl MS MD FR ACS1 5 BACKGROUND Extracorporeal life support (ECLS) is a valuable tool for situations in which cardiac disease acutely threatens the life of a child. Residual anatomic lesions have a strong negative influence on survival when ECLS is used after cardiac operations. Accurate diagnostic information is essential and although noninvasive studies are preferred (eg echocardiography and thoracic computed tomographic angiography) they are not always logistically practical nor adequate in complex situations under the loading and nonpulsatile flow conditions of ECLS. METHODS We analyzed our experience (February 2009 to August 2012) with cardiac ECLS for 59 children. Of the 59 children 22 (median age and weight 19.5 days and 4 kg) with advanced cardiac dysfunction had catheter studies performed during support. RESULTS The 22 patients had 28 studies without major adverse events relating to the procedure or transport. Problems leading to further therapeutic procedures (catheter based seven hybrid two or surgical eight) were discovered in 17 of the 22 patients. For 22 catheterized patients total time on ECLS weaning probability and survival to discharge were 151.6 122.6 hours 81% and 68% respectively similar to that for the 37 cardiac support patients not requiring catheter studies during support (P 0.94 0.37 and 0.59 respectively). CONCLUSION Assuming that undiscovered anatomic and or hemodynamic issues would have had a strong negative influence on survival we may conclude that the risk benefit ratio was positive and favorable. Catheter studies during ECLS are safe and should be performed expeditiously when diagnostic questions cannot be resolved by noninvasive means. NOVEL EQUIPMENT FOR SAFER ECLS TRANSPORT by Molly Oldeen CCP The article above written by Panda et al describes a risk-benefit analysis of ECLS transport for cardiac catheter procedures at the Mater Children s Hospital. The need to obtain additional diagnostic information is so common with our complex patients we wanted to make transport as safe as possible to reduce the risk of preventable events that may further complicate the patient s course of treatment. It is not uncommon to travel to cath lab CT or transport patients from the NICU on ECLS. In the past (as described in this article) during transport we had a surgical fellow or perfusionist stand between the patient s bed and ELCS sprinter cart to hold tubing and cannulas in order to maintain a safe distance between the two. This was not efficient as it was tiring and uncomfortable for the person in this position and relied on them alone to set the pace and communicate. As an adjunct to this article we want to include a piece of equipment that biomedical engineering and one of our clever perfusionists Anthony Black designed together a tow bar . This tow bar consists of three parts. Two metal bars are fitted to securely attach to the patient s bed and our ECLS sprinter cart. Between the two is a third bar that maintains a fixed distance but also serves as a hinge to allow for flexible movement around corners. We have two different bars customized to fit different ICU beds as well. When you re traveling 500 metres to the cath lab it s comforting to not have to worry about tubing kinks or cannula dislodgement. As perfusionists it s stressful enough just being on battery power and gas bottles 28 DECEMBER 2014 AUTOTRANSFUSION COURSE AUSTRALASIAN BOARD OF CARDIOVASCULAR PERFUSION 2015 The ABCP invites all healthcare workers interested in Autotransfusion to enrol in the 2015 Autotransfusion Course. The purpose of the course is to provide current and future autotransfusionists with the background information necessary to provide a safe and effective service. The course runs for 10 weeks and is conducted three times per year at a total cost of 250.00 (free to ANZCP members). We are currently registering students for 2015 course commencement dates 16 February (applications close 9 Feb) 25 May (applications close 18 May) 31 August (applications close 24 Aug) For additional information and enrolment details please contact the course co-ordinator Chris Morley at 29 Chrismo DECEMBER 2014 The following pages contain the abstracts from the 1st Intraoperative Management of Blood Meeting Sydney. THE COLLECTION OF INTRA OR POST-OPERATIVE RED CELL SALVAGE Royal North Shore Hospital Sydney NSW North Shore Private Hospital Sydney NSW Mr Darryl McMillan Introduction The aim of any intraoperative blood management (IBM) program is to utilise autologous blood retrieval procedures and to reduce homologous transfusion in the operating room where blood loss is expected or more importantly unexpected. Patients are targeted for intra or post-operative red cell salvage based on a pre-operative assessment of the risk of a patient requiring a red cell transfusion. Indicators used are the blood bank group and hold listing for the surgical procedure anticipated surgical blood loss blood groups in short supply or objections to homologous transfusion. If there is any doubt as to whether cell salvage is necessary a collection reservoir should be made available. Shed blood is vacuum aspirated into a filtered reservoir using a double lumen sucker tube that allows immediate anticoagulation with heparin or citrate. The surgical site collection apparatus can be varied from hand held suckers sump drains and drainage bag collectors depending on the demands of the surgery. Once collected the filtered anticoagulated blood is then processed in a centrifuge bowl. The bowl size is the next decision in the process to be made. For orthopaedic surgery we prefer to use low volume bowls with a high wash volume to try and removal as much debris material as possible. In the final process before transfusion the filtration for the washed return blood MUST BE considered. In orthopaedic surgery where fat embolism syndrome may occur the use of filters may lower the fat burden in salvaged blood. Lipigard filters may also be beneficial for the reduction of the anaphylatoxin C3a and the numbers of potentially harmful microaggregates leukocytes and lipid particles. This assessment of the surgical procedure and the use of the appropriate cell salvage equipment is important to optimise the salvage blood collection and the safe return of the patient own blood reducing the patient requirements and exposure to allogeneic blood. CHANGES TO TRANSFUSION PRACTISE AND THE OUTCOMES IN BLOOD MANAGEMENT Dr Bruce Cartwright Introduction of a blood conservation programme requires coordination of the entire cardiac team and modification of practise in all aspects of care ranging from preoperative assessment through the intraoperative phase and post operatively through to discharge. This talk with overview the practical aspects of introducing a blood conservation programme at a typical cardiac surgical centre together with an overview of the clinical and economic advantages that result. Finally future directions in blood conservation will be discussed. 30 DECEMBER 2014 THE ROLE OF FACTOR CONCENTRATES IN CARDIAC SURGERY Dr Bruce Cartwright Cardiac surgery worldwide consumes up to 20% of blood product supply. Around 5% of patients return to the operating room for investigation of bleeding and microvascular coagulopathy is diagnosed in greater than 50%. These patients could possibly have avoided a return trip to the OR However the eternal dilemma is to balance not transfusing with the risk of re-exploration for bleeding and acute bleeding associated haemorrhagic shock and cardiac decompensation against the risks of transfusion which include TR ALI allergy alloimmunisation TACO and increasing cost. Is there another approach and what is the evidence to support the alternative approach using factor concentrates to target replacement in cardiac surgery. Evidence for and against will be considered and discussion will focus on fibrinogen concentrate and prothrombin complex concentrates. POINT OF CARE COAGULATION TESTING AND THE ROLE IN BLEEDING MANAGEMENT FOR CARDIAC SURGERY PATIENTS Ms Bronwyn Pearse Management of haemostatic dysfunction in the cardiac surgery patient requires the ability to differentiate between surgical bleeding and coagulopathy. Haemostasis assessment and goal directed therapy can be challenging if timely diagnostic results are not available. Slow turn-around of standard laboratory tests can lead to ad hoc administration of blood products. Real time haemostasis monitoring permits a prompt comprehensive patient focussed assessment of coagulopathy and allows a team approach to administering appropriate therapy. To improve our assessment of haemostatic dysfunction and bleeding management in the cardiac surgery program we implemented a clinician driven Point of Care Testing (POCT) service using ROTEM and Multiplate to guide blood product use. The operating theatre was identified as the site of the earliest bleeding event. Implementation was focussed on users from this area followed by the ICU team where post-operative care occurred. A multidisciplinary multimodal approach was taken and involved appointment of a project lead identifying stakeholders developing a project plan educating POCT operators interpreters developing quality control infrastructure and monitoring analysing outcomes. Nominated key performance indicators included blood product transfusion ventilation time length of ICU and hospital stay reexploration rate for bleeding. A comparison of post POCT implementation data with historical data demonstrated a statistically significant reduction in the number of patients receiving RBC transfusions (526 vs 371 p 2.965e-08) fresh frozen plasma (293 vs 99 P 2.2e-16) and platelets (383 vs 153 p 2.2e-16). A trend towards a reduction in return to theatre for bleeding was reported (p 0.05) as well as a reduction in median hospital LOS (p 9.3657e-09). A nonstatistically significant reduction in deep sternal wound infections and 30 day mortality was noted. Implementation of our POCT service reduced percentage of patients receiving blood products as well as quantity of products transfused. Timely results allowed clinicians to treat coagulopathy with only those products required to resolve haemostatic dysfunction. Key to this success was a multidisciplinary multimodal approach involving all stakeholders and a dedicated driver of change with accountability for quality control quality assurance and sustainability. DECEMBER 2014 31 THE TRUE COST OF BLOOD TRANSFUSION Clinical Professor of Medicine Sydney Medical School Royal North Shore Hospital of Sydney james.isbister The true cost of blood transfusion remains a work in progress but in relationship to the fresh (labile) blood components when the whole process is considered it is likely that total cost is several times the cost of production of the blood The Process and Econnomics of Effective and Safe Allogeneic Blood Transfusion Professor James Isbister component and could run into several billion dollars. The figure probably correlating poorly with cost-effectiveness In this presentation a wholistic approach will be taken to the true costing of blood transfusion. TOTAL 2013 14 Blood Budget 1 140 000 000 32 DECEMBER 2014 WHAT CAN REGISTRIES TELL US ABOUT CRITICAL BLEEDING AND MASSIVE BLOOD TRANSFUSION Clinical Professor of Medicine Sydney Medical School Royal North Shore Hospital of Sydney james.isbister Why have Registries 1. 2. RCT s don t or can t answer every question especially relating to safety Medico-political landscape a. Issues relating to the off-label pharmaceuticals b. Quality & Safety c. Benchmarking (variations in clinical practice especially where there is no good evidence-based clinical practice guidelines available d. Data linkage between registries and other databases e. Liability - early detection of problems recall of products or pharmaceuticals 3. Because we can a. improvements in technology and data management Professor James Isbister DECEMBER 2014 33 WHAT THE MASSIVE TRANSFUSION REGISTRY IS AND WILL BE TELLING US Clinical Professor of Medicine Sydney Medical School Royal North Shore Hospital of Sydney james.isbister Information about the clinical context of massive blood transfusion . The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion was largely unknown. The registry has elucidating the clinical characteristics of patients captured using different definitions of massive transfusion. massive transfusion patients were identified according to three definitions 10 units RBC in 24h (10 24h) 6 units RBC in 6h (6 6h) and 5 units RBC in 4h (5 4h). Clinical coding data were used to assign bleeding context. Data on inhospital mortality were also extracted. The 5 4h massive transfusion definition was the most inclusive. differences in the pathophysiology of critical bleeding across clinical settings and the management and outcomes of this diverse patient population. Information about the use of blood components and products Use of guidelines and massive blood transfusion protocols. Some information about the efficacy and safety of therapies especially if it is unlikely there will be RCTs. The practice and role of point of care testing (POCT). Benchmarking information on variations in clinical practice. Initial results show variation in management of massive transfusion across clinical groups and high mortality in patients with conditions associated with critical bleeding requiring massive transfusion. Professor James Isbister Information about pathophysiology of haemostatic failure. Presence of coagulopathy early in massive transfusion varied accordingly to clinical context with patients undergoing liver surgery vascular surgery and trauma having the highest rates of coagulopathy and obstetric haemorrhage the lowest. Coagulopathic trauma patients had worse outcomes consistent with findings reported by others. Coagulopathy remained a predictor of in-hospital mortality independent of the clinical context. Clinical groups with higher mortality included medical patients vascular surgery GI haemorrhage and trauma. Education and input to the development of National clinical practice guidelines for managing critical haemorrhage and massive blood transfusion. Networking of clinicians scientists nurses pharmacists blood bankers researchers and other paramedicals and administrators. Increasing interest in transfusion medicine and patient blood management Data linkage to other registries and health administration databases. Data generated by the Australian and New Zealand Massive Transfusion Registry provide a unique opportunity to explore Remember to book early for the next IMOB Meeting. For Details visit 34 DECEMBER 2014 CALENDAR of EVENTS NOVEMBER 2014 6-8 ANZCP Annual Scientific Meeting Hilton Auckland New Zealand DECEMBER 2014 4-6 First Latin American ELSO Conference Sao Paulo Brazil http FEBRUARY 2015 4-7 Sanibel Symposium Sanibel Harbor Resort and Spa Fort Myers Florida http 5-8 The 2015 Annual Academy Meeting American Academy of Cardiovascular Perfusion Omni La Mansion del Rio San Antonio Texas http Annual%20Meeting.htm 11-14 CREF 2015 35th Annual Cardiothoracic Surgery Symposium Hilton San Diego Bayfront San Diego California http 22-26 31st Annual Children s National Symposium ECMO and the Advanced Therapies for Respiratory Failure Keystone Resort Keystone Colorado http events 31st-annual-cnmc-symposiumecmo-the-advanced-therapies-for-respiratory-failure eventsummary-f16c987c4dca47789aec1aa95f3371b4.aspx MARCH 2015 27-28 Intraoperative Management of Blood Amora Hotel Sydney Australia APRIL 2015 14-18 53rd International Conference American Society of Extracorporeal Technology Marriot Tampa Waterside Tampa Florida JUNE 2015 10-13 16th European Congress on Extracorporeal Technology Krakow Poland http 10-13 11th International Conference Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion University of Verona School of Medicine Verona Italy http web pedscpb home conferenceinfo AUGUST 2015 6-8 Perfusion Down Under Novotel Barossa Valley Resort The Barossa Valley South Australia http NOVEMBER 2015 5-7 Annual Scientific Meeting of the ANZCP Novotel Manly Pacific Hotel Manly New South Wales DECEMBER 2014 35 ANZCP 31ST ANNUAL SCIENTIFIC MEETING AUCKLAND Coming up in the next issue of the Gazette... conference report meeting abstracts life membership awards and more 36 DECEMBER 2014 DECEMBER 2014 37 KYOTO The 2nd Conference of Asia-Pacific Chapter of Extracorporeal Life Support Organization Japan Society of Respiratory Care Medicine Under the Joint Auspiced of Japanese Society of Intensive Care Medicine Jointly hosted with The 37th Annual Meeting of the Japan Society of Respiratory Care Medicine Under the Auspiced of Period July 17-18 2015 Venue Kyoto International Conference Center President Satoru HASHIMOTO Intensive Care Medicine Kyoto Prefectural University of Medicine JAPAN APELSO2015 Period July 17-19 2015 Venue Kyoto International Conference Center Kyoto JAPAN President Ryoichi OCHIAI Anesthesia and Intensive Care Medicine Toho University Faculty of Medicine JAPAN 38 DECEMBER 2014 http CARDIOHELP The world s smallest portable heart-lung support system Maquet has developed CARDIOHELP as a multitherapy heart-lung assist system which can be rapidly deployed and used for a wide range of indications in Intensive Care Emergency Medicine Cardiology and Cardiac Surgery. The CARDIOHELP device is a compact and light weight system making it ideal for transporting patients whilst on respiratory and or circulatory support. The combination of a newly designed user interface and intuitive software optimises existing therapies and is compatible with the wide range of new upcoming therapies. VKMO 70000 and VKMO 71000 the next step to optimize perfusion outcomes Data on file Guan et al. Evaluation of Membrane Oxygenators and Reservoirs in Terms of Capturing Gaseous Microemboli and Pressure Drops. Artif. Organs 2009 Vol.33 No.11 1042 The reliable VKMO includes the new generation VHK 70000 71000 and therefore integrates the best of oxygenator and reservoir. The VKMO combines the tried and tested QUADROX-i adult or Small Adult oxygenator with the VHK 70000 71000 reservoir for a solid combination. QUADROX-i Adult and Small Adult stand for1 Extremely low pressure drop2 also with integrated filter Low priming volume e.g. 215ml or 175ml... Only 1.8m2 gas fiber surface area Effective gas exchange (O2 and CO2) Highly efficient heat exchanger Optimised surface refinement with SOFTLINE Coating Easy handling and an easy priming procedure Maquet The Gold Standard VKMO DECEMBER 2014 Visit us at the ANZCP booth 14 15 39 Amora Hotel Jamison St Sydney March 27th & 28th 2015 You are formally invited to attend the IMOB conference. National and International Experts will lead you through the best evidence based medical and surgical concepts designed to minimize blood loss increase haemaglobin and improve haemostasis in the intraoperative environment. Targeted to Surgeons Anaesthetists Nurses Perfusionists and Autotransfusionists this conference aims to outline the risks associated with transfusion and educate you in practical tools to avoid transfusing your patients. A special focus on Intraoperative Cell Salvage (Autotransfusion) during the first day of this conference will enhance your knowledge and ability to apply cell salvage in your hospital. The internationally renowned faculty includes experts in intraoperative blood management with keynote speaker Professor Bruce Spiess MD FAHA (Anaesthetist Richmond VA USA) returning for his second IMOB conference. In addition to this there will be well known national identities. Full program information registration and accommodation options are available from the Please register early as places are limited. We look forward to seeing you in the Harbour City in March. IMOB Organising Committee. proudly bought to you by 40 DECEMBER 2014 inspired choice personalized perfusion because no two of your patients are the same EQUIPPED TO PERFORM PPED A complete new family of adult oxygenator systems raising performance expectations and ease of use while providing clinicians an unprecedented choice of new solutions to improve outcome in cardiopulmonary bypass. perfusion solutions 2013 Sorin Group info.cardiacsurgery ETHICAL COLLABORATION IN HEALTHCARE CERTIFIED Licensed by Eucomed Proudly distributed by DECEMBER 2014 41 42 DECEMBER 2014