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The AUSTRALIAN AND NEW ZEALAND COLLEGE of PERFUSIONISTS GAZETTE JUNE 2016 www.anzcp.org Gazette Issue 6 16 TABLE OF CONTENTS Page 2 Page 3 Page 4 A Message from the Editor Molly Oldeen A Message from the President Jon Van den Berg Board Report Mark Mennen Page 14 Update Mycobacterial Infections Associated with Heater Cooler Units Used in Cardiac Surgery Original Articles Page 16 Page 18 Page 20 Page 22 Page 24 Cardiac Morphology at the Children s Hospital at Westmead Martin Gill Del Nido Experience Carla Zazulak Perfusing a Hemophiliac at the Canberra Hospital Casey Edwards Vacuum Assisted Venous Drainage (VAVD) Pitfalls and Suggestions Monique Brouwer & Ray Miraziz Cerebral Protection Management during DHCA A Review of Current Methods Emerson Sgammotta Perfusion News Page 4 Page 6 Page 7 Page 8 Page 11 Page 12 ASAP Through the Eyes of a Trainee Nicole Shrimpton Around the Pump Room Emerson Sgammotta Auckland City Hospital Double Trouble Kate Rawlings & Camilla Hand New Heart Lung Machines for the Prince Charles Hospital Nicole Tysoe Clinical Perfusionists in the Media Molly Oldeen Australia and New Zealand Collaborative Perfusion Registry Update Richard Newland & Rob Baker Page 28-49 Abstracts from the 32nd Annual Scientific Meeting Page 50 Calendar of Events Introducing CAPIOX FX Advance Oxygenator with Integrated Arterial Filter and Hardshell Reservoir Enhanced flow dynamics. Expanded patient range. The AUSTRALIAN AND NEW ZEALAND COLLEGE of PERFUSIONISTS GAZETTE www.anzcp.org EDITOR Molly Oldeen CCP Perfusion Department Lady Cilento Children s Hospital Level 7F Clinical Directorate 501 Stanley Street South Brisbane QLD 4101 Tel 07 3068 3692 EDITORIAL CORRESPONDENCE Editorial correspondence should be addressed to the Gazette Editor gazette anzcp.org (postal address as above). The ANZCP Gazette is the official publication of the Australian and New Zealand College of Perfusionists. Copyright 2007 by the ANZCP Inc. All rights are reserved. No part of this publication may be reproduced or transmitted in any form or by any means. Permission for reprinting should be obtained from the Gazette Editor. ASSOCIATE EDITORS Carla Zazulak CCP Lady Cilento Children s Hospital Brisbane QLD Carla.zazulak health.qld.gov.au Jane Ottens CCP Ashford Hospital Ashford SA Email jane.ottens acha.org.au DISCLAIMER All views expressed are that of an individual or institution and are not necessarily the expressed views of the Editors the ANZCP Executive Committee or Members of the ANZCP. EDITORIAL POLICIES Manuscripts are accepted for consideration on the condition that the Editorial Committee has the final decision on publication. The Editorial Committee reserves the right to reject or edit any material submitted for publication without reason. Preparing material for publication Preferred delivery method is by e-mail using document attachment in Microsoft Word to the editorial correspondence address. Authors who do not have access to e-mail please mail material. Correspondence should be on A4 paper type written with double-spaced lines. Please do not fold mail use an A4 sized envelope. Please supply direct contact numbers and address for the corresponding author. Material should contain (1) Title (2) Subject (3) Author(s) (4) Co-author(s) and (5) Institution(s). British Australian English is the preferred language. SUBSCRIPTIONS Subscription is only available through membership of the ANZCP. Please visit www.anzcp.org for the latest membership rates terms and conditions. Note that all monies quoted are in Australian dollars and are inclusive of GST. New Zealand Members fees for Australian Members less GST. One year free subscription is available to student perfusionists enrolled in the ABCP course. For further information on membership subscription please contact the ANZCP Secretary c - PO Box 921 Parkville Victoria 3025 Australia. ADDRESS FOR SUBSCRIPTION Change of address including both the old and new addresses of the member subscription should be forwarded to the ANZCP Secretary at least one month in advance. ADVERTISING To advertise in the Australian and New Zealand College of Perfusionists Gazette contact the Gazette Editor. Tel. 07 3068 3692 email. gazette anzcp.org. This edition of the Gazette has been proudly supported by Cellplex. JUNE 2016 www.anzcp.org 1 A MESSAGE FROM THE EDITOR by Molly Oldeen CCP. Welcome to my 5th edition as Editor. As usual I m impressed by the number of people that come through even at the last minute to help with submitting articles. It might result in the occasional delay in publication but it is well worth it so thank you to everyone for your efforts. In this edition we have the abstracts from the 2015 Annual Scientific Meeting as well as a great variety of case reports techniques and other interesting pieces. I hope you enjoy I look forward to choosing two awards ( 250 cash) for the best articles again to be presented at the next ASM. I m going to keep this letter short as I have been quite busy. As some of you know I am currently in Saint Petersburg Florida at Johns Hopkins All Children s Hospital. This October I will be attending my third trip to Cambodia with Open Heart International. It s wonderful to continue contributions to such a great organization and team I enjoy keeping up with my Australian colleagues and hope to make it to one of the excellent conferences this year. Thank you again Kind regards Molly Oldeen The Gazette Editor ANZCP STRUCTURE The Executive Jon Van den Berg - President Mark Ambrose - Vice President Matt Sheminant - Secretary Carla Zazulak - Treasurer Jack Bhana - Registrar Jack Bhana - Webmaster Charles McDonald - Member The Board Mark Mennen - Chairman Chris Morley - Member Andrew Lahanas - Member Vincent Rajkumar - Secretary Sarah Varghese - Member Sub-Committees Alison Horton - Registration Committee Jane Ottens - Simulation Committee Tim Willcox - PIRS Editor Andrew Sanderson - Webmaster 2 JUNE 2016 www.anzcp.org A MESSAGE FROM THE PRESIDENT by Jon Van den Berg CCP. In my fi rst six months as President I have come to appreciate the commitment members have to their profession. Recently there have been a number of experienced members pass on existing roles to newcomers as they move to emerging new roles. This is very positive for our organisation. Australasian Simulation and Perfusion Meeting (ASaP) I was privileged to be a participant at the inaugural Simulation Meeting held at the Royal North Shore Hospital in May. Congratulations to Darryl McMillan Jane Ottens and Arthur Preovolus for putting together a very good training programme. I m sure everyone who enrolled for the course had some apprehension being placed in front of equipment destined to go wrong in front of our peers. However this was quickly put to rest as instructors ensured a safe environment and peers remained supportive. The sharing of ideas and solutions flowed magically in the sessions. Seventeen participants including six local Trainees along and four Vietnamese Perfusionists attended. In line with overseas practice it is perhaps near time the Board allocate a higher number of education points to simulation attendance over other meetings. Perfusionists at all levels of experience should be encouraged to attend the 2018 meeting. Website My fi rst report outlined a planned overhaul of the College website. Thank you to Andrew Sanderson for his years of service to the site and facilitating the transition to our new provider. Jack Bhana has stepped into the role as webmaster. (See report in this issue) Perfusion Staff Survey The survey has now progressed to draft form. After review it will be sent to Chief Perfusionists in early August. There will be two sets of questions. The unit specific questions directed to Chief Perfusionists a second set of questions for Staff Trainee Perfusionists. The survey will also seek volunteers to participate in a more in depth study aimed to identify key attributes of the successful Perfusionist. Education Board Planning Meeting. On the 18th of June the ANZCP Board will meet in Melbourne for a Planning Day. Board members are scattered throughout Australia and seldom have the opportunity to meet as a working group. There are a number of issues planned for discussion including restructuring of the course new content and allocation of the workload. I look forward to being part of this meeting. In closing thankyou to Molly Oldeen and contributors to the December gazette for an exceptional edition. Jon Van den Berg President ANZCP jon.vandenberg waikatodhb.health.nz New Zealand Regulation Progress toward regulating Perfusion in New Zealand was placed on hold in October 2015 awaiting Cabinet approval for a number of amendments to the Act mainly around disciplinary procedures. On the 27thof May the NZ Ministry of Health Published amendments to the Health Practitioners Assurance Act. The Minister of Health can now review applications and regulate other professions. N JOURNAL OF Official Journal of American Society of Extra Corporeal Technology Volume 47 Number 1 INVITED EDITORIALS 5 10 20 Years On Is It Time to Redefine the Systemic Inflammatory Response to Cardiothoracic Surgery R. Clive Landis Perspective on Cerebral Microemboli in Cardiac Surgery Significant Problem or Much Ado About Nothing Simon J. Mitchell Alan F. Merry EXTRACORPOREAL TECHNOLOGY re OF FOR CE JOURNAL EXTRACORPOREAL TECHNOLOGY March 2015 Australian and New Zealand College of Perfusion Volume 47 Number 1 REVIEW ARTICLE 16 VOLUME 47 NUMBER March 2015 Acute Kidney Injury Subsequent to Cardiac Surgery INVITED EDITORIALS ORIGINAL Cardiothoracic Surgery ARTICLES 29 5 Robert S. Kramer Crystal R. Herron Robert C. Groom Jeremiah R. Brown 20 Years On Is It Time to Redefine the Systemic Inflammatory Response to R. Clive Landis Problem or JUNE 2016 www.anzcp.org 3 10 Safety Testing of Left Ventricular Vent Valves Perspective on Cerebral Microemboli in Cardiac Surgery Significant Caroline Gavin John Coblentz Jeffrey R. Acsell Anthony G. Shackelford and Joseph J. Sistino AUSTRALASIAN BOARD OF CARDIOVASCULAR PERFUSION by Mark Mennen Chairman ABCP After almost four years since the recommencement of ABCP run Diploma course it s been noted that the presentation format and some content has become a little stale. This will be the focus of the Board with the aim of setting goals for the immediate future. We will be holding a planning day at the Alfred Hospital in Melbourne on the 18th June to discuss the course as well as the where the Board s focus should be and setting goals for the next few years. All input is welcome at the meeting and beyond so please feel free to contact the board with suggestions particularly current supervisors and students. Four candidates successfully completed the Diploma of Perfusion programme and or certification exams in February including our fi rst two graduates from Hong Kong. There will not be a midyear exam this year but beginning next year we will again be conducting two sets of exams each year to tie in with individuals completing their studies in August now that we are taking enrolments in September. The Autotransfusion course is now well established and has taken over 200 enrolments since commencing in 2013 and continues to take strong enrolments. Most of our group continue to recertify each time around although each cycle loses two or three to non-return. Should lapsed members wish to recertify at any stage please feel free to contact the board and we should be able to accommodate. I would also like to take this opportunity to thank the rest of the Board including past members who continue to contribute over many years for their continued effort. ASAP THROUGH THE EYES OF A TRAINEE By Nicole Shrimpton Lady Cilento Children s Hospital What a fantastic experience I ve just returned from the inaugural Australian Simulation and Perfusion meeting held at Royal North Shore Hospital in St Leonards and my mind is abuzz with new concepts and skills. The meeting took place over two days covering topics including the do s and don ts of vacuum assisted venous drainage trouble shooting of VA and VV ECMO management of anticoagulation prime reduction techniques and the applications of cerebral oximetry. Seven trainees from Australia and New Zealand had the opportunity to attend and broaden their perfusion experience. I m sure I speak for all trainees in saying that the meeting was an invaluable experience and we were warmly welcomed by fellow participants and instructors alike all whom were keen to ensure we left with a wealth of knowledge and skills. We were all stretched safely beyond our comfort zone which is a fantastic advantage of simulation perfusion. Whether it be by having to adapt to a L R setup configuration roller vs. centrifugal pump operation use a hard vs. soft shell reservoir or by the simulations themselves we were all challenged in a safe environment where help and advice were forthcoming. As the saying goes there certainly is more than one way to skin a cat. I left the meeting thankful to return to the comfort and familiarity of the setup at Lady Cilento Children s Hospital but excited to have discovered a world of perfusion now at my fi ngertips. Many thanks to Jane Ottens and Darryl McMillan and all others who put in the hard yards to make the meeting such a success. I encourage you all to take the opportunity to attend when the next ASaP rolls around. I know my name will be on the attendees list 4 JUNE 2016 www.anzcp.org Australian and New Zealand College of Perfusionists 3rd INTEROPERATIVE MANAGEMENT OF BLOOD --------------------------------------------------------------------------------------------------------------------- 5th and 6th May 2017 Amora Hotel Sydney New South Wales Key Note Speakers Dr Jonathan. H. Waters Magee Womens Hospital of UPMC Pittsburgh. USA Professor James Isbister A M University of Sydney Major Sponsor Dr Bruce Cartwright Staff Specialist Anaesthetist RPAH Clinical Lecturer University of Sydney JUNE 2016 www.anzcp.org 5 AROUND THE PUMP ROOM Emerson Sgammotta Perfusion Services Melbourne As the latest graduate of the Perfusion diploma course and the newest member of the College I thought I would give a snap shot of the people and places that have aided my journey in the last 3 years at Perfusion Services in this edition of around the pump room. As a company we recently celebrated completing 25 000 cardiac cases across 2 hospitals Cabrini Hospital in Malvern and Monash Medical Centre in Clayton. Last year we completed 932 bypass cases across the two hospitals including CABG valve replacement and repairs aorta and arch replacements minimally invasive surgery adult congenital surgeries and 3 renal cell carcinoma cases. We are also involved in Intra Aortic Balloon Pump insertions and transfers from other hospitals auto transfusion cases across Melbourne HIPEC at the Peter MacCallum Cancer Centre and ECLS of which we had 16 cases in the last year. An increasing number of TAVIs and Trans Apical Mitral Valve Replacements have seen us spend some time in our hybrid theatres and cath labs over the past few years. Our pump room can be quite a vibrant place usually with music playing a discussion about an interesting article in the latest journal or someone taking a coffee order (which I have learnt is very essential to being a Perfusionist). Being quite a large and diverse group of Perfusionists allows some lively and spirited discussions Our current team consists of James McMillan (managing director) Michael McDonald (Director) and four qualified Perfusionists Kyriakos Angus-Anagnostou Kamala Priyadarshini Vanessa Perafan and myself. We also have two trainees currently in their last year of their studies Mitchell Bago and Jane Ennor who will be qualified by the beginning of next year. There s always a topic of research that is taking place within our company. The recent heater cooler water quality issues have given us an opportunity to determine whether the latest cleaning protocol released by the company are proving to be effective and comparing this to our previous methods of water tank cleaning with a paper being produced soon. We are also currently testing out some essential point of care machines such as the TEG 6s iStat blood gas and act analysers and the Coaguchek by Roche. Our aim is to determine whether the results from these devices produce similar accuracies as our current gold standard devices. One of the benefits of having a large team is the fact that we re able to send a representative to many domestic and international perfusion conferences and workshops. ANZCP AGM ANSCPR CREF EuroELSO and simulation meetings have been some of the events we have attended over the past year with an interesting round table discussion upon the return of the representative to discuss any interesting issues that may arise from the conference. I am lucky enough to be attending my first international meeting in October at the Canadian Society of Clinical Perfusion AGM and hope to gain some worthy knowledge and possibly run into some of you 6 JUNE 2016 www.anzcp.org AUCKLAND CITY HOSPITAL DOUBLE TROUBLE By Kate Rawlings & Camilla Hand Auckland City Hospital Double Trouble Introducing Auckland City Hospital s newest trainees Kate and Camilla We started training at the end of 2015 beginning of January of this year from back grounds of physiology and exercise physiology specialising in cardiac rehabilitation. Before this we had never set foot in a cardiac theatre and were excited to begin our career as perfusionists which none of our friends and families had ever heard of before. We are both very similar and are constantly confused by multiple staff members gaining the nicknames Kate Middleton and Camilla Parker Bowles or the staff favourite Katmilla. By training together we are able to share and understand each other s experiences and have become a good team. Despite our similarities we are trained in very different ways we have our main mentors Alex Peterson Shuja Zahidani Tim Willcox and Jake Wojdyla as well as the rest of the perfusion department who all play a role in our training. This means our perfusion techniques are considerably different and have accepted that there are multiple ways to get to the same end point. We have each combined multiple perfusion concepts to create our own personal methods. The perfusion course has been challenging as both of us have had to adjust from University study. This includes having to get used to working full time while juggling study and not getting regular lectures. Luckily we have been given an afternoon a week to study which reduces the work load and allows us to seek advice from the rest of the perfusion team. As we get further into our training we are both becoming more confident in our own abilities and being more comfortable in a range of scenarios. We are looking forward to being exposed to more challenging surgeries and growing as perfusionists. JUNE 2016 www.anzcp.org 7 NEW HEART LUNG MACHINES FOR THE PRINCE CHARLES HOSPITAL Nicole Tysoe The Prince Charles Hospital (TPCH) is situated within the Metro North District of Brisbane. We are comprised of 6 full time experienced Clinical Perfusionists and one trainee. We perform approximately 1200 open heart surgeries (on adults) and 800 other types of cases per year. These other cases include heart and lung transplants ECMO (V V and VA) VAD implants (Heartware) IABP and Transapical Valve Insertions (TAVI s). TPCH is home to the Heart Failure Unit (HFU) so we are exposed to a large number of patients from across Queensland and northern NSW that fall into this category and require some kind of intervention by Cardiac Staff. We have had 128 ECMO (VA & V V) cases since 2009 with the longest patient being supported on ECMO for 85 days (2016). The only Ex-Vivo Lung Reconditioning machine in the Southern Hemisphere is also located at TPCH. This machine reconditions donor lungs for transplant. It is set up and operated by Perfusionists. 19 sets of lungs have been placed on the Ex-Vivo machine since its acquisition with a total of 16 sets of these lungs being transplanted into a recipient. Research is currently underway at TPCH with assistance from one of our Perfusionists into a similar reconditioning machine for the Heart. Excitingly we recently acquired a new fleet of 5 Heart Lung Machines. The new S5 Sorin HLM s are replacing our old HL20 Jostra Machines that were in the vicinity of 15 years old. These new machines are a welcome addition to the Prince Charles Team. See photos below. Now retired HL20 HLM s 5 new S5 Sorin HLM s ready to be set up Setting up the S5 HLM s ready for theatre 8 JUNE 2016 www.anzcp.org XTRA Innovative intuitive and powerful ATS system The complete solution for blood management and neurological protection. LivaNova XTRA autotransfusion device is part of the integrated HeartLinkTM System. It delivers washed fresh and vital autologous red blood cells significantly decreasing the inflammatory response. Graphic color touch screen user interface New PFAT protocol for effective fat particle elimination while maintaining good hematocrit and optimal supernatant wash-out Fat Particles Removal 99% Fast intuitive and safe setup Seyfried et al. Transfusion. August 2015 (average value using 225 ml bowl on 10% and 25% inlet hematocrit) Fully automated processing Thanks to the new PFAT protocol XTRA removes more than 99% of fat particles from processed blood mitigating potential risk of fat embolism. www.livanova.com JUNE 2016 www.anzcp.org 9 Highest performance Clinical Workshop Details and usability Heater Cooler Unit HCU40 Easy rapid and precise temperature control are essential requirements for a hypo- hyperthermia unit for use during extracorporeal circulation. Maquet s HCU 40 combines the latest proven technology with outstanding performance and unique usability. In addition to the automated Chloramine Halamid cleaning cycle the HCU40 has an integrated UVC lamp to prevent the growth of algae fungi mould bacteria and other microorganisms in the internal water circuitry. UVC lamp For more benefits of Maquet s HCU40 access www.maquet.com www.getingegroup.com 10 JUNE 2016 www.anzcp.org CLINICAL PERFUSIONISTS IN THE MEDIA Molly Oldeen Keeping Australia Alive is a recent documentary series aired on ABC that fi lms snapshots into the world of the Australian health system focused on sharing the stories behind the patients the families and the healthcare workers. It was all fi lmed on Wednesday October 28th 2015 utilizing 100 cameras 350 researchers producers camera operators sound recordists and editors examining 80 hospitals clinics surgeries and homes all over Australia and generating 600 hours of video that turned into seven episodes of a documentary series . Executive producer Karen Dunaway focused on covering hospitals across the entire country as well as a broad range of some of the top ten causes of death. Two of the episodes featured cardiac thoracic surgical patients and mentioned the important role of clinical perfusionists. Pediatric perfusionists were aired in episode 4 Love and Sacrifice which was fi lmed at the Lady Cilento Children s Hospital in Brisbane. In addition adult perfusionists were shown in episode 7 The Costs The Challenges and the Future fi lmed at Saint Vincent s Hospital in Sydney. Episode 4 follows nine month old Ariana through her open heart surgery to repair her diagnosis of Tetralogy of Fallot. They fi lm cardiac surgeon Nelson Alphonso as he describes the process of the repair including steps specifically related to the heart lung machine. He describes how the perfusionist Carla Zazulak is doing all the work right now and the processes of stopping the heart to create a bloodless and motionless field. Episode 7 features a woman Kerry who she needs surgery to remove clots in her lungs as they are leading to right heart failure and increased shortness of breath. Associate Professor Kumad Dhital a cardiothoracic and transplant surgeon describes how he will need to support her on the heart lung machine in order to perform the operation. He also describes the process of cooling the patient to 20 degrees C so that they are able to stop the heart turn off the pump and safely remove the clots. Jonathan Cropper the perfusionist in the episode is fi lmed running the heart lung machine through all steps of the procedure. His significantly important role is exemplified throughout the procedure especially during a short period of instability post CPB where bypass was nearly reinitiated. Well done to the Perfusionists and hospitals involved Not only is it great to see our profession in the media but one can appreciate the surgical experience from the family s perspective as well. JUNE 2016 www.anzcp.org 11 Australian & New Zealand Collaborative Perfusion Registry ANZCPR Quality Perfusion through reporting Last year the Perfusion Downunder Collaboration underwent a name change to the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR). Recently we completed the 9th annual data harvest and have now collected data for nearly 25 000 procedures from 9 centres throughout Australia and New Zealand since 2007. This data provides us with an opportunity to meet the objectives of the collaboration to understand our clinical practice of cardiopulmonary bypass (CPB) provide a foundation for research and to facilitate quality improvement. One of the ways in which we can utilise the data to understand clinical practice is to be able to determine whether existing published studies of observational data can be reproduced. Since these publications are commonly from single centres with relatively small patient cohorts often from other parts of the world it leads us to question how applicable these studies might be to our own patients.. The ANZCPR provides us with the opportunity to determine whether these observations can be observed in our regional multicentre practice or in other words our patients This is an important aspect of contributing to clinical science that is often overlooked. An example that we have recently been looking at relates to the data published by Marco Ranucci and co-workers that describes determinants of hyperlactatemia during CPB and its impact on postoperative outcome (1). In this paper Ranucci hypothesises that certain perfusion related parameters may contribute to the hyperlactatemia associated with postoperative morbidity and mortality with specific respect to hemodilution and oxygen delivery. The premise that these factors are related to lactate production is based on the concept of a critical value of oxygen delivery the assumption being that below this critical value oxygen consumption becomes limited by oxygen delivery and energy production is partially supplied by anaerobic glycolysis. As a result lactate production increases. So does our data support this assumption Figure 1 shows the relationship between peak CPB arterial blood lactate values and CPB duration lowest oxygen delivery (figure 2) and the peak blood glucose concentration (figure 3) in 20 938 patients from the ANZCPR dataset. Peak arterial blood lactate (mmol l) 3 Peak arterial blood lactate (mmol l) Peak arterial blood lactate 2.5 1.8 1.6 2 1.5 50 100 150 Cardiopulmonary bypass duration (min) 200 1.4 200 250 300 Lowest oxygen delivery (ml min m2) 350 1.5 2 2.5 3 3.5 2 6 8 10 Peak blood glucose (mmol l) 12 14 Figure 1 Figure 2 Figure 3 Figure 1-3. Peak arterial blood lactate during cardiopulmonary bypass relative to the duration of bypass lowest oxygen delivery and peak blood glucose.. Data are represented as a median spline by using cross medians as knots to fit a cubic spline. 12 JUNE 2016 www.anzcp.org If you compare the ANZCPR results with those published by Ranucci (http ccforum.com content 10 6 R167) the results are strikingly similar. Ranuccis work indicated that the value of oxygen delivery below which the blood lactate starts increasing was approximately 260 ml min m2 similar to the cut-off values identified in other studies looking at the relationship between lowest oxygen delivery and acute kidney injury (262 ml min m2 (2) and 262 ml min m2 (3)). Our corresponding plot derived from multicentre data supports these findings. Furthermore similar observations for the data for CPB duration and blood glucose levels and lactate concentration are evident. The ANZCPR data provides compelling support for the assumption of a critical value of oxygen delivery given a sample size of 20 938 patients compared with 500 in the published study. This is just one example of how ANZCPR data can be utilised to confirm (or dispute) existing published studies. The next step in this work will be to evaluate the relationship between lactate levels and morbidity and mortality so watch this space or even better become involved in the collaboration. Recent example of using the registry data for research is the collaboration s publication in the Annals of Thoracic Surgery Rewarming Temperature During Cardiopulmonary Bypass and Acute Kidney Injury A Multicenter Analysis (http www.annalsthoracicsurgery.org article S00034975(16)00099-0 fulltext). This study was able to use the power of our multicentre registry to generalise the findings from a single centre study looking at the influence of hyperthermia on acute kidney injury. In our most recent paper we were able to demonstrate that in patients propensity matched based on the likelihood of being exposed to hyperthermic perfusion (rewarming temperature greater than 37oC) that the duration of hyperthermic perfusion was an independent predictor of acute kidney injury (4). Such a relationship was not observed for rewarming temperature duration above 36 or 36.5oC with the implication being that avoidance of hyperthermic perfusion may be more beneficial in reducing AKI than avoidance of rewarming per se. Although this data has been only recently published we have been able to share this knowledge within the Australasian perfusion community for some time. The avoidance of hyperthermic perfusion has been a focus for quality improvement initiatives within the collaboration since 2011 when we introduced benchmarking as a tool for leveraging the data for this purpose. If we track the compliance with Compliance with temperature QI by Year 90 100 this quality indicator over this period we can see the impact of embracing the ethos of data collection reporting and feedback on clinical practice (figure 4 figure 5). Since the introduction of benchmarking we have seen a reduction in the overall requirement for postoperative dialysis (figure 5.) We look forward to sharing more of the knowledge gained from participation in the ANZCPR at the upcoming Australian and New Zealand College of Perfusionists Annual Scientific Meeting in Townsville and the Perfusion Downunder Meeting in Queenstown this year. We really are very privileged to have access to this unique dataset as it is the only perfusion registry in the world to have incorporated data collected electronically from the heart lung machine software. Please visit our new website ANZCPR.org for more details about how you can get involved. Richard Newland and Rob Baker on behalf of the ANZCPR. References 1. Ranucci M De Toffol B Isgro G Romitti F Conti D Vicentini M. Hyperlactatemia during cardiopulmonary bypass determinants and impact on postoperative outcome. Critical Care 2006 10 R167. (http ccforum.com content 10 6 R167 accessed 1 6 2016) 2. Ranucci M Romitti F Isgr G Cotza M Brozzi S Boncilli A Ditta A Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg 2005 80 2213-2220. 3. O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury time for a goal-directed perfusion management Filip de Somer John W Mulholland Megan R Bryan Tommaso Aloisio Guido J Van Nooten and Marco Ranucci. Critical Care 2011 15 R192. 4. Rewarming Temperature During Cardiopulmonary Bypass and Acute Kidney Injury A Multicenter Analysis. Richard F. Newland Robert A. Baker Annette L. Mazzone Steven S. Quinn Derek P. Chew Perfusion Downunder Collaboration. Ann Thorac Surg 2016 Vol. 101 Issue 5 p1655 1662. (http www.annalsthoracicsurgery.org article S0003-4975(16)000990 fulltext accessed 1 6 2016) Postoperative dialysis by Year 5 % of procedures 1 2007 2 3 4 % of procedures 0 10 20 30 40 50 60 70 80 2007 2008 2009 2010 2011 2012 2013 2014 2015 2008 2009 2010 2011 2012 2013 2014 2015 outlet temperature 37oC by year. Overall incidence for the ANZCPR is currently maintained 90% compliance. Figure 4. Incidence of avoidance of oxygenator arterial outlet temperature 37oC by year. Overall incidence for the ANZCPR is currently maintained 90% compliance. Figure 5. Incidence of avoidance of oxygenator arterial JUNE 2016 www.anzcp.org 13 UPDATE MYCOBACTERIAL INFECTIONS ASSOCIATED WITH HEATER COOLER UNITS USED IN CARDIAC SURGERY June 2016 Background There is a risk that heater cooler perfusion units used in cardiac surgery may be contaminated with Mycobacterium chimaera and that exposure of patients to the aerosolised exhaust from these units in the operating theatre may lead to the development of a serious infection up to several years post-surgery. There are no known cases in Victoria to date. There have been reports of infections and deaths in the US and Europe although the actual risk of infection appears extremely low. Infections appear to be generally confined to patients who have had a valve insertion or repair or a prosthetic graft. The Victorian public health laboratory Microbiological Diagnostic Unit (MDU) has developed an assay for testing water samples from heater cooler units. The turnaround time for the test is six to eight weeks. If a positive result is returned the Australian sponsor company for the Sorin heater cooler units will decontaminate the unit provided that it is less than eight years old. The Therapeutic Goods Administration (TGA) has provided advice for health services and staff in a recent Medical Devices Safety Update (see References). The TGA is continuing to investigate the risk of contamination with heater cooler unit manufacturers. In Victoria on Friday 13 May 2016 the Department of Health and Human Services (the department) held a meeting for health services who undertake cardiac surgery for the purpose of sharing information and providing a forum for discussion. Following this meeting the department has revised and reissued its list of recommended actions for health services (see below). 8. Ensure the heater cooler unit is positioned as far away from the patient as possible in the operating theatre and ensure that the fan exhaust is directed away from the patient and is close to the suction exhaust outlet of the operating theatre. Seek assistance from the manufacturer if required in order to accomplish this safely and effectively. 9. Ensure patient records include a reference to the individual heater cooler unit used for their procedure to facilitate tracing if required. 10. Consider amending patient consent information to include the (low risk 1%) possibility of developing serious infections postoperatively up to several years after cardiac surgery. 11. Consider the possibility of Mycobacterium chimaera infection for cardiac surgery patients presenting postoperatively with symptoms of unexplained infection seek infectious diseases specialist advice to assist diagnosis and management. Contingency plans 12. Undertake local contingency planning for the ongoing provision of cardiac surgery in the event of a positive test result for Mycobacterium chimaera. Sampling and testing If your health service is yet to do so contact MDU as soon as possible to arrange testing of units. Labelling Ensure that samples are correctly labelled including date hospital name heater cooler unit serial number sample site (ie which circuit) and details of a designated point of contact for results. Sampling procedure The two tests undertaken on heater cooler unit water samples are a heterotrophic plate count (surrogate measure of cleanliness overall water quality results available in 3-5 days) and mycobacteria cultures (results available in 6-8 weeks). The sampling procedure recommended is that described by Public Health England (see References) with key points as follows Units should be connected and running for at least five minutes before water samples are taken Ideally sampling should take place just prior to the machine undergoing its disinfection cycle Water should be sampled from both the patient circuit and the cardioplegia circuit Sample volume of 100 mL (ie 100 mL from each circuit) If not processed immediately water should be stored between 2 C and 8 C for up to 24 hours. Frequency of sampling There is no consensus around departmental requirements for frequency of sampling at this time guidance on this issue will be provided as soon as possible. Recommended actions for health services Testing 1. Undertake testing of heater cooler units as a matter of urgency to determine if the unit is contaminated. 2. Inform the department of all microbiological test results from heater cooler units until further notice. 3. Ensure maintenance records and any microbiological sampling results are kept for all heater cooler units. 4. Report any confirmed Mycobacterium chimaera infections suspected to be associated with heater cooler unit use to the department the TGA and to the manufacturer of the unit. Maintenance 5. Provide the department with the contact details of a designated person from your health service who has been allocated the responsibility of responding to this issue. 6. Advise the department of the brand model serial number and age of all heater cooler units in use at your health service. 7. Strictly adhere to the manufacturers instructions for cleaning disinfection and maintenance of the heater cooler unit. Seek clarification from the manufacturer if the instructions are unclear. Patient Care Responding to test results 14 JUNE 2016 www.anzcp.org If the results test positive for mycobacteria do not use the heater cooler unit report positive results to the department the TGA and the manufacturer as soon as possible contact the manufacturer to discuss decontamination. LivaNova Australia Pty Ltd provides a decontamination service for Sorin heater cooler units that are less than 8 years old. Note that this may be a lengthy process depending on the manufacturers workload constraints. Follow up testing of samples from decontaminated heater cooler units are currently subject to an 8 week wait for confirmation of negative mycobacterial cultures access backup or loan heater cooler unit if possible. If the results are negative for mycobacteria but the heterotrophic plate count is high disinfect the heater cooler unit prior to further use and re-test as per the manufacturers instructions for use seek advice from the manufacturer on how to deal with persistently high heterotrophic plate count results. All microbiological test results from MDU (ie for Mycobacterium chimaera and heterotrophic plate count) are to be reported to the department until further notice regardless of whether these are positive or negative. At this time the department does not require results of any additional heterotrophic plate count tests undertaken by local health service laboratories. It is advised that health services develop a local contingency plan for the ongoing provision of cardiac surgery in the event of a positive test result for Mycobacterium chimaera. This may include sourcing a back-up or loan heater cooler unit and or working with other health services. If you think the provision of cardiac surgery at your health service will be affected please contact the department. Once initial test results are known the department will provide further information on system level contingency plans if required. Microbiological Diagnostic Unit Public Health Laboratory University of Melbourne Parkville VIC Ph (03) 8344 5701 Reporting of a suspected adverse event relating to a medical device Therapeutic Goods Administration Medical Devices Branch Ph 1800 809 361 email iris tga.gov.au Further information and references American Thoracic Society 2007. An Official ATS IDSA Statement Diagnosis Treatment and Prevention of Nontuberculous Mycobacterial Diseases. Available at https www.thoracic.org statements resources mtpi nontuberculous-mycobacterial-diseases.pdf (accessed 1 June 2016) European Centre for Disease Prevention and Control (ECDC) April 2015. Rapid risk assessment Invasive cardiovascular infection by Mycobacterium chimaera potentially associated with heater-cooler units used during cardiac surgery. Available at http ecdc.europa.eu en publications Publications mycobacterium-chimaera-infection-associated-with-heater-coolerunits-rapid-risk-assessment-30-April-2015.pdf (accessed 1 June 2016) Falkinham JO Pruden A Edwards M. Opportunistic Premise Plumbing Pathogens Increasingly Important Pathogens in Drinking Water. Pathogens 2015 4 373-386. (open access) Garvey MI Ashford R Bradley CW et al. Decontamination of heater-cooler units associated with contamination by atypical mycobacteria. Journal of Hospital Infection 2016. G tting T Klassen S Jonas D et al. Heatercooler units contamination of crucial devices in cardiothoracic surgery. Journal of Hospital Infection 2016. Kohler P Kuster SP Bloemberg G et al. Healthcare-associated prosthetic heart valve aortic vascular graft and disseminated Mycobacterium chimaera infections subsequent to open heart surgery. European Heart Journal 2015 36 2745-2753. Public Health England webpage last updated November 2015. Mycobacterial Infections Associated with Heater Cooler Units. Investigation updates sampling protocol and guidance updates for health services available to download. https www.gov.uk government collections mycobacterial-infections-associated-withheater-cooler-units Sax H Bloemberg G Hasse B et al. Prolonged outbreak of Mycobacterium chimaera infection after open-chest heart surgery. Clinical Infectious Diseases 2015 61 67-75. Available at http cid.oxfordjournals.org content early 2015 03 11 cid. civ198.abstract (accessed 1 June 2016) Therapeutic Goods Administration. Medical Devices Safety Update Vol 4(3) May 2016. Non-tuberculous mycobacterium infections associated with heater-cooler devices. Available at http www.tga.gov.au publication-issue medical-devices-safetyupdate-volume-4-number-3-may-2016 (accessed 31 May 2016) US Centers for Disease Control and Prevention. October 2015. Non-tuberculous Mycobacterium (NTM) Infections and HeaterCooler Devices Interim Practical Guidance Updated October 27 2015. Available at http www.cdc.gov HAI pdfs outbreaks CDC-Notice-Heater-Cooler-Units-final-clean.pdf (accessed 31 May 2016) US Food and Drug Administration safety communication October 2015. Non-tuberculous mycobacterium infections associated with heater-cooler devices FDA safety communication. Available at http www.fda.gov MedicalDevices Safety AlertsandNotices ucm466963.htm (accessed 31 May 2016) Record keeping As per the recommendations for health services above records must now be kept for all heater cooler units if this is not already done. Records must include as a minimum Heater cooler unit details including make model serial number date of manufacture and date of commencement of use at health service Dates and sufficient detail of all maintenance and disinfection procedures All microbiological test results Patient medical records including details of the individual heater cooler unit used in the procedure Note that record keeping is the responsibility of the health service. While the department will also monitor and record microbiological test data from Victorian health service heater cooler units over the next 1-2 years this does not take the place of health service records. Costs The cost of testing by MDU is anticipated to be 230 per sample. LivaNova Australia Pty Ltd is currently charging health services 6 400 to decontaminate affected Sorin heater cooler units. Contacts Department of Health and Human Services (for submission of test results) Glenda Gorrie Assistant Director Quality and Safety Ph (03) 9096 7553 email glenda.gorrie dhhs.vic.gov.au Sampling and testing inquiries JUNE 2016 www.anzcp.org 15 CARDIAC MORPHOLOGY AT THE CHILDREN S HOSPITAL AT WESTMEAD By Martin Gill Morph - meaning form - Ology meaning the study of As a trainee perfusionist at the Children s Hospital at Westmead one of the highlights for me was Dr Richard Hawkers Morphology Pathology days. These infamous sessions saw a group of people huddled around a table whilst Dr Hawker removed sealed plastic bags from a white bucket sliced them open with a somewhat rusty scalpel blade thus permitting the contents to spill out onto a conveniently placed tray. The smell of Formalin was close to overpowering resulting in every eye in the room watering. Occasionally one or two medical students would leave the room retching. Those that managed to remain were in for a real treat. The cardiac specimens available for analysis were approximately 20-30 years old with conditions ranging from ventricular septal defects right through Tetralogy of Fallot to Truncus Arteriosus and Hypoplastic Left heart Syndrome. Some of the conditions had had corrective surgery some not and one had most likely passed away in the cath lab. as evidenced by the rather large hole in the side of the RV to PA conduit. People in the room would have the opportunity to handle the specimens and hopefully under the experienced eye of Dr Hawker correctly diagnose the cardiac abnormality. The atmosphere in the room was always non-threatening and surprisingly fun despite the slightly macabre undertones. The educational value of an extensive understanding of cardiac morphology cannot be overestimated. Such an understanding is essential if one is to understand surgical correction and treatment. For the perfusionist this results in better being able to predict what is happening or going to happen within the surgical field thus being able to take measures to ensure safe practice or to optimise the flow of the procedure. Unfortunately as Dr Hawker wound down towards retirement so did the morphology sessions. For a time they were occasionally discussed with fondness but after a while became all but forgotten....... Fast forward to 2015 and the Children s Hospital has employed several new cardiologists and was about to host a Hands-on Cardiac Morphology course ran by Dr Andrew Cook. Dr Cook is Senior Lecturer and heads the Cardiovascular Morphology and Education Unit at the UCL Institute of Cardiovascular Science Great Ormond Street Hospital London UK. The two day course was primarily geared to improving knowledge of cardiac anatomy in particular congenital heart malformations from fetal life to adulthood. Information was imparted through didactic lectures and of course hands-on Now I am sure you can imagine the Australian Customs and Border Protection service is not going to waive someone through Kingsford-Smith with a suitcase full of preserved hearts. What was needed was a ready supply of preserved hearts demonstrating an array of congenital cardiac malformations......which brings us full circle to Dr Hawkers samples from my trainee days. Dr Hawkers cardiac samples had not seen the light of day for some 5 years. Each sample HAD been individually sealed in a plastic bag filled with Formalin then placed in a bucket with other specimens of a similar ilk. Unfortunately many of the specimens were completely decimated due to leakage or evaporation of the preservation solution. Out of 300 specimens approximately half were completely useless and many more were significantly damaged. Luckily enough had survived and of sufficient variability to be used. The two day course was fantastic with just the right mixture of lecture and hands-on components. Under expert guidance course participants had the opportunity to handle analyse and attempt to diagnose some of the wide array of congenital malformations on offer. Each specimen used throughout the course had been previously cut by a pathologist thus permitting ready access to all chambers and associated structures of the heart. Dr Cook subscribes to Sequential Segmental Analysis as a means of determining and categorising cardiac malformations. Sequential Segmental Analysis of 16 JUNE 2016 www.anzcp.org the congenitally malformed heart is based on the premise that the heart possesses three component parts namely the atriums the ventricular mass and the arterial trunks. These parts are known as segments and each of the segments in the normal heart contains two parts the right and left atriums and ventricles and the aorta and the pulmonary trunk. When a heart is abnormal there are limited ways in which these components can be deranged. Describing the derangements is the essence of sequential analysis. Following any conference I attend I usually have a period of feeling completely reinvigorated academically speaking. I do of course struggle with prolonging this feeling for any significant period of time. Fortunately I was not the only one who felt this way after this particular course. Approximately six months after the course one of our cardiologists approached me for help in restarting Dr Hawkers Morphology Pathology sessions. The cardiologist in question had already catalogued all the surviving cardiac specimens and after speaking to the head of the Pathology laboratory had decided to place the samples in a 10% honey solution. The thought being that after approximately 30 years in Formalin the specimens had been sufficiently stabilised we now just needed to preserve them. Such a strategy had the added bonus of avoiding the rather confronting odour of the former preservation solution. So the date was set for the first in a new series of morphology pathology sessions. The chosen topic was to be Tetralogy of Fallot. Three buckets of samples were available containing approximately fifteen hearts. I must admit to being fairly excited as I made my way down to the pathology laboratory to retrieve and prepare the samples about an hour or so before the session commenced. This excitement soon dissipated when I opened the first specimen bucket to a smell of alcohol and a nice growth of yeast on top of the hearts a situation that was repeated in the second and third buckets. The growth was easily washed off but clearly the 10% honey was not a long term solution to the preservation of the cardiac specimens. The session went ahead and was a great success. As I had experienced during Dr Cooks two day course the participants attending this hour long session all immensely enjoyed the opportunity to handle and again under tutelage systematically work their way through the heart in such a way that maximised the educational impact of the session. Participants included cardiac surgeons cardiologists perfusionists nursing staff and medical students with each bringing a unique and different perspective to the session. Once the session was finished the next task was returning the specimens to their buckets and preservation solution..... Obviously this was not going to be possible in the honey solution. We once again spoke to the pathology laboratory manager who suggested adding copper to the honey to kill the yeast. This may well be a long term solution to our solution problems but we were not willing to take any chances with the specimens. So it was back to the old tried and tested Formalin. This required the opening and washing of some 150 samples. A mixture of aerobic and anaerobic fungus was found in many of the buckets containing the 10% honey. This situation most certainly will not occur with Formalin.... Just smell lots of smell. I am pleased to report that we are going to continue to run the sessions. I can certainly recommend attending any such sessions if you have the opportunity at your institution. If not I can recommend Dr Cooks morphology course if and when it returns to Australia. In the meantime you can visit http www.cardiacmorphology.com and register for free to obtain access to a truly great online resource containing videoed morphology examinations of cardiac specimens... Enjoy JUNE 2016 www.anzcp.org 17 DEL NIDO EXPERIENCE By Carla Zazulak - Lady Cilento Children s Hospital - South Brisbane Approximately 8 months ago at the Head surgeons request we investigated the possibility of adding del Nido Cardioplegia 1 4 ratio of blood to crystalloid to our Perfusion imprest alongside our current Paediatric Buckberg Cardioplegia 4 1 blood to crystalloid - which has been used here for the past 8 years and that we have found to provide good myocardial protection. The perceived benefits were that the surgeon could continue operating with less time spent in delivering cardioplegia doses on long complex cases and that perhaps we would see a longer period before return of activity. The fi rst issue encountered was around del Nido not being available commercially in Australia or New Zealand. We liaised closely with our in-house Pharmacy staff providing literature reviews and the current recipe that existed from Boston Children s Hospital in the USA. Pharmacy conducted their own research as well as surveying colleagues around Australia to gauge the interest in del Nido use and the possibility of it being produced commercially in the future. Our Pharmacy was then able to offer us del Nido cardioplegia made by them and prescribed labelled for each individual patient that required it. This proved to be challenging at times when there were last minute changes to the list. Our next step was to then fi nd a way to use our current Cardioplegia set in a way that allowed us to be able to use either of the Cardioplegia solutions as well as continue to be able to use it for Modified Ultrafi ltration. A review of our circuit allowed us to make a small change and add one 1 4x1 4 luer lock connector pre cardioplegia pump to give us the ability to deliver the del Nido at that connector without drastically changing our design. When the del Nido is attached to the tap on the connector a clamp is placed proximal to the connector allowing the del Nido crystalloid to flow in to the 1 4 tubing rather than blood from the oxygenator. We then bag off some patient blood after going on bypass and connect this to the 1 8 line that would normally have the Buckberg CP connected to it and this gives us the 1 part blood needed for del Nido delivery. Once the cross clamp is off we simply clamp off the del Nido bag turn the tap off on the 1 4x1 4 Luer Lock connector and remove the proximal clamp on the tubing. This then allows us to convert our cardioplegia circuit to our normal MUF configuration in preparation for Modified Ultrafi ltration post bypass. To date we have used del Nido in over 60 patients. The average time between doses is around 80 -90 minutes. We currently select del Nido for any patient where we expect the cross clamp time to be over 60 minutes or at the surgeons specific request. We are still getting to grips with how best to utilise it and how often we should be re-dosing with del Nido - especially in cases where we are keeping the patient normothermic or only cooling slightly. I would be interested in hearing about other units experiences with del Nido and their protocols for use. Our Pharmacy currently copes with the demand of making this solution in-house and are prepared for us to increase our usage in the future if need be. Carla Zazulak Lady Cilento Children s Hospital - South Brisbane 18 JUNE 2016 www.anzcp.org JUNE 2016 www.anzcp.org 19 Case Report PERFUSING A HEMOPHILIAC AT THE CANBERRA HOSPITAL Casey Edwards Introduction Hemophilia patients in the Western world now have higher life expectancies than ever before. It is suggested that children born today with hemophilia will have an equivalent life expectancy to unaffected persons (Mejia-Carvajal et al. 2006). As healthcare professionals we will be increasingly faced with the prospect of treating age-related disorders in hemophiliacs. Cardiac surgery in particular poses a significant hemostatic challenge because of the need for a sternotomy heparinization extracorporeal circulation hypothermia and cardiac arrest (Tang et al. 2009). On the 3rd of November 2015 we were presented with this particular challenge at the Canberra Hospital. Cardiopulmonary bypass The Stockert SIII heart lung machine was set up as per routine with a Medtronic Fusion oxygenator and patented bonded circuit. It was then primed with 1500mL of Plasmalyte 250mL of 4% Albumex and 15 000U of heparin sodium. After the induction of anaesthesia a baseline blood gas and activated clotting time (ACT) was obtained returning a reading of 133 seconds. After administering 35 000IU of heparin sodium the ACT elevated to 756 seconds. The lowest ACT recorded during bypass was 603 seconds and no additional heparin was given on pump aside from the 15 000 units added to the priming solution. The case was uneventful. The bypass time was 64 minutes the cross clamp time was 53 minutes and the patient spontaneously converted to sinus rhythm. In the immediate postoperative period following heparin reversal with protamine sulfate the patient s ACT returned to 130 seconds. Minimal postoperative blood loss was observed thus the patient was transferred smoothly to the intensive care unit for ongoing treatment and monitoring. Hemophilia details and mechanism Hemophilia is a hereditary clotting disorder with a X-chromosomal inheritance pattern. It manifests as a deficiency of either clotting factor VIII (hemophilia A) or factor IX (hemophilia B). There are a number of genetic mutations that result in hemophilia with different mutations resulting in different levels and morphologies of the affected clotting factor production. Consequently the disease has a spectrum of severity. A patient with less than 1% active factor VIII or IX is classified a severe hemophiliac 1 5% active factor a moderate hemophiliac and 5 40% a mild hemophiliac (Butenas et al. 2002). Postoperative outcome In addition to routine post-cardiac surgical care the patient s factor VIII levels were checked at non-specific time intervals during his intensive care stay. His factor VIII levels are depicted in the following graph A hemophiliac patient s factor VIII levels pre and post cardiac surgery Patient parameters The patient to be discussed is a 72-year-old male with hemophila A. His average factor VIII levels were 36% of normal production. Therefore he is considered a mild hemophiliac. He was otherwise fit and well at the time of surgery measuring 171cm tall weighing 84kg and with a body surface area of 1.98cm2. He suffered from severe triple vessel disease and was admitted to the Canberra Hospital consenting to 3 coronary artery bypass grafts. Preoperative care A specialized hemophiliac nurse managed the patient s preoperative care. Thirty minutes prior to surgery he received a 2500IU bolus of Advate (recombinant factor VIII concentrate). A continuous factor VIII infusion (CFI) of 130IU hour was instituted from then on with the intent to titrate this infusion post-operatively in response to factor VIII levels observed. 20 JUNE 2016 www.anzcp.org It is evident from the above graph that the patient s factor VIII levels signif icantly exceeded 100% of normal peaking at 144%. Shortly after extubation and the patient returning to consciousness it was noted by ICU staff that he had suffered a cerebral event. He exhibited dysphasia and muscle weakness. At four months post surgery his diff iculty speaking and impaired comprehension were persistent as a result of his stroke. There we no other complications of note with regard to his recovery from surgery. References Butenas S. Brummel K. Branda R. Paradis S. and Mann K. (2002). Mechanism of factor VIIa dependent coagulation in hemophilia blood vol. 99 (3). Hogue C. Murphy S. Schechtman K Davila-Roman V. (1999) R isk factors for early or delayed stroke after cardiac surgery . Circulation vol. 100 642-647 Mejia-Carvajal C. Czapek E. Valentino A. (2006). Life expectancy in hemophilia outcome . Journal of Thrombosis and Haemostasis. vol. 4 (3) 507-509. Tang M. Wierup P. Terp K. Ingerslev J. S rensen B. (2009). Cardiac surgery in patients with haemophilia . Haemophilia. vol.15(1) 101-10 Discussion and conclusion It is well understood that strokes are a risk of cardiac surgery with cardiopulmonary bypass. It is also understood that such events may result from a variety of causes (Hogue et al. 1999) therefore it may not be possible to delineate the specif ic causative agent of a stroke following bypass. It has been speculated that in our case excessive factor VII rendered the patient hypercoagulable thus resulting in clot formation and stroke. This hypothesis cannot be conf irmed nor rejected but from experience we can suggest that maintaining postoperative factor VII less than or equaled to 100% may be prudent to ameliorate the risk of cerebral events. The case outlined above highlights that being overzealous with blood management may be just as dangerous as being lax. Perhaps more frequent monitoring of factor VIII levels at f ixed time intervals post-bypass may have enabled the patient s hemophilia coordinator to titrate his factor VIII infusion more accurately and identify excessive factor VIII levels more quickly in the immediate postoperative period. This would have minimized time the patient spent in a potentially hypercoagulable state. Additionally no factor VIII level tests were completed between the preoperative bolus and the commencement of surgery. Perhaps the effect of the bolus could have been evaluated before progressing to surgery which may have affected the rate of infusion that was subsequently commenced. Our f irst experience perfusing a hemophiliac was both eventful and informative. No f irm conclusions can be drawn about the cause of our patient s stroke however our management of hemophiliacs in the future is likely to be different as a result of his experience. Since the life expectancy of those with the disease continues to improve we do anticipate facing similar cases in future. In such circumstances as a team we would endeavor to monitor factor VIII levels more closely and adjust infusion doses with greater vigilance to ensure factor levels do not exceed 100% of normal. In doing so we would hope to avoid one of the many risk factors for post cardiac-surgical stroke. JUNE 2016 www.anzcp.org 21 VACUUM ASSISTED VENOUS DRAINAGE (VAVD) PITFALLS AND SUGGESTIONS Monique Brouwer and Ray Miraziz Westmead Hospital Sydney The Inaugural Australasian Simulation and Perfusion (ASaP) meeting was held in May this year at Royal North Shore hospital. One of the simulation sessions included in this meeting featured VAVD. An overview of the technique was provided whilst the safety issues were demonstrated and strategies to prevent inadvertent pressurisation implosion were discussed and practiced. As minimally invasive surgical procedures become more prevalent it is likely that there will be an increase in the need for VAVD. As with many safety practises it is easy to become complacent in their use. It is important to review safety measures periodically and refine or expand on how we approach a technique. Caution will lead to safer outcomes. We have compiled a summary of the safety features for VAVD as reviewed at the ASaP meeting. The do s and don ts of VAVD The do s 1. Ensure the use of a functioning calibrated vacuum regulator with built in positive relief valve (or a regulator with both - relief valves if available). Ensure your hard shell reservoir has a positive and negative pressure relief valve (or add via a leur port). Include a moisture trap when using a Y connector to protect the patient s circulation from contamination (condensation leaking back from the vacuum line into the patient reservoir). Pressure displays must have audible alarms to alert the perfusionist of any positive pressure at all and negative pressures beyond acceptable ranges. Remembering that the effective negative pressures are the sum of the 2. 3. 4. 22 JUNE 2016 www.anzcp.org vacuum (as per your regulator) the siphon contribution (depending on the height of the table above the reservoir). We choose a positive pressure alarm setting of 7mmHg (allowing for some inaccuracies) and a 60mmHg (a sum total of -75 to -90 mmHg depending on table height). 5. In difficult cases with the use of multiple suckers vents consider the use of a separate cardiotomy reservoir in order to overcome the effects of free air flow. Air pumped directly into the reservoir by the sucker or vent May reduce the ve pressure applied and interfere with venous drainage May produce excessive ve pressures and overcome the -ve pressures (especially if only using low levels of ve pressures). Consider the use of an empty prime bag connected to the reservoir as a visual sign that the reservoir is pressurised. This may however delay the audible alarm from alerting the perfusionist of an urgent problem. Apply safe levels of vacuum. Normally -20 to -40 mmHg to augment venous drainage after commencing bypass. Always stop the vacuum before you come down on arterial blood flow or as the first step in weaning the patient off bypass. Excessive -ve pressures in the reservoir can pull air across the microporous membrane oxygenator and allow air to enter the patient s circulation. The main arterial pump pressurises the oxygenator however this positive pressure is lost when the flow is reduced and the negative pressure in the reservoir is then transmitted to the oxygenator. Maintain adequate blood level in the reservoir to protect the patient from GME. 4. Decrease the efficiency of the arterial pump (negative pressure effect on the raceway tubing). Decompress the reservoir providing false assurance that adequate blood levels are present Increase gases coming out of solution in the blood leading to GME. Do not fully clamp the side line if using a Y connector as this can provide an escape for air when vacuum is discontinued. Watch your vacuum line carefully ensuring it is not kinked or inadvertently clamped trapping pressures within the reservoir. What you should not do when you hear an audible VAVD alarm Reduce pump flow without first releasing vacuum Clamp venous line to protect the patient from a pressurised reservoir before releasing vacuum 5. 6. 6. 7. 8. Remember you must release the vacuum first. Reducing pump flows when your -ve pressures are too high may result in air being pulled across the membrane Clamping the venous line if you have a pressurised reservoir may lead to a reservoir exploding something that is hard to recover from. 7. Do not increase your vacuum when there is a significant amount of air entrained in the venous line. 9. 10. What you should do when you hear an audible VAVD alarm Any VAVD alarm get rid of vacuum then assess the situation Stop suckers and or vent pumps immediately (unless using a separate cardiotomy). 11. Include VAVD in your pre-bypass checklist. Checks should include Positive and negative pressure relief valves are insitu Alarm limits are set and audible alarms are functioning There are no leaks in the system (caps tightly on all ports) Wall suction is connected and working well. Increasing the vacuum increases the GME delivered to the patient. Air in the venous line needs surgical intervention. The venous cannula needs to be sitting in a pool of blood in order for an increase in vacuum to effectively increase venous drainage and facilitate the emptying of the heart. If vacuum is increased when the caval cannulae are poorly snared or if there is a hole in the atrium then you are only increasing the GME delivered to the patient (accelerating venous air entrainment sucking in more air ) The ASaP meeting was terrific opportunity to practice VAVD and simulate many of its pitfalls. We look forward to future simulation meetings and congratulate Darryl Jane and Arthur on this initiative. References Durandy Y. Vacuum-assisted venous drainage angel or demon PRO J Extra Corpor Technol 2013 45 122-127. The don ts 1. Do not leave syringes with drugs attached to the manifold. Syringes can be aspirated into the reservoir if ports are not fully closed or accidently forgotten. Do not apply ve pressures more than -60mmHg as this may De-prime the oxygenator when pump flows are low Fiorucci A Gerometta PS DeVecchi M Guzman C Costantino ML Arena V. In vitro assessment of the vacuum-assisted venous drainage (VAVD) system risks and benefits. Perfusion 2004 19 113-117. Willcox TW Mitchell SJ Gorman DF. Venous air in the bypass circuit a source of arterial line emboli exacerbated by vacuum-assisted drainage. Ann Thorac Surg 1999 68 1285-1289. 2. 3. JUNE 2016 www.anzcp.org 23 CEREBRAL PROTECTION MANAGEMENT DURING DHCA A REVIEW OF CURRENT METHODS Emerson Sgammotta Perfusion Services Abstract The idea of Deep Hypothermic Circulatory Arrest (DHCA) regarding cerebral protection has been around since 1975. First performed by Greipp and colleagues DHCA aims to provide a decrease in the brains metabolic rate and oxygen requirement with the reduction of temperature allowing a bloodless field for the surgeon. Its use is commonly used for surgical correction of paediatric cardiac anomalies but routinely used for complex aortic surgery in adults. DHCA has its disadvantages such as coagulopathy extended bypass time elevated inflammatory response and end-organ dysfunction with neurologic injury being of the highest concern. Continuing development of cerebral monitoring and pharmacologic advancements have caused a great discussion in optimal cerebral protection during DHCA. This review aims to provide an update of practices and methods of the last decade concerning cerebral protection with focus on pharmacologic protection cannulation techniques and the discussion of use of antegrade cerebral perfusion. The purpose of this review is to determine the most effective method of which cerebral protection can be achieved when under hypothermic circulatory arrest. techniques and the discussion of moderate vs deep hypothermia. The goal of this review is to determine the gold standard for temperature and techniques whilst undergoing circulatory arrest in achieving optimal cerebral protection. Pharmacologic management Pharmacologic interventions regarding DHCA and organ protection namely cerebral protection have been under constant debate and a standardization of treatment is nonexistent. Hypothermia itself is able to protect against cerebral ischemic injury by reducing CMRO2 attenuating Ca 2 accumulation and other mechanisms. 5Pharmacological agents aim to reduce the basal metabolism of the brain about 20% of which hypothermia does not affect. The beneficial use of barbiturates steroids lidocaine and calcium channel blockers have all been demonstrated in animal trails however further have stopped short of concluding beneficial evidence in clinical trials. Barbiturates in particular thiopental are the most commonly used pharmacologic agent for cerebral protection (59% of respondents) according to a survey of the Association of Cardiothoracic Anesthetists in the UK in 20026. The use and protocols of administration of barbiturates vary from hospital to hospital. They are used in addition to hypothermia to increase the tolerance of cerebral tissues to ischemia that may be caused temporarily from circulatory arrest. Used for its ability to reduce CMRO2 cerebral edema and free radicals it was first reported by Nussmeier et al in 1986 that the use of thiopental prevented neuropsychiatric complications 10 days after cardiac surgery7. Zaidan et al. then found that there was no significant difference of the action of thiopental on the postoperative neurocognitive dysfunction of the patient. 8It is still used today as the drugs ability to reduce cerebral oxygen demands as well as intracranial pressure. A study by Schwer et al. in 2013 showed molecular evidence that thiopental inhibits global protein synthesis in neurons reducing the ATP consumption as well as cellular damage in oxygen deprived cells9. This energy balance in hypoxic cells is crucial in maintaining cerebral protection especially under rewarming. As Hirotani et al. in 1999 showed decreased oxygen delivery calculated through jugular venous saturation upon rewarming can be avoided with the use of thiopental as oxygen consumption is decreased10. As thiopental will lower the energy state of the brain the timing and dosage being administered is also quite crucial. If thiopental is administered too early before being cooled the vasoconstriction effect of the barbiturate will reduce cerebral blood flow and impair cerebral cooling. 11The inhibition of glycolysis would prove detrimental to the energy state of the brain if administered to early12. Hirotani et al showed that thiopental being administered 5 mins prior to circulatory arrest at a dose of 30mgkg-1 resulted in lower cerebral oxygen consumption when compared with a lower dose combined with no neurologic complications8. Introduction The idea of Deep Hypothermic Circulatory Arrest (DHCA) regarding cerebral protection has been around since 1975. First performed by Greipp and colleagues 1 the use of hypothermia aims to provide a decrease in the brains metabolic rate and oxygen requirements of hypoxic tissues. It is said that the cerebral metabolic rate decreases by 50% for every 6oc drop in brain (core) temperature permitting a longer period of interrupted blood flow to the brain. 2Initially used for the replacement of the aortic arch DHCA is today used in surgery concerning complex cerebral aneurysms complex paediatric cardiac anomalies throacoabdominal aneurysms and renal carcinomas extending to the right atrium. As little as 10 years after DHCA was being implemented in arch surgeries cooling to deep and profound temperatures during circulatory arrest caused concern for the patients physiologic consequences. Concerns such as hypothermiainduced bleeding complications and prolonged perfusion times causing an increase in systemic inflammatory response led researchers to support lesser degrees of hypothermia. 3 Optimal circulatory arrest temperature during arch surgery remains under great debate and strategies for HCA very greatly between centers around the world. In recent times there have been concerns over the neurocognitive deficits potentially being caused by hypothermic neuronal injury Permanent and Temporary Neurological Dysfunction.4 This review aims to provide an update of practices and methods of the last decade concerning cerebral protection with focus on pharmacologic protection cannulation 24 JUNE 2016 www.anzcp.org Steroids are used in conjunction with thiopental namely dexamethasone and methylprednisolone to offset the systemic inflammatory response of cardiopulmonary bypass. It is known to reduce proinflammatory cytokines and cerebral edema with the optimal timing and dosage relatively unclear. The effect of cerebral response to ischemia was first shown by Langley et al. 13when high dose methylprednisolone was given to piglets prior to induction of anesthesia resulting in a significant recovery of cerebral blood flow and cerebral metabolism in the steroid-treated animals. Further research by Shum-Tim et al. 14 and Lodge et al. 15both showed that steroid treatment given systemically pre-operatively showed a significantly reduced inflammatory response reduced body oedema as well as improved immunohistochemical markers of neuroprotection. Based on studies concerning positive results of large doses of methylprednisolone given to patients after spinal cord injuries there is continued support for the use of corticosteroids during DHCA for neuroprotection. At a dose of 30 mg kg either preoperatively or as early as possible would be beneficial to the patient with a close monitoring of hyperglycemia caused by the corticosteroid. Mannitol is another commonly administered drug by the perfusionist during DHCA as not only does it protect the kidneys by decreasing the renal vascular resistance reduces endothelial oedema and preserving tubular integrity as an osmotic diuretic and can also reduce cerebral edema and scavenge free radicals leading to a decrease in tissue damage. 16 Its effect on improving blood rheology and the osmotic potency is treatment for cerebral edema. 17Since 1981 it has also been shown by Hanley and Davidson 18 that the combination of furosemide and mannitol being administered preserves renal function in ischemic conditions. Standard dose of 0.5g kg for administering mannitol with Appoo et al. 19suggesting 0.25g kg 10 to 15 minutes prior to exsanguination and a further 0.25g kg upon the restart of CPB. Lidocaine is also used as a cerebral protective agent as it reduces cerebral metabolism and has membrane stabilizing properties by selectively blocking Na channels in neuronal membranes. 20These properties were initially shown in dogs to prolong the safe duration of DHCA by inducing an isoelectric EEG reducing the CMRO2 by an additional 15-20%21. In a more recent study on humans doses of greater than 42.6mg kg in non-diabetic patients were shown to improve cognitive outcome 1 year after surgery however in diabetic patients high doses showed an increased postoperative neurocognitive decline22. With the aim to prevent ischaemic cerebral injuries during arch surgery Temporary and Permanent Neurological Dysfunction have become indicators in assessing cerebral injury post bypass. The incidence of Temporary Neurological Dysfunction after arch surgery using DHCA alone is quite significant. A study by Ergin et al. 23 in 1999 was conducted to determine the correlation of the incidence and severity of TND post DHCA. The study found that in a patient group of 71 28.1% of all patients who underwent DHCA acquired a TND resulting in deficits in memory and motor functions at 6 weeks of testing. It was concluded that the temporary exclusion of cerebral circulation may attribute to this result however further research is needed to determine the contributing cause of this complication. Studies were then performed to determine whether the addition of Antegrade Selective Cerebral Perfusion (ASCP) to patients undergoing DHCA would help resolve the incidence of this complication. A multicentre study by Di Eusanio et al. in 2003 24 evaluated the results of ASCP as a method of brain protection whilst under DHCA and its effectiveness in reducing TND. Their results showed that in 588 patients across the 3 centres there was a reported TND rate of 5.6%. They successfully showed a lower result of TND when ASCP was used in conjunction with DHCA. In recent times there have been several studies performed around the world trying to evaluate the use of moderate hypothermia with routine ASCP and its effect on TND when compared to deep hypothermic circulatory arrest. In 2007 the Bologna group performed a study of 205 aortic arch operations employing the cooling protocol of either moderate or deep hypothermic circulatory arrest 25. With no significant difference in ASCP time or CPB time they found that there were no differences between the groups with regard to 30 day mortality and permanent or temporary neurological dysfunction. In 2010 Leshnower and his colleagues presented a retrospective review of 5 years of data for arch cases involving were able to show very low neurological complications in more than 400 patients undergoing moderate hypothermic circulatory arrest.26By using selective antegrade cerebral perfusion at an average of 26 degrees they were able to achieve a TND rate of 5.1% with other morbidity outcomes being very low as well. They effectively showed that MHCA in combination with SACP provides and effective cerebral protective method in patients requiring arch reconstruction. Moderate vs deep hypothermia The role of temperature control and adjunctive perfusion in hypothermic circulatory arrest is of vital importance with the debate over ideal hypothermic temperature a contentious issue. Ever since Griepp and his associates first described performing aortic arch surgery with hypothermic circulatory arrest 40 years ago the ideas and techniques of arch surgery have continued to change and cerebral perfusion has evolved into a standard method of cerebral protection during arch surgery. They initially reported on 4 patients undergoing aortic arch surgery using profound hypothermic circulatory arrest. With one patient dying 4 days in the post-operative period they concluded that their experience of using this total body hypothermia and circulatory arrest can be carried out with an acceptable mortality rate1. The outcome of this study was a huge development in surgery of the aortic arch. As time progressed moderate hypothermic circulatory arrest with adjunctive cerebral perfusion was proposed to negate potential hypothermia-related comorbidities whilst still maintaining adequate cerebral protection. Cannulation Site The idea of providing continuous perfusion to the brain at a moderate temperature has reasonably been shown by the literature to be a viable and safe practice for surgeries on the aortic arch. However it is the location of the cannulas to perfusion the brain which has also caused some debate. When referring to permanent neurological dysfunction incidences have been shown to be directly related to the site of arterial cannulation after arch reconstruction mainly due to embolization from atheroma of the cannulated vessels and possible further aortic dissection The cannulation of the right axillary was initially described in 1995 by the Cleveland Clinic group as these arteries are usually free from atheroma are rarely involved in aortic dissection in cases of Type A dissections. It was a more advantageous location in which to provide antegrade systemic perfusion during the rewarming phase. Auxillary cannulation can provide unilateral or bilateral cerebral perfusion. The JUNE 2016 www.anzcp.org 25 choice between these techniques has also been a highly published issue. In determining which method of cerebral perfusion should be chosen a pre-operative assessment of the cerebral circulation is recommended as an incomplete circle of willis can occur in 6 to 17% of cases17. It has been controversially hypothesized by Urbanski that the Circle of Willis is not the only pathway for cerebral cross-perfusion and that extracranial collateral circulation most likely plays a meaningful role during unilateral SCP in patients with incomplete Circle of Willis27 . However the use of Near Infrared Spectroscopy is said to be able determine if bilateral cerebral perfusion is necessary if there is an incomplete circle of Willis and no extracranial collateral circulation. In a large study by Zierer et al in 2012 they reported on 1002 patients who underwent partial or total aortic arch repair. They compared the results of patients receiving uni- and bi-lateral cerebral perfusion under mild HCA. Their results showed that unilateral ACP offers as much brain and visceral organ protection as bilateral ACP and could be advantageous as it avoids the manipulation of the arch vessels and possible embolization. They noticed a trend towards a reduced PND (p 0.06) after unilateral ACP and no difference in the occurrence of transient neurologic deficits.(p 0.6)28. There are quite a few studies that back up this claim such as a recent single centre study by Preventza et al in 2015 on 157 patients undergoing proximal aortic dissection. With a mean ACP time of 34 mins the study found no significant difference between unilateral and bilateral ACP in many variable outcomes. As one of the largest single centre studies of the efficacy of unilateral and bilateral cerebral perfusion in patients with type a dissection they concluded that unilateral cerebral perfusion is a reasonably justified for most operations with circulatory arrest times of greater than 40 minutes being recommended to use bilateral antegrade perfusion. 29 This conclusion of the appropriate time for cerebral perfusion in relation to cannulation site was assessed by Malvindi and associates. They performed a meta-analysis of 2949 patients receiving bilateral cerebral perfusion and almost 600 receiving unilateral perfusion. Their findings showed that when unilateral antegrade perfusion was performed for a period of 30 to up to 50 mins they produced similar neurological injury rates when compared to bilateral antegrade perfusion periods of over 86 mins at 5%. 30 This article like many in the past has shown that there is still no definitive answer to the question of which optimal temperature should be universally applied to hypothermic circulatory arrest whilst performing arch operations. However it does show that the following protocol in terms of anesthetic management cannulation position and temperature provides optimal cerebral protection in patients requiring hypothermic circulatory arrest. Administration of steroids (dexamethasone at 30 mg kg) as early as possible to reduce proinflammatory cytokines and cerebral oedema. Barbiturates (thiopental 30mg kg) to reduce CMRO2 cerebral edema and free radicals and given 5 minutes before arrest to avoid cerebral vasoconstriction and limit uniform cerebral cooling. Mannitol to decrease the renal vascular resistance reduce endothelial oedema and preserving tubular integrity as an osmotic diuretic and can also reduce cerebral edema and scavenge free radicals 0.25mg kg 10-15 mins prior to arrest 0.25mg kg upon reperfusion. Lidocaine to reduce cerebral metabolism 42mg kg in non-diabetic patients. If possible a pre-operative CT scan to determine the communication of the Circle of Willis. Cannulation of the right auxillary artery at moderate (2832oc) hypothermia Unilateral cerebral perfusion for periods of 30-50 mins with bilateral perfusion for periods above 86 minutes. References 1 Griepp RB Stinson EB Hollingsworth JF Buehler D Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 70 10511063 1975. 2 Gega A Rizzo JA Johnson MH et al Straight deep hypothermic arrest Experience in 394 patients supports its effectiveness as a sole means of brain preservation. Ann Thorac Surg 84 759-766 2007. 3 Livesay JJ Cooley DA Reul GJ et al. Resection of aortic arch aneuryms a comparison of hypothermic techniqes in 60 patients. Ann thorac Surg. 36 19-28 1983. 4 Kumral E Yuksel M Buket S et al. Neurologic complications after deep hypothermic circulatory arrest types predictors and timing. Tex Heart Inst J. 28 83-88 2001. Hogue CW Palin CA Arrowsmith JE Cardiopulmonary bypass Management of Neurologic Outcomes An Evidence-Based Appraisal of Current Practices. Anesth Analg 103 21-37 2006. 5 6 Dewhurst AT Moore SJ Liban JB Pharmacological agents as cerebral protectants during deep hypothermic circulatory arrest in adult thoracic aortic surgery. A survey of current practice. Anaesthesia 57 1016-1021 2002. 7 Nussmeier NA Arlund C Slogoff S Neuropsychiatric complications after cardiopulmonary bypass cerebral protection by a barbiturate. Anesthesiology 64 165-170 1986. Zaidan JR Klochany A Martin WM et al Effect of thiopental on neurologic outcome following coronary artery bypass grafting. Anesthesiology 74 406-411 1991. Schwer CI Lehane C Guelzow T et al Thiopental Inhibits Global Protein Synthesis by Repression of Eukaryotic Elongation Factor 2 and Protects from Hypoxic Neuronal Cell Death. PLOS 8 e77258 2013 8 9 10 Hirotani T Kameda T Kumamoto T Et al Protective effect of thiopental against cerebral ischemia during circulatory arrest. Thorac Cardiovasc Surg 47 223-228 1999 11 Reid RW and Warner DS Arguments for use of barbiturates in infants and children undergoing deep Hypothermic Circulatory arrest. J Cardiovsc Anesth 12(5) 591-594 1998 12 Siegman M. et al Barbiturates Impair Cerebral Metabolism During Hypothermic Circulatory Arrest. Ann Thorac Surg. 54(6) 1131-1136 1992. 13 Langley S Chai P Jaggers J et al Preoperative high dost methylprednisolone attenuates the cerebral response to deep hypothermic circulatory arrest. Eur J Cardiothroac Surg. 17 414-421 2000 26 JUNE 2016 www.anzcp.org 14 Shum-Tim D Tchervenkov C Lalberte E et al. Timing of steroid treatment is important for cerebral protection during cardiopulmonary bypass and circulatory arrest minimal protection of pump prime methylprednisolone. Eur J Cardiothorac Surg. 24 125132 2003 15 Lodge A Chai P Daggett C et al. Methylprednisolone reduces the inflammatory response to cardiopulmonary bypass in neonatal piglets timing of dose is important. J Thorac Cardoivasc Surg. 117 515-522 1999. 16 Yang MW Lin CY Hung HL et al Mannitol reduces plasma hydrogen peroxide free radical in patients undergoing coronary artery bypass graft surgery. Ma Zui Xue Za Zhi. 20 65-70 1992. 17 Rabinstein AA. Treatment of cerebral edema. Neurologist. 12 59-73 2006. Hanley Mj Davidson K Prior mannitol and furosemide infusion in a model of ischaemic acute renal failure. Am J Physiol. 241 556-564 1981. 18 19 Appoo JJ Ralley F Baslaim G Varennes B Anaesthesia for Deep Hypothermic Circulatory Arrest in Adults Experience with the First 50 patients. JCardiovsc Anesth. 12 260-265 1998. 20 Zhou Y Wang D Du M et al Lidocaine prolongs the safe duration of circulatory arrest during deep hypothermia in dogs. Can J Anaesth. 45 692-698 1998. 21 Svyatets M Tolani K Zhang M et al Perioperative Management of Deep Hypothermic Circulatory Arrest. J Cardiovasc Anaes 24 644655 2010. 22 Mathew JP Mackensen GB Phillips-Bute B et al Randomised double-blinded placebo controlled study of neuroprotection with lidocaine in cardiac surgery. Stroke. 40 880-888 2009. 23 Ergin MA Uysal S Reich DL et al Temporary neurological dysfunction after deep hypothermic circulatory arrest a clinical marker of long-term functional deficit. Ann Thorac Surg. 67 188718890 1999. 24 Di Eusanio M Scheppens MAAM Morshuis WJ et al Brain Protection Using Antegrade Selective Cerebral Perfusion A multicentre Study. Ann Thorac Surg. 76 1181-1189 2003. 25 Pacini D Leone A Di Marco L et al Antegrade selective cerebral perfusion in thoracic aorta surgery safety of moderate hypothermia. Eur. J Cardoithorac Surg. 31 618-622 2007. 26 Lechnower BG Myung RJ Kilgo PD et al Moderate Hypothermia and Unilateral Selective Antegrade Cerebral Perfusion A Contemporary Cerebral Protection Strategy for Aortic Arch Surgery. Ann Thorac Surg. 90 547-554 2010. 27 Urbanski PP Lenos A Zacher M and Diegeler A. Unilateral cerebral perfusion right versus left. Eur J Cardiothorac Surg. 37 1332-1336 2010. Zierer A El-Sayed Ahmad A Papadopoulos N et al Selective antegrade cerebral perfusion and mild (28oC-30oC) systemic hypothermic circulatory arrest for aortic arch replacement results from 1002 patients. J Thorac Cardiovasc Surg. 144(5) 1042-1049 2012. 28 29 Preventza O Simpson KH Cooley DA et al Unilateral Versus Bilateral Cerebral Perfusion for Acute Type A Aortic Dissection. Ann Thorac Surg. 99 80-87 2015. 30 Malvindi PG Scrascia G and Vitale N. Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery Int cardiovasc and thorac surg. 7 891-897 2008. JUNE 2016 www.anzcp.org 27 The following pages contain the abstracts from the 32nd Annual Scientific Meeting Australian and New Zealand College of Perfusionists. LOW PRIME AND AUTOLOGOUS PRIME ABSTRACT James Ferguson Blood Conservation remains an ongoing quest since the early times of cardiac surgery. Many improvements occurred during the last decades and have allowed a move to bloodless cardiac surgery. Moreover blood transfusions have been associated with increased mortality rate and remains unclear if blood transfusion improves survival. In adults low hematocrits during CPB have been shown as an independent predictor of operative mortality prolonged ICU stay postoperative hospital stay and worse 0 to 6 year survival. Blood conservation usually utilizes methods to limit Hemodilution and to limit blood loss during surgery. 1. Methods to limit Hemodilution include low prime circuits remote pump head systems ultrafiltration antegrade and retrograde autologous priming of the circuit and red cell salvage. 2. Methods to limit blood loss include surface modifying additives accuracy of heparin therapy during CPB pharmacologic modulation of the coagulation system. This presentation will discuss designs of Minimally Invasive Extracorporeal Circulation Technology (MiECT) systems and associated literature with the use of MiECT systems. Also the use of antegrade and retrograde autologous priming will be discussed with regards to its benefits on blood conservation. SETTING ABOUT CHANGE IN FLUID MANAGEMENT Jon Van Den Berg Waikato Hospital New Zealand. In 2004 we invited The New Zealand Blood Service to present transfusion data from five major Cardiac Centres at our National Cardiac Surgery meeting. The results were blinded and clearly one unit had a much lower transfusion rate than others. We were quite clear our unit was one of the remaining four. Given the significant number of delegates attending from our unit the drive for blood management change had begun. Initiating blood cellsaving and reducing circuit prime are two easy strategies reaping instant benefit. However what more can be done Reviewing the circuit prime composition and fluid replacement strategy promoted stability and improved outcomes from bypass. What more can be done A Team approach to fluid management resulted in further benefits. The Perfusion and Anaesthetic Teams now combine strategies to manage blood conservation and fluid replacement. Furthermore intra-operative fluid management strategies have now begun to influence post-operative intensive care management. 28 JUNE 2016 www.anzcp.org WATER QUALITY OF HEATER-COOLER UNITS WOULD YOU DRINK IT Darryl McMillan CCP Dip Perf Kieron C. Potger BSc CCP Dip Perf Joanne Southwell BSc. Cardiopulmonary Perfusion & Autotransfusion Unit Royal North Shore Hospital Sydney. In the operating theatre (OT) resides the heater-cooler unit (HCU) containing a reservoir of water which is used to control the temperature of our patients on cardiopulmonary bypass (CPB). A reservoir of water that may be used any number of times over days to weeks and longer without being cleaned or changed. The water quality issue of HCUs was noted in 2001 by Weitkemper and colleagues who were able to culture Pseudomonas and Legionella in six Jostra HCU-20s noting a mass of particles and vegetation in the inner tank (1). After a spate of cardiac surgical site infections in the USA between 2008 and 2011 a self-contained overhead water reservoir for CPB heat regulation was implicated in growing M. wolinski (a rapidly growing nontuberculous mycobacterium [NTM] commonly present in water). Frequent dripping and atomization of the grossly discolored and particulate contaminated water was noted associated with the connection and disconnection of the heat exchanger to the water supply. Hoping to resolve the problem the system was replaced by portable HCUs (2). However as already seen portable HCUs are not infallible as was reported in Swizerland last year (3). Invasive M. chimaera infections (a slow growing NTM) were initially found in two cardiac surgery patients launching a systematic investigation to identify the source and extent of the potential outbreak and to implement preventive measures. Water and air samples were collected from operating theaters and elsewhere within the hospital. Cases were also identified retrospectively on archived histopathology samples and prospectively on patients considered at risk. Consequently six adult male patients were identified with prosthetic valve endocarditis or vascular graft infection due to M. chimaera of which two died due to the infection. M. chimaera was found in the tap water filled Sorin 3T HCUs and in the air samples collected when these units were in use both sites yielding identical M. chimaera strains. However these environmental samples did not exactly match the patient samples. Nevertheless the authors concluded that there was evidence for the airborne transmission of M. chimaera from contaminated water tanks to patients during open-heart surgery presumably due to airborne transmission of microbes sprayed from the ventilation outlets of the HCUs (3). In a follow up article a further four cases of M. chimaera infections subsequent to valvular or aortic surgery purportedly (but not conclusively) originating from airborne contamination associated with the HCU were identified (of which 2 died) 1 from Germany and 3 (including one child) from the Netherlands. The authors estimated the rate of infections being approximately 1-2 per 1000 patients undergoing open heart surgery (4). Alerted by the events in Europe the UK s Department of Public Health identified 13 probable cases of M. chimaera infections subsequent to valve surgery from all cardiac cases in the NHS but did not confirm them as being linked to the HCU. However M. chimaera had been identified in the HCU water and they confirmed the feasibility of the HCU generating a microbial aerosol by experimental testing (5). Mycobacterium chimaera is commonly found in soil and drinking water and is not harmful to most healthy people however it causes respiratory infections and disseminated infections in immunocompromised patients and post cardiac surgery after a lag time of months to years has been associated with endocarditis or septicaemia. Here the outcome is very poor despite surgical reintervention and long term antimicrobial therapy (4). The M. chimaera found in the HCU may reflect a diffuse contamination from local water sources or represent a single identifiable point source contamination (6). Measures to reduce possible contamination and improve the water quality include filtering the tap water used to fill the HCU frequent HCU water changes hose changes inline water filtering and use of cleaning solutions. However measures to clean and decontaminate the HCU according to manufacturer s recommendations in Switzerland were followed by recontamination (3). Also contamination of a Jostra HCU-30 with M. chimaera was also recently reported in the USA despite weekly cleaning and maintenance as per the manufacturer s instructions (7). An issue is that after contamination a biofilm may form within the HCU tanks and hoses. This would limit the effectiveness of any ongoing cleaning maintenance as biofilms are resistant to standard disinfection procedures. If for example the hoses are not change there may be a reinfection of the HCU from the colonisation formed within the biofilm of the water circuit (8). Further measures may include the removal of the heart-lung machine from the surgical area prior to disconnecting the heat-exchanger hoses positioning the HCU condensing fan away from the patient or positioning the HCU as far from the patient in the operating room as possible. As M. chimaera has only been detected in units that locate their HCUs within the OT Kohler et al. recommends that either the HCUs should be placed outside the OT with independent air flow or that the water reservoir and tubing are air-tight (4). Indeed in Holland several elective heart cases were postponed until measures such as placing the HCU outside the OT was taken. In one Swiss hospital customized cabinets were built to house the HCU within the OT (9). What should be the quality of the water used in the heatercoolers The answer may simply be drinking water . As recommended to minimize the risk of infection Sorin reiterates that the water in their 3T HCU should meet microbiological requirements for drinking water and testing should include Coliform bacteria and Pseudomonas aerginosa (10). Although recommended drinking water testing entails using the heterotrophic plate count (a test used to detect a number of micro-organisms present in water) no Australian guideline has yet been set for heterotrophic plate counts in drinking water for NTM. A positive result of a heterotrophic plate count test does not represent a health risk but provides JUNE 2016 www.anzcp.org 29 useful information on the general microbiological content of the water and hence a measure of the effectiveness of disinfection (11). Concerned European agencies have stated that it is not conclusive that the HCU is the cause of the infections but recommend following manufacturers guidelines on disinfecting and cleaning the HCU and ensuring that departmental protocols include these practices. At this stage it would be inefficient for each perfusion unit in Australia and New Zealand to independently identify the problems and formulate protocols to deal with something that affects us all. It may be better to have a unified strategy to approach the Australian and New Zealand health authorities in conjunction with the manufactures to formulate and establish an appropriate decontamination protocol. This will be an ongoing issue as new yet unidentified microbes may begin to haunt us into the future. REFERENCES 1. Weitkemper HH Spilker A Knobl HJ K rfer R. The HeaterCooler Unit-A Conceivable Source of Infection. J Extra Corpor Technol.2002 34 276-80. 2. Nagpal A Wentink JE Berbari EF Aronhalt KC et al. A cluster of Mycobacterium wolinsky surgical site infections at an academic center. Infec Control Hosp Epidemiol. 2014 35 116975. 3. Sax H Bloemberg G Hasse B et al Prolonged outbreak of Mycobacterium chimaera infection after open-chest heart surgery. Clin Infect Dis.2015 61 67-75. 4. Kohler P Kuster SP Bloemberg G Schulthess B et al. Healthcare-associated prosthetic heart valve aortic vascular graft and disseminated Mycobacterium chimaera infections subsequent to open heart surgery. Eur Heart J.2015 doi 10.1093 eurheartj ehv342. 5. Public Health England. Mycobacterial Infections Associated with Heater Cooler Units Used in Cardiothoracic Surgery. Advice for providers of cardiothoracic surgery. Version 1.0 Published June 2015 PHE publications gateway number 2015104. 6. Meera C. Mycobacterial infections associated with heater cooler units used for cardiopulmonary bypass during surgery. UK Health Briefing Note Serial number 2015 04 11 June 2015. 7. MDR Report Key 4927415 Report Number 8010762-201500527. THE ORIGINS OF CLINICAL GOVERNANCE Steve Bolsin In July 1998 on the 50th Anniversary of the NHS an article entitled Clinical governance and the drive for quality improvement in the new NHS in England was published in the BMJ. Prior to this there had been 20 articles linking Quality Improvement to Governance of Clinical processes in healthcare. Since this article there have been 2500. The failure of clinical accountability that led to this proposal for Clinical Governance arose directly from the stark failings in a UK Cardiac Surgical unit at the Bristol Royal Infirmary. These events led directly to the unnecessary deaths of 171 children in the unit despite the knowledge of the Surgical Director the Hospital Medical Director the Chief Executive the Royal College of Surgeons the Royal College of Anaesthetists the Department of Health and the Health Minister. Several inquiries were held including an external review a GMC Disciplinary Inquiry and finally a Royal Commission. Eventually 3 doctors were found guilty of Serious Professional Misconduct and two doctors were struck off the Medical Register these were the Medical Director and the Chief Executive of the hospital. This talk will illuminate the events that led to Clinical Governance as we know it. 8. Cardiac surgery Mycobacterium risks. Disinfection and cleaning of Sorin heater cooler devices [Important information letter] 14 July 2014]. IIS9611109-07-14-14. Sorin Group Deutschland GMBH. M nchen. 9. European Centre for disease Prevention and Control. Invasive cardiovascular infection by Mycobacterium chimaera 30 April 2015. 10. FAQs for the Heater-Cooler System 3T Disinfection Process Sorin USA FAQ 3-08- 2015. 11. The Australian Drinking Water Guidelines (ADWG0) www. measurement.gov.au ... TestingDrinkingWaterDomesticUse. pdf. AMSECT S STANDARDS & GUIDELINES COMPLEMENT OR CONTRADICTION Steve Bolsin In 2013 the American Society of Extracorporeal Technology (AmSECT) revised their Standards & Guidelines for the management of adult cardiopulmonary bypass. Over the last 2 years the Perfusion community has expressed concern that some of the Standards & Guidelines contradict current practice. In this presentation delegates will be engaged in a discussion regarding the Standards & Guidelines and some of the challenges to implementation. 30 JUNE 2016 www.anzcp.org Designed by perfusionists. Engineered by Medtronic. Thoughtful design from inlet to outlet. Built on the input of more than 500 perfusionists worldwide Fusion is the result of a unique collaboration between perfusionists and Medtronic. A fundamentally different design approach yielding 79 new design enhancements including a fully integrated oxygenator and arterial filter. An advancement in oxygenation system design. To find out more visit www.fusionoxygenator.com Affinity Fusion is a registered trademark of Medtronic Inc. UC201301071a EE Medtronic Inc. 2013. All Rights Reserved. JUNE 2016 www.anzcp.org 31 THE PRESENT STATE OF EVIDENCE BASED PERFUSION Robert A Baker PhD CCP(Aust) Cardiac Surgery Research and Perfusion Cardiac and Thoracic Surgery Unit Flinders Medical Centre and Flinders University Adelaide Australia. Traditionally the pyramid of our knowledge base is capped with meta-analyses and multiple randomised controlled trials however in our field of cardiopulmonary bypass (CPB) there is a lack of this high level evidence for many of the activities that we perform. Bartel and colleagues in 2002 highlighted this in their paper Cardiopulmonary bypass evidence or experience based concluding that For most CPB principles the scientific background is not conclusive enough to allow general recommendations. Therefore recommendations should be based on a consensus of numerous expert opinions on CPB in combination with a review of the literature. The authors went on to highlight the responsibility of the profession towards developing improved clinical outcomes using evidence based medicine principles and developing a culture of creating quality scientific research. Have we progressed since 1992 has the knowledge base grown sufficiently or have we worked towards developing consensus based guidelines since that time A number of publications and initiatives have evolved to help develop perfusion practices by providing guidelines and recommendations for practice these include guidelines looking at glucose management and blood management developed under the auspices of the Society of Thoracic Surgeons (refs). In 2006 the International Consortium for Evidence Based Perfusion was initiated to help provide inertia in this area and in 2010 the Perfusion Task Force was formed combining surgical anesthesia and perfusion disciplines in a multidisciplinary attempt to promote the development of guidelines in CPB. This initiative has resulted in temperature management guidelines (finalized) and anticoagulation renal and neuro-protection guidelines in development. These initiatives help provide some direction to how our clinical practices can be shaped. In parallel multi-centre perfusion registries have developed in Australia and New Zealand (Perfusion Downunder Collaboration) USA (PERForm Registry Northern New England (NNE) Registry) Japan and Europe allowing an understanding of current practices to be developed. These registries now have over 50 000 patient records and help us understand our current practices and demonstrate areas where practices vary and those that may need dedicated research. One current focus of these registries has been to look at blood management and the role of perfusion in patient blood management practices a second to look at factors influencing acute kidney injury following CPB. Collectively the use of registry in cardiac surgery offers enormous opportunity for us to learn from our experience and develop improved practices as we develop. The nestling of the PERForm and NNE perfusion registries within large quality improvement collaboratives highlights this. The paradigm of evidence based medicine has been in vogue for over 20 years it s application in the field of CPB has been limited. This provides us with a unique opportunity to learn from the experiences of EBM in other disciplines and to develop a balance rather than a reliance on standardization of practice and recognition of the value that can be gained from variation s in practice when evidence ethics the individual and judgment combine to deliver real evidence based medicine. QUALITY SAFETY & ETHICS Stephen Bolsin Medical ethics are continually evolving to accommodate changes in medical knowledge and the expectation of society and patients. Some changes in medical ethics occur in response to the failure of the medical profession to practice according to the standards society expects. This presentation will trace the history of changes in medical ethics brought about by the failure of the medical profession to adhere to the standards expected by civilised society. The impact of human experimentation in the 2nd World War and the Tuskegee Experiment illustrate the reassertion of the Hippocratic Oath and the introduction of the Four Pillars of Beneficence Non-malificence Autonomy and Justice. However have the 4 Pillars worked or is the burden of healthcare error something that should be addressed by a change in ethical principles This question will be answered and some alternative ethical reasoning offered to improve outcomes and reduce error rates in complex healthcare environments. 32 JUNE 2016 www.anzcp.org SEVEN TEAM TASKS APPROACH Stephanie O Regan Sydney Clinical Skills and Simulation Centre When errors occur in medicine it can be devastating for both the patient and their family and for the health professionals involved in the case. Clinical competence is often not the reason for these errors rather they are often related to a combination of human factors environmental factors and organisational issues. The World Health Organisation refers to human factors as environmental organizational and job factors and human and individual characteristics which influence behavior at work in a way which can affect health and safety. A simple way to view human factors is to think about three aspects the job the individual and the organization and how they impact people s health and safety-related behavior . (www.who.int patientsafety research methods_measures human_factors en ) Decision-making is complex and frequent. Estimates suggest we make more than 35 000 decisions per day or nearly 2000 per awake hour. It stands to reason that some of these decisions will be less than optimal. During stress our ability to think broadly is reduced so finding solutions is impaired and again poor decision-making may ensue. The Seven Team Tasks Approach using a human factors focus provides one strategy to reduce mediate and prevent errors. The Seven Team Tasks are 1. 2. 3. 4. 5. 6. 7. Assemble the Right Team Plan and Prepare Manage Resources Manage People Communicate Effectively Monitor and Evaluate Support Each Other TEAMWORK CORPORATE SECTOR AND PERFUSION IT S ALL ABOUT THE PATIENT Arthur Preovolos CCP(Aus) Perfusionist Technical Product Specialist Medtronic Australasia At the core of the relationship between Perfusionists and the corporate sector it s all about providing what is best for the patient. The teamwork that exits between the corporate sector and perfusionists extends beyond providing quality products in a timely manner for clinical use. There has been a long history of cooperation between clinicians and the corporate sector. This cooperation over the years has led to the development of innovative products and techniques that improve patient care. A newer area of cooperation is in the sphere of education. The corporate sector when asked can and does provide clinical support and training and education in the use of their products. This clinical support of education and training of perfusionists has been extended to include simulation training. Basic perfusion training crisis management and teamwork simulations are taught to groups the aim of these courses is to improve clinical patient management and patient outcome. JUNE 2016 www.anzcp.org 33 SIMULATION A FOCUS ON TEAMWORK Kenneth G Shann CCP This interactive session will promote the long term interaction in simulation of all the disciplines involved in cardiac surgery (surgical anaesthesia nursing perfusion and industry). To gain an understanding of the complex environment of the cardiac theatre through the lens of different members of the cardiac team. The concept of simulation and team work will be presented utilizing video scenarios. PRESERVE BLOOD EVERY DROP COUNTS Rona Steel A.Prof Peter Klineberg Ray Miraziz Monique Brouwer Grace Agbulos Dr Hugh Playford Dr Kate Harris Pauline Hinks Dr Adam Eslic There is overwhelming evidence that RBC transfusion is associated with increased mortality and morbidity (2 3 4 7). The incidence of RBC transfusion has been associated with an increase in risk of bacterial infections (1 9) low-output failure (6) arrhythmias (10) acute kidney injury (11) longer ICU and hospital stays (3) and poorer quality of life post operatively (8). In 2013 a comparison of 9 cardiac surgical units in Australia and New Zealand found that Westmead s transfusion rates far exceeded its peers. A collaborative project was formed at Westmead Hospital comprising 14 representatives from key disciplines impacting blood usage. This collaboration enabled the project to drive change in practice across these key disciplines resulting in a significant reduction in transfusion rates for cardiac surgical patients at Westmead Hospital. The methodology applied was transferred from the US (5) and is expected to be readily transferable to other units. It is simple cost effective and easily reproducible and supported by evidence based guidelines. A noteworthy inclusion to our practise changes was the adoption of a venous RAP technique. This technique removes a large volume of prime from our circuits at the initiation of bypass quickly and without delay and is fully controlled by the perfusionist. This technique has resulted in an impressive reduction to our patients hemodilution during bypass. A video demonstration of this technique will be presented. TEG 6S EVALUATION DEFYING THE ODDS R. Miraziz Chief Perfusionist Westmead Public Hospital Sydney Point of Care Haemostatic Assessment Devices utilising emerging cartridge-based technology (TEG 6s and ROTEM sigma) are increasingly being evaluated and used in Cardiac Surgery. The benefit of such analysers in cardiac theatres relates to their convenience speed and their precise and reproducible assessment of haemostatic alterations. The alterations in haemostasis are influenced by a number of parameters that contribute to postoperative bleeding and the necessity for transfusion of blood products. The transfusion of blood products can be life-saving during surgery however with each blood product transfused carries a small risk of an acute or late adverse effect. Alternative strategies towards restrictive transfusion practices have shown to be equivalent or better than liberal practices. Westmead Hospital evaluated the TEG 6s predominantly for the management of cardiac patients post cardiopulmonary bypass in order to reduce the transfusion of blood products. The evaluation of the intraoperative coagulation and platelet function with the use of appropriate cartridges (Citrated Multichannel and PlateletMapping Cartridges) optimised the transfusion therapy and the administration of pharmacological drugs by achieving a targeted haemostasis. The use of TEG 6s analyser has led to change of practice at Westmead Hospital and now guides the transfusion practice following cardiac surgery. A review of a series of cardiopulmonary bypass cases defied the odds by using the TEG 6s analyser including redo procedures aortic dissection and DHCA cases with 4hr bypass time requiring the transfusion of nil or minimal blood products. REFERENCES 1. Chelemer SB Prato BS Cox PM Jr et al. Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery. Ann Thorac Surg 2002 73 138e42. 2. Corwin HL Gettinger A Pearl RG et al. The CRIT Study anemia and blood transfusion in the critically ill-current clinical practice in the United States. Crit Care Med 2004 32 39e52. 3. Ferraris VA Brown JR Despotis GJ et al. 2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines. Ann Thorac Surg 2011 91 944-982. 4. Koch CG Li L Duncan AI et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006 81 1650e7. 5. Likosky DS Surgenor SD Dacey Lj et al. Rationalising the treatment of anaemia in cardiac surgery short and mid-term results from a local quality improvement initiative. Qual Saf Health Care 2010 19 392-398. 6. Surgenor SD DeFoe GR Fillinger MP et al. Intraoperative red blood cell transfusion during coronary artery graft surgery increases the risk of postoperative low-output heart failure. Circulation. Jul 4 2006 114(1 Suppl) I43-48. 7. Zindrou D Taylor KM and Bagger JP (2002). Preoperative haemoglobin concentration and mortality rate after coronary artery bypass surgery. Lancet 359(9319) 1747-1748. 8. Koch CG Khandwala F Li L Estafanous FG Loop FD and Blackstone EH (2006). Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery. Annals of Thoracic Surgery 82(1) 13-20.R 9. Rogers MAM Blumberg N Heal JM and Hicks GL (2007). Increased risk of infection and mortality in women after cardiac surgery related to allogeneic blood transfusion. Journal of Women s Health 16(10) 1412-1420.CE 10. Koch CG Li L David R Duncan AI Gillinov AM and Blackstone EH (2006). Red cell transfusion is associated with an increased risk for postoperative atrial fibrillation. Annals of Thoracic Surgery 82(5) 1747-1756.BASED 11. Huybregts Rien AJM de Vroege Roe l Jansen Evert K van Schijndel Anne W Christiaans Herman MT van Oeveren Willem (2009). The Association of Hemodilution and Transfusion of Red Blood Cells with Biochemical Markers of Splanchnic and Renal Injury During Cardiopulmonary Bypass. Anesthesia & Analgesia 109(2) 331-339 34 JUNE 2016 www.anzcp.org Maquet Australia Extracorporeal Membrane Oxygenation 8 hours Clinical Workshop Clinical Workshop Details Aimed at All Clinical Staff actively involved in patient cannulation device priming set up and managing a patient supported by Extracorporeal Membrane Oxygenation (ECMO) in the Clinical environment. This comprehensive one day program offers a combination of theory interactive group sessions and simulation enabling the participant to apply theoretical knowledge to clinical practice in a safe and supported environment. Workbook and catering are included. For course outline price and further details please email ncas.au maquet.com Getinge Group Unit 9 35 Paringa Road Murarrie 4172 QLD www.getingegroup.com JUNE 2016 www.anzcp.org 35 THE ROLE OF TRANSFUSION IN POST-OPERATIVE MORBIDITY AND MORTALITY EMERGING SCIENCE AND CLINICAL REGISTRIES Robert A. Baker TOPIC OBJECTIVES 1. Review and discuss randomised controlled trial data evaluating transfusion as it contributes to the evidence base for post-operative morbidity and mortality 2. Review and discuss registry data evaluating transfusion as it contributes to the evidence base for post-operative morbidity and mortality Understanding clinical practice allows the clinician the opportunity to treat every patient appropriately however what do we do when the science behind our clinical practice does not clearly define the optimal pathway forward. Our current literature has many publications that have evaluated the role of preoperative anaemia and the effect of blood transfusion on patient s morbidity and mortality. In the realm of cardiac surgery the question of causation rather than association is widely discussed with advocates suggesting preoperative anaemia and the patients co-morbidities provide the most significant driver of poor outcome (eg Kulier et al 20071) while others are firmly entrenched with the view that red blood cell transfusion is central to poor outcome (eg Koch et al 20062). Layered upon this is the question of when should transfusion occur. The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists has made the following recommendations in relation to transfusion3 During cardiopulmonary bypass (CPB) with moderate hypothermia transfusion of red cells for hemoglobin 6 g dL is reasonable except in patients at risk for decreased cerebral oxygen delivery (ie history of cerebrovascular attack diabetes cerebrovascular disease carotid stenosis) where higher hemoglobin levels may be justified. (IIa Level of evidence C) In the setting of hemoglobin values exceeding 6 g dL while on CPB it is reasonable to transfuse red cells based on the patient s clinical situation and this should be considered as the most important component of the decision making process. Indications for transfusion of red blood cells in this setting are multifactorial and should be guided by patientrelated factors (ie age severity of illness cardiac function or risk for critical end-organ ischemia) the clinical setting (massive or active blood loss) and laboratory or clinical parameters (eg hematocrit SVO2 electrocardiogram or echocardiographic evidence of myocardial ischemia etc.). (IIa Level of evidence C) With hemoglobin levels below 6 g dL red blood cell transfusion is reasonable since this can be life-saving. Transfusion is reasonable in most postoperative patients whose hemoglobin is less than 7 g dL but no high level evidence supports this recommendation. (IIa Level of evidence C). Whilst these recommendations are actionable the level of evidence supporting them is not high. The difficulty in applying these recommendations is reflected in data demonstrating variation in transfusion practices in United States Cardiac Surgery Units in an analysis of data from the STS database which was performed after the initial publication of the guidelines in 2007. There was large variability among hospitals in the rate of red blood cell transfusion ranging from 7.8% to more than 92.8% among coronary-artery bypass graft surgery patients with this variation only partly explained by case mix (20%) and geographic location academic status and volume (11%)4. Contemporary data from the PERForm registry (2010-2014) has shown red blood cell transfusion rates to vary from 16.8% to 57.6% in the perioperative setting for coronary artery bypass grafting in contributing centres. Given the STS recommendations and the paucity of evidence are current randomised controlled trials (RCT) and registry data helping improve the level of evidence for clinical practice. Much of the RCT evidence base for cardiac surgery is limited as has been reported in both the most recent Cochrane review5 and the recent meta-analysis6 or is taken from the critical care or other surgical specialty literature. The most recent RCT was published by Murphy7 in March this year aimed at determining if a restrictive threshold for red cell transfusion (Hb 7.5 g dl) as compared with a liberal threshold (Hb 9.0 g dl) in an postoperatively anaemic patients (Hb 9.0 g dl) would reduce morbidity and health related costs found that the restrictive transfusion threshold after cardiac surgery was not superior to the liberal threshold with respect to morbidity (primary outcome occurred in 35.1% of the patients in the restrictive-threshold group and 33.0% of the patients in the liberal-threshold group (odds ratio 1.11 95% confidence interval [CI] 0.91 to 1.34 P 0.30) or health care costs. They reported a secondary outcome suggesting more deaths in the restrictive-threshold group than in the liberal-threshold group (4.2% vs. 2.6% hazard ratio 1.64 95% CI 1.00 to 2.67 P 0.045). This study has been met by much commentary in relation to non adherence to the transfusion thresholds the exclusion of the role of oxygen consumption and delivery the question as to how restrictive the restrictive threshold actually was (63.7% transfusion versus 94.9%) transfusion was controlled only in post operative period ignoring the intraoperative period and the role of a patient blood management focussed approach8. However it is consistent with other RCT s such as the FOCUS 36 JUNE 2016 www.anzcp.org trial in hip fracture patients9 that showed liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors no benefit on long-term mortality or affects cause of death. Findings that do not support the hypothesis that blood transfusion leads to long-term immunosuppression that is severe enough to affect the long-term mortality rate by more than 20 25% or cause of death. These results challenge the current practices promoting restrictive transfusion which have been supported by the Cochrane review5 whilst the 2014 meta-analysis6 recommended further studies were necessary to determine the optimal strategy. A number of trials are underway including the TRICS III study evaluating restrictive versus liberal transfusion protocols. Interestingly the TRICS III trial will include intraoperative interventions and is not restricted to the postoperative period. Observational studies and registry data has suggested that transfusion is harmful after cardiac surgery with associations reported between transfusion and mortality and morbidity including infection low cardiac output and acute kidney injury2 10. These earlier studies are complimented by more recent studies which have similarly been able to demonstrate under a number of different conditions that the association between mortality and transfusion remains strong. For example Engoren et al11 in 2014 in a small single institution study examined the interaction between anaemia and red blood cell transfusion with respect to late mortality finding anaemia and transfusion were associated with increased risk of late mortality in CABG patients (4 years). Whilst most recently we have evaluated the interaction of transfusion and anemia in the PDU registry in both a mixed and CABG only cohort. We have using a propensity model designed to predict the likelihood of transfusion looked at the association of transfusion and anemia (standardise WHO criteria). Propensity matching allowed us to incorporate many of the factors previously identified to limit observational and registry studies for example the influence of oxygen delivery during bypass7 12 and postoperative blood loss13. We have shown that after propensity matching anaemia without transfusion was not found to be a predictor of mortality or morbidity. Transfusion was found to be an independent predictor of mortality with or without anaemia (An Tx OR 5.62 95% CI 1.59-19.82 P 0.007 An-Tx OR 6.66 95% CI 2.08-21.29 P 0.001). Transfusion was also found to be an independent predictor of morbidity with or without anaemia (An Tx OR 2.24 95% CI 1.68-2.99 P 0.001 An-Tx OR 3.53 95% CI 2.71-4.52 P 0.001). The issues associated with RCT s and registry studies are well reported. Perhaps the answer may lie in the methodology proposed by Lauer and D Agostino14 who noted the intellectual trap between randomized trials that lack external validity (generalizability) and observational studies that lack internal validity owing to unmeasured confounders . They proposed registry-based randomized trials to achieve both internal and external validity. Perfusion with robust clinical registries such as the PERForm and the PDUC Registries may be well positioned to undertake these important studies. REFERENCES 1. Bennett-Guerrero E Zhao Y O Brien SM et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010 304 1568-1575). 2. Ferraris VA et al. 2011 update to the society of thoracic surgeons and the society of cardiovascular anesthesiologists blood conservation clinical practice guidelines. Annals of Thoracic Surgery 2011 91(3) 944-982. 3. Koch CG et al Transfusion in Coronary Artery Bypass Grafting is Associated with Reduced Long-Term Survival. Ann Thorac Surg 2006 81 1650-7. 4. Kulier A Levin J Moser R Rumpold-Seitlinger G Tudor IC Snyder-Ramos SA et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation. 2007 116 471-9. 5. Carson JL Carless PA Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2012 4 CD002042. 6. Curley GF Shehata N Mazer CD Hare GM Friedrich JO. Transfusion triggers for guiding RBC transfusion for cardiovascular surgery a systematic review and meta-analysis . Crit Care Med. 2014 Dec 42(12) 2611-24. doi 10.1097 CCM.0000000000000548. 7. Murphy GJ et al. Liberal or restrictive transfusion after cardiac surgery. NEJM 2015 372(11) 997-1008. 8. Correspondence Liberal or restrictive transfusions after cardiac surgery. NEJM 2015 373(2) 190-193 9. Carson JL et al. Liberal versus restrictive blood transfusion strategy 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet. 2015 Mar 28 385(9974) 1183-9. doi 10.1016 S0140-6736(14)62286-8. Epub 2014 Dec 9. 10. Murphy GJ Reeves B Rogers CA Rizvi SI Culliford L Angelini GD Increased mortality post-operative morbidity and cost following red blood cell transfusion in patients having cardiac surgery. Circulation 2007 116 2544 2552. 11. Engoren M The independent effects of anemia and transfusiuon on mortality after coronary artery bypass. Ann Thorac Surg 2014 97 514-21. 12. Karkouti K et al Risk associated with preoperative anemia in CAriac Surgery a multi center cohort study. Circulation 2008 117 478-484 13. Ranucci M et al. Major bleeding transfusions and anemia The deadly triad of Cardaic suregy. Ann Thorac Surg 2013 96 478-85. 14. Michael S. Lauer M.D. and Ralph B. D Agostino Sr. Ph.D. The Randomized Registry Trial -- The Next Disruptive Technology in Clinical Research n engl j med 369 171579-81 JUNE 2016 www.anzcp.org 37 FIFTY YEARS OF HIGH POTASSIUM CARDIOPLEGIA IS IT TIME FOR CHANGE Geoffrey P.Dobson PhD FAHA Professor Personal Chair Heart Trauma & Sepsis Research Laboratory Australian Institute of Tropical Health and Medicine College of Medicine and Dentistry James Cook University Cardiothoracic surgeons anesthetists and perfusionists are confronted with unprecedented challenges in myocardial protection from an aging population and more complex pediatric surgeries. Notwithstanding the multi-factorial etiology of myocardial injury one area identified as a potential contributor leading to sub-optimal protection is high potassium (K ) in surgical cardioplegia. As extracellular K is raised above 10 mM the voltage-dependent Na fast channel availability and Na conductances are dramatically reduced and the heart arrests in diastole at depolarized potentials. Prolonged K depolarization can lead to 1) intracellular Na and Ca2 loading and mitochondrial dysfunction 2) coronary vasoconstriction and spasm 3) endothelial activation 4) arrhythmias and conduction disturbances and 5) low cardiac output and ventricular stunning. While moderate hypothermia may partially offset some of these negative effects the most vulnerable period for the depolarized heart may not be during surgical ischemia but during rewarming reperfusion and arousal. We will discuss these potential limitations and possible alternatives. 38 JUNE 2016 www.anzcp.org THE SO-COOL STUDY Tim Willcox THE AVOIDANCE OF HYPEROXAEMIA DURING CARDIOPULMONARY BYPASS A DUAL-CENTRE PHASE IIB RANDOMISED CONTROLLED TRIAL PRELIMINARY RESULTS PRESENTED AT PDU 2015 ADELAIDE Auckland City Hospital Auckland New Zealand Shay McGuinness Rachael Parke Cornelius Kruger Tim Willcox Megan Baker Keri-Anne Cowdrey Eileen Gilder Lianne McCarthy. Calvary Wakefield Hospital Adelaide South Australia Kate Drummond Tom Painter. toxic molecules is in part dependent on arterial oxygen levels. There is also evidence suggesting that high levels of arterial oxygenation may exacerbate ischaemic-reperfusion injuries and this effect is attenuated by avoiding hyperoxaemia.[6 7] Hyperoxaemia has also been shown to have significant adverse haemodynamic effects after coronary artery bypass surgery.[8] As mentioned above current standard practice is to use supranormal arterial blood oxygen tensions during CPB however the recent commercial availability of real-time continuous in-line blood gas analysis now provides the opportunity to safely use lower more physiological arterial oxygen tensions. AIM The aim of this study was to determine a negative impact of arterial hyperoxia during cardiac surgery with the hypothesis that avoidance of perioperative arterial hyperoxia decreases the degree of oxidative stress and thus reduces the severity of the multi-organ dysfunction that is common following cardiac surgery utilising cardiopulmonary bypass. Primary endpoint was the difference between groups (hyperoxaemia v normoxaemia) in CSA-AKI as demonstrated by KDIGO classification during hospital admission. Secondary Outcomes included changes in a range of serum biomarkers known to correlate with specific end organ damage including Troponin T AST and Amylase. BACKGROUND Cardiac surgery utilising cardiopulmonary bypass (CPB) is one of the most common forms of major surgery with more than 1 million patients undergoing this surgery worldwide each year including around 2500 in New Zealand. Despite recent improvements to both surgical techniques and the equipment used for CPB mortality and significant morbidity remains high. During CPB it is common practice to oxygenate the arterial return blood to supra-normal levels in part because monitoring of the blood oxygen levels and thus the function of the oxygenator is only done intermittently using blood gas sampling. Cardiac surgery associated multi-organ dysfunction (CSAMOD) is well recognised and includes cardiac surgery associated Acute Kidney Injury (CSA-AKI) [1] acute hepatic impairment myocardial damage and post-operative neurological deficit. The pathophysiology of CSA-MOD involves numerous injurious pathways linked to the use of CPB[2]. Although there is considerable overlap between them the principle processes include the exposure of circulating blood to the non-biocompatible surfaces of the HLM and red-cell damage and haemolysis caused by mechanical stress from the blood circulating pumps and suction equipment. The subsequent activation of inflammatory pathways ischaemia-reperfusion injury decreased end-organ perfusion and haemolysis are contributors to CSA-MOD.[1] These complications result in significant morbidity and mortality as well as increased intensive care and hospital length of stay and a consequential increase in healthcare costs.[3] Although the deleterious effects of CPB affect all body systems they are most marked on the kidney with renal damage occurring in up to 30% of patients[1]. Oxidative stress the creation of oxygen free radicals and haem or iron containing reactive oxygen species is recognised as an important factor in the development of CSA-AKI.[4 5]. The production of these STUDY DESIGN AND METHODOLOGY This study conducted in two hospitals (Auckland City Hospital Auckland New Zealand and Calvary Wakefield Hospital Adelaide South Australia) was parallel group Phase IIb RCT of the use of an arterial oxygenation strategy that avoids hyperoxaemia vs. standard care to reduce CSA-MOD in patients undergoing cardiac surgery using cardiopulmonary bypass. Following approval from the Northern X regional ethics committee patients scheduled for elective cardiac surgery at the study centre and who met the inclusion criteria (adult patient (16 yrs) scheduled to have cardiac surgery using cardiopulmonary bypass) were approached for consent and enrolled in the study pre-operatively. Exclusion criteria included pre-operative acute renal failure within 6 weeks (acute rise in serum creatinine 50% from baseline) or Preoperative end stage renal disease (serum creatinine 300 mol L) present or receiving any form of renal replacement therapy or pre-operative hepatic dysfunction (AST 2 upper limit of normal) or Recent ( 6 weeks) cerebrovascular event (Including CVA TIA or intracerebral bleed) or pregnant planned hypothermic circulatory arrest pre-operative IABP. JUNE 2016 www.anzcp.org 39 STUDY DESIGN Patients were randomised 1 1 to the intervention or standard care. Subjects were stratified into high risk of AKI and low risk of AKI using well recognised criteria[9] (We know from previous studies that approximately 45% of patients in our unit will be in the high risk group). The intervention groups were protocoled to receive control of arterial oxygenation from induction of anaesthesia until the end of surgery to maintain arterial oxygen tensions of 10 - 12 kPa. It was recognised that not all anaesthetists would be happy with this approach and may wish to administer 100% FiO2 (as opposed to the recommended target SpO2 of 92 - 95%) during part or all of the pre and post CPB period. During CPB the oxygen tension of the arterial return blood flow target was 10 - 12 kPa using continuous in-line real-time blood gas monitoring (Terumo CDI 500 Terumo Corporation and Spectrum M4 Spectrum Medical Gloucester UK) providing arterial saturation was 97% (If it is less than 97% then the PaO2 to be increased beyond 12 kPa). Control group were to receive standard care including selection of appropriate supplemental oxygen by the treating anaesthetist and clinical perfusionist. A total of 286 patients were required to enter this twotreatment parallel-design study such that the probability was 80 percent that the study would detect a treatment difference at a two-sided 0.05 significance level if the true difference between treatments is 0.333 times the standard deviation. The same power existed for the secondary biomarker endpoints. In our experience loss to follow up is extremely low for this sort of study however 298 patients were enrolled to account for this. The randomisation sequence was generated by an independent statistician using computer-generated random numbers and participants were randomised to treatment just prior to surgery. Troponin T AST and Amylase and C Reactive protein and serum selenium were measured at baseline (immediately prior to induction of anaesthesia) immediately prior to commencement of bypass 6 hrs and 24 hrs post commencement of bypass. Other secondary outcomes measured were length of ICU and hospital stay duration of mechanical ventilation development of AKI as defi ned by RIFLE and acute kidney injury network (AKIN) criteria RESULTS Between December 2012 and May 2014 298 patients were randomized to either the avoidance of hyperoxaemia or standard care at two hospitals in New Zealand and Australia. All patients were followed to day 90. There were no significant differences in baseline characteristics and excellent treatment separation was achieved between the two groupsno significant differences in baseline characteristics and excellent tr There were (Table 1). (Table 1). CONTROL Age (years) 65.25 74 INTERVENTION 65.8 72 There were no significant differences n 148 characteristics and excellent treatment sepa in baseline n 150 (Table 1). There were no significant differences in baseline characteristics and excellent treatment separation was achieved n 148 n 150 (Table 1). Isolated CABG (%) 43 48 Sex (% Male) CONTROL 65.25 INTERVENTION 65.8 72 48 109 Age (years) Sex (% Male) CPB time (mins mean) 74 Isolated CABG (%) Age (years) Isolated CABG (%) n 148 CONTROL 106 INTERVENTION n 150 65.8 72 48 109 65.25 43 Table time (mins mean) 74 106 1Male) Demographics CPB Sex 1 Table(% Demographics 43 There was excellent treatment separation during CPB however there was signifi Table time (mins mean) CPB 1 was excellent 106 109 There Demographics treatment separation during CPB however post CPB period. (Fig 1) therewas excellent treatment separation during CPB however there was significant hyperoxa was signifi There Demographics cant hyperoxaemia in the intervention group Table 1 post CPB period. (Fig 1) in the pre and post CPB period. (Fig 1) There was excellent treatment separation during CPB however there was significant hyperoxaemia in the interven post CPB period. (Fig 1) Figure 1 Perioperative PaO2 for the standard care and intervention groups. Figure 1 Perioperative PaO2 for the standard care and intervention groups. STATISTICS DATA ANALYSIS Data from the trial was entered into an excel spreadsheet and then extracted into STATA for analysis. All data analyses were carried out on an intention-to-treat basis. Incidence rates and absolute differences (with corresponding NNTs) and 95% CIs were obtained for binary variables in the fi rst instance with subsequent multiple logistic regression adjusted for stratification factors. Time to event data was analysed using Cox regression modelling thereby taking into account known covariates and the varying times since randomisation. Continuous data was analysed using the appropriate parametric or non-parametric analysis after testing for normality. There was no difference the standardthe the control arm in thearm and of any AKI (72% vs Figure 1 Perioperative PaO2 for intervention armcare intervention groups. There was no difference between the between and and intervention development severe AKI (KDIGO 2 or 3 27% vs. development of the control arm in the30% p 0.56). (Table 2) any AKI (72% vs. 66% p 0.28) or more severe AKI (KDIGO 2 or 3 27% vs. 30% CSA-AKI CONTROL INTERVENTION p intervention groups. Figure 1 Perioperative PaO2 p 0.56).no difference betweenfor the standard care and control arm in the developmen n 150 There was (Table 2) n 148 the intervention arm and the severe AKI (KDIGO 2 or 3 27% vs. 30% p 0.56). (Table 2) 0.28 KDIGO - Any 72% 66% KDIGO Stage 1 36% 45% 0.12 CSA-AKI INTERVENTION p KDIGO Stage 2 29% CONTROL 24% There was no difference between the intervention 0.32 and the control arm in th arm n 148 n 150 0.26 KDIGO Stage 3 1% 27% vs. 30% p 0.56). (Table 2) 3% severe AKI (KDIGO 2 or 3 Table 2 CSA-AKI KDIGO - Any 72% 66% 0.28 KDIGO Stage 1 CSA-AKI KDIGO Stage 2 36% CONTROL 45% 29% n 148 24% 1% 72% 3% 0.12 INTERVENTION n 150 0.32 p 0.28 0.12 0.32 0.26 KDIGO - Any 35 KDIGO Stage 3 KDIGO Stage Table 2 CSA-AKI 1 Table 2 CSA-AKI 2 KDIGO Stage 66% 45% 24% 3% 0.26 36% 29% 1% 35 KDIGO Stage 3 Table 2 CSA-AKI 40 JUNE 2016 www.anzcp.org 32nd Annual 32nd Annual Scientific Meeting Scientific Meeting AustralianCollege of Zealand College of Perfusionists and New Perfusionists Australian and New Zealand There was also no difference in the multiple markers of other CONCLUSION organ damage measured (fig2) or in ICU and hospital length of stay. (Fig 3). This study did not demonstrate any benefits from avoiding hyperoxaemia during CPB however it did show that 32nd Annual Scientific Meeting length of stay. (Fig 3). There was also no difference in the multiple markers of other organ or in ICU measured (fig2) or in ICU and hospital damage and hospital length of stay. (Fig 3). also no difference in the multiple markers of other organ damage measuredand New Zealand College of Perfusionists Australian (fig2) maintaining normal physiological PaO2 was feasible. Further studies extending the intervention in to the pre and post CPB period are warranted. was also no difference in the multiple markers of other organ damage measured (fig2) or in ICU and hospital length of stay. (Fig 3). REFERENCES 1. Rosner M.H. and M.D. Okusa Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol 2006. 1(1) p. 19-32. 2. Laffey J.G. J.F. Boylan and D.C. Cheng The systemic inflammatory response to cardiac surgery implications for the anesthesiologist. Anesthesiology 2002. 97(1) p. 215-52. 3. Elahi M. et al. Acute kidney injury following cardiac surgery impact of early versus late haemofi ltration on morbidity and mortality. Eur J Cardiothorac Surg 2009. 35(5) p. 854-63. condary Biomarker 2 Secondary Biomarker Outcomes Figure Outcomes CONTROL Figure 2 Secondary Biomarker Outcomes INTERVENTION CONTROL 7.2 7.2 P 4. Carlucci F. et al. Cardiac surgery myocardial energy balance antioxidant status and endothelial function after ischemiareperfusion. Biomed Pharmacother 2002. 56(10) p. 483-91. P 0.35 0.75 0.65 h of stay (hours median) stay (hours median) INTERVENTION P 0.75 22.8 23.3 22.823.3 CONTROL ICU length of ength time (hrs(days median) of stay (days median) 9 8.95 8.95 lation of stay median) 7.2 7.2 0.35 0.65 Hospital length 9 23.3 22.8 0.75 2 Secondary median) n time (hrs Biomarker Outcomes (hrs median) Ventilation time 7.2 INTERVENTION 0.35 7.2 ength of stay (hours median) 5. Haase M. R. Bellomo and A. Haase-Fielitz Novel biomarkers oxidative stress and the role of labile iron toxicity in cardiopulmonary bypass-associated acute kidney injury. 2010. 55(19) p. 2024-33. 6. Caputo M. et al. The effects of normoxic versus hyperoxic cardiopulmonary bypass on oxidative stress and inflammatory response in cyanotic pediatric patients undergoing open cardiac surgery a randomized controlled trial. J Thorac Cardiovasc Surg 2009. 138(1) p. 206-14. 7. Kilgannon J.H. et al. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA 2010. 303(21) p. 2165-71. ABSTRACTS Table 3 Secondary 8.95 ital length of stay (days median) outcomes - LOS and ventilation time 9 0.65 ondary outcomes - LOS and ventilation time Table 3 Secondary outcomes - LOS There was no differenceand ventilation selenium between groups at in serum time no difference in serumLOS and ventilation time selenium between groups at any of the time points.(Fig 3) 3 Secondary outcomes - the time points.(Fig 3)between groups at any of the time points.(Fig 3) any of no difference in serum selenium There was was no difference in serum selenium between groups at any of the time points.(Fig 3) 8. Harten J.M. et al. Normobaric hyperoxia reduces cardiac index in patients after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2005. 19(2) p. 173-5. 9. Thakar C.V. et al. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol 2005. 16(1) p. 162-8. Figure 3.Serum selenium. 3.Serum selenium. 1 baseline 2 6hrs 24hrs1 baseline 2 6hrs 3 24hrs post start CPB um selenium. 1 baseline 2 6hrs 33 24hrs post start CPB post start CPB Figure 3.Serum selenium. 1 baseline 2 6hrs 3 24hrs post start CPB DISCUSSION We conducted a phase IIb study of the avoidance of hyperoxaemia in adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). In the 298 patients included we achieved excellent treatment separation but failed to demonstrate any significant difference in either the incidence of acute kidney injury or in any of the other secondary endpoints. A limitation of the study is that the intervention only occurred during CPB and thus there was significant hyperoxaemia both pre and post CPB. It is possible that these times represent at risk periods for hyperoxaemia mediated cellular damage. 36 36 36 ABSTRACTS ABSTRACTS JUNE 2016 www.anzcp.org 41 PLASMA LEAKAGE THROUGH A POLYMETHYLPENTENE OXYGENATOR K O Shaughnessy CCP J Dittmer CCP Martin Gill CCP Prior to the advent of Polymethylpentene (PMP) oxygenators plasma leakage was an unwelcome occurrence that complicated many ECMO runs. The introduction of PMP fibres into ECMO oxygenators is widely regarded to have eradicated plasma leakage from ECMO. We describe a paediatric ECMO case during which plasma leakage occurred and oxygenator function gradually deteriorated ultimately necessitating device replacement. To our knowledge this is the first case of plasma leakage described using a PMP device during paediatric ECMO. Subsequent detailed investigation is described demonstrating the relative porous nature of this fibre and how a protein coating reduces the free passage of solution across the PMP membrane. Discussion of possible patient specific contributing factors will also be given. Whilst PMP oxygenators offer resistance to plasma leakage they remain a microporous device. Whilst PMP fibres may improve the long term capabilities of such devices plasma leakage should not be disregarded as a possible clinical occurrence. A NOVEL APPROACH TO ECMO TRAINING FOR NURSES IN A HIGH FIDELITY SIMULATED ENVIRONMENT Andrew Lahanas Prince of Wales Hospital Sydney Children s Hospital Barker Street Randwick N.S.W. 2031 Australia. Extracorporeal membrane oxygenation (ECMO) is a modality of treatment offering cardiac and or respiratory support in critically ill patients1. Our institution has an active education program for ECMO nurses relying predominantly on didactic sessions with wet lab drills to ensure the skills are maintained at a high standard. The inauguration of a new high fidelity simulation centre has provided the opportunity to modify our ECMO training program within the more realistic setting. Although wet lab drills are frequently used to simulate catastrophic events the presence of props and personnel required to manipulate the circuit detracts from the fidelity of the simulation one of the key purposes of team based exercises and learning2. Our aim was to design a simulation program with an appropriately high level of clinical authenticity to enable the application of wetlab drills in a realistic patient setting. The simulation space was replicated to match the Children s Intensive Care Unit (CICU) environment. The ECMO circuit was connected to a reservoir bag placed inside the manikin also accessible via central peripheral intravenous access lines. Subsequently any volume shifts produced real fluctuations to circuit dynamics. A novel method for remotely inflating intraluminal balloons positioned inside the circuit tubing allowed us to simulate complete arterial or venous line obstruction from the control room via concealed tubing fed through a specifically designed sub-floor conduit in the simulation centre. In addition simulation of hypovolaemia and massive venous air entrainment was also possible from the control room. The ECMO console continuously displayed flow rates revolutions per minute venous inlet and arterial outlet pressures and pre-programmed alarms which the participants used for troubleshooting. A very high level of authenticity was achieved with the simulation co-ordinator working in tandem with the perfusionist to vary physiological parameters. CONCLUSION Techniques for remote control of the ECMO circuit have been described. Changes to circuit volume introduction of venous air and remote inflation of intraluminal balloons positioned inside the circuit tubing via a subfloor conduit allows manipulation of circuit physiology and the creation of various emergencies. We believe this system which has yet to be described in the literature offers a very high degree of realism in duplicating real life situations. REFERENCES 1. Freeman R Nault C Mowry J Baldridge P. Expanded resources through utilization of a primary care giver extracorporeal membrance oxygen model. Crit Care Nurs Q. 2012 Jan-March 35(1) 39-49. PubMed PMID 22157491. 2. Thompson JL Grisham LM Scott J Mogan C Prescher H Biffar D Jarred J Meyer RJ Hamilton AJ. Construction of a reusable high-fidelity model to enhance extracorporeal membrane oxygenation training through simulation. Adv Neonatal Care. 2014 April 14(2) 103-109. PubMed PMID 24675629. 42 JUNE 2016 www.anzcp.org ALM POLARSHOT CARDIOPLEGIA LESSONS FROM NATURAL HIBERNATORS Geoffrey Dobson Natural hibernators do not flood their hearts with high K during hibernation as is standard practice in cardiac surgery today. Could the human heart be pharmacologically manipulated to operate like the heart of a natural hibernator The overall objective was to arrest the heart at its natural or polarised resting membrane potential (-80 mV) by 1) inhibiting the voltage-dependent Na fast channels responsible for the phase O upstroke of the cardiac action potential (lidocaine) and 2) simultaneously decreasing the action potential duration by opening K ATP channels (adenosine). Magnesium was included to reduce Ca2 entry and protect the heart from ischemia-reperfusion injury and post-operative arrhythmias. Early proof-of-concept studies in the isolated working rat heart at James Cook University and the canine cardiopulmonary bypass model at Emory University showed superiority of ALM cardioplegia compared to high K solutions. More recently two prospective randomized human trials have been completed showing that whole blood ALM microplegia is superior to modified Buckberg solution in high risk and low risk patients. Superiority was based on significantly lower coronary sinus Troponin-1 and lactate levels at 10 min reperfusion improved cardiac performance improved left ventricular-arterial coupling reduced need for blood transfusions and one-day less in the ICU. Further multi-centered trials are required and future studies are planned to compliment the new polarising cardioplegia with a low volume ALM IV drip administered after anaesthesia but before the first incision to reduce the patient s stress response against the trauma of surgery. OPTIONS FOR CORRECTING SEVERE ACID-BASE AND ELECTROLYTE DISTURBANCES DURING CARDIOPULMONARY BYPASS Melissa Donnellan. Department of Perfusion and Autotransfusion Department of Anaesthesia and Pain Management Royal North Shore Hospital Sydney. Increasingly complex cardiac surgery performed while on cardiopulmonary bypass presents a number of challenges to the metabolic management of the patient. This discussion has been prompted by a small proportion of cases at our institution. These cases had in common long duration of bypass hypothermia and a degree of perioperative vasoplegia. We decided to reinvestigate possible options for correcting severe acid-base and electrolyte disturbances as flagged by extreme blood gas results routinely obtained during bypass. In general cardiopulmonary bypass associated physiological disturbances result from haemodilution hypoperfusion hyperkalemia and hypothermia. Some options for the tackling of these issues beyond alterations in main pump and gas flows may include pharmacological fluid and blood management and the addition of haemoconcentration ultrafiltration and dialysis. This discussion primarily focuses on the possibilities for filtration dialysis available intraoperatively during elective cases and during emergency out of hours situations. DUAL VOLATILE ANAESTHETIC AGENT USE IN CARDIAC SURGERY QUIRK OR CONCERN Mark Ambrose. Department of Perfusion and Auto Transfusion Department of Anaesthesia and Pain Management. Royal North Shore Hospital Sydney. While much research has been conducted in Cardiac Anaesthesia regarding the use of volatile anaesthetic agents with cardiopulmonary bypass there seems to be scant information about the use of simultaneous differing volatile anaesthetic agents. While perhaps an unintentional situation differing volatile anaesthetic agents can be placed on the anaesthetic and Cardiopulmonary Bypass machines simultaneously. This Perfusion Concept presentation will discuss the issue of different volatile anaesthetic agents being simultaneously used. Three time points in the intra-operative phase will be identified and pose the question is there any harm . JUNE 2016 www.anzcp.org 43 HYPOBARIC OXYGENATION A NOVEL APPROACH TO DECREASING GASEOUS MICROEMBOLI eN w Mark Ambrose. Department of Perfusion and Auto Transfusion Department of Anaesthesia and Pain Management. Royal North Shore Hospital Sydney. The existence of gaseous micro emboli (GME) leaving the arterial line of the heart lung machine has long been of concern to the perfusionist. Negative neurocognitive and neuropsychological changes associated with exposure to GME has influenced many perfusion management strategies (1). Efforts to reduce exposure of the patient to GME has also had a lasting clinical impact on circuit component evaluation and design (2). One novel technique for the reduction of patient exposure to GME is the use of Hypobaric Oxygenation . This involves ventilating the gaseous phase of the oxygenator with sub atmospheric pressures using 100% oxygen (3). This Perfusion Concept presentation will outline the principle of Hypobaric Oxygenation. It will attempt to explain the etiology of GME minimization as a result of this technique. Advantages and concerns in using this novel approach to GME reduction will be discussed. REFERENCES 1. Lynch J.E. Wells C. Akers etal. Monitoring Microemboli During Cardioplumonary Bypass with the EDAC Quantifier. JECT. 2010 42 212-218. 2. Riley J. B. Arterial Line Filters Ranked for Gaseous Micro-Emboli Separation Performance An In Vitro Study. JECT. 2008 40 21-26. 3. Keith E. Gipson MD PhD David J. Rosinski MS CCP Robert B. Schonberger. Elimination of Gaseous Microemboli From Cardiopulmonary Bypass lla-stfi-enO Using Hypobaric Oxygenation. Ann Thorac Surg. 2014 97 879-87. METSYS NOISUFSNARTOTUA ygolonhceT wolF suounitnoC rebmahc gnihsaw lla rof elbatius gnildnah eht sefiilpmis dna emit sevas .semulov doolb SEIZURES POST CARDIOPULMONARY BYPASS srosneS gniogtuo dna gnimocni rotinom ylsuounitnoc noitarapes llec der dna seulav tircotameh Monique Brouwer .tnemeganam tneitap retteb rof ecnamrofrep and William McMeniman Westmead Private Hospital Mons Road and Darcy Roads Westmead NSW 2145 Seizures following cardiopulmonary bypass are an immediate and alarming indication that a neurologic event has occurred. A case report is reviewed highlighting the possible causes of seizures following bypass in a 67 year old man undergoing aortic valve surgery. suproc fo tnemtsujda thgieh euqinU dradnats dna rennacs edoc rab htiw .ecafretni BSU CEREBRAL PROTECTION MANAGEMENT DURING DHCA tnemegREVIEWfE A anam atad tneicfi OF CURRENT METHODS Emerson Sgammotta Perfusion Services Melbourne .ecneinevnoc resu rof 44 The idea of Deep Hypothermic Circulatory Arrest (DHCA) regarding cerebral protection has been around since 1975. First performed by Greipp and colleagues DHCA aims to provide a decrease in the brains metabolic rate and oxygen requirement with the reduction of temperature allowing a bloodless field for the surgeon. Its use is commonly used for surgical correction of paediatric cardiac anomalies but routinely used for complex aortic surgery in adults. DHCA has its disadvantages such as coagulopathy extended bypass time elevated inflammatory response and end-organ dysfunction with neurologic injury being of the highest concern. Continuing development of cerebral monitoring and pharmacologic advancements have caused a great discussion in optimal cerebral protection during DHCA. This review aims to provide an update of practices and methods of the detimiL y P a art uA ibaK s in last decade concerning cerebral protection with focus on pharmacologic protection cannulation techniquestandilthesdiscussionuof eserF 37method of bmyP yawhgiHshould 469 02 WSN el which DHCA cfiicaP use of antegrade cerebral perfusion. The purpose of this review is to determine the most effective 100 237 0031 enohpeleT be carried out to achieve optimal cerebral protection. ua.moc.ibak-suineserf.www 760.5102MP JUNE 2016 www.anzcp.org New AUTOTRANSFUSION SYSTEM Continuous Flow Technology One-fits-all washing chamber saves time and simplifies the handling suitable for all blood volumes. Sensors continuously monitor incoming and outgoing hematocrit values and red cell separation performance for better patient management. Unique height adjustment of corpus for user convenience. Efficient data management with bar code scanner and standard USB interface. Fresenius Kabi Australia Pty Limited 964 Pacific Highway Pymble NSW 2073 Telephone 1300 732 001 www.fresenius-kabi.com.au PM2015.067 JUNE 2016 www.anzcp.org 45 DOES RETROGRADE AUTOLOGOUS PRIMING FLUID BALANCE Keith Adkins Saint Vincent s hospital Darlinghurst Sydney NSW 2010. The purpose of this study was to determine the effects of retrograde autologous (R AP) on fluid balance both during CPB and the total operating theatre fluid balance. This was a retrospective analysis comparing the fluid balance of R AP patients versus non R AP patients. There were 50 consecutive patients each group. The inclusion criteria were elective surgery 1st time sternotomies and single procedure only (i.e. single valve replacement or coronary artery bypass grafting only). All pre and post bypass fluids all CPB fluids and urine output were accounted for. Peri-operative blood loss was not accounted for. Pre bypass fluids were similar (595mls R AP 703 non R AP p 0.22) priming volume was also similar (2000 R AP 2028 non R AP p 0.22). A mean amount of 633mls was removed from the prime by retrograde autologous priming. On 78% of occasions some of the R AP volume was returned and on 64% of occasions all the R AP volume was returned. The mean fluid balance at the end of CPB was 2375 mls in the R AP group and 2903 mls in the non R AP group p 0.001. The total operating theatre fluid balance was 2416 mls in the R AP group and 3045 mls in the non R AP group p 0.004. The conclusion was that retrograde autologous priming does significantly reduce fluid balance both during CPB and the total operative fluid balance. 1. Eisling et al Retrograde Autologous Priming Is It Useful in Elective On-pump Coronary Artery Bypass Surgery Annals of thoracic surgery 2003 75 23-7 2. Balachandran et al Retrograde Autologous Priming of the Cardiopulmonary Bypass Circuit Reduces Blood Transfusion After Coronary Artery Surgery Annals of Thoracic Surgery 2002 73 1912-8. 3. Hirleman et al Cardiopulmonary bypass and edema physiology and pathophysiology Perfusion 2008 23 311-322. HYDRODYNAMIC EVALUATION OF AORTIC CARDIOPULMONARY BYPASS CANNULAE USING PARTICLE IMAGE VELOCIMETRY Charles I. McDonald1 El onore Bolle2 Hansi F. Lang 2 Camille Ribolzi 2 Bruce Thomson2 3 Geoffrey D. Tansley 4 John F. Fraser 2 5 and Shaun D. Gregory 2 5 1 Department of Anaesthesia and Perfusion The Prince Charles Hospital Brisbane Qld Australia 2 The Innovative Cardiovascular Engineering and Technology Laboratory Critical Care Research Group The Prince Charles Hospital Chermside Australia 3 Department of Cardiothoracic Surgery The Prince Charles Hospital Brisbane Qld Australia 4 School of Engineering Griffith University Gold Coast Qld Australia 5 School of Medicine University of Queensland Brisbane Qld Australia PURPOSE Rotary blood pumps are often used during cardiopulmonary bypass (CPB) where the arterial cannula is inserted into the distal ascending aorta. Arterial cannula design and placement in an atherosclerotic aorta can contribute to neurologic deficits post-cardiac surgery with stroke and other cognitive deficits occurring in up to 30% of patients after surgery. Therefore the aim of this study was to analyse the exit jet profile and velocity in various dispersion and non-dispersion cannulae to provide a clinical recommendation to reduce neurological deficits. of the exit jet was assessed at 20 and 40 mm from the cannula tip at both flow rates with each cannula. RESULTS Dispersion and non-dispersion cannulae were characterized by a fan shape and narrow velocity profile respectively. With the exception of one cannula all dispersion cannulae had lower maximum velocities than non-dispersion cannulae. From the 19 cannulae the respective highest and lowest velocities at 20 mm from the tip were 3.06 (non-dispersion) and 0.63 m s (dispersion) at 5 L min and 1.55 (non-dispersion) and 0.25 (dispersion) at 3 L min. METHOD Particle image velocimetry was used to assess 19 (7 dispersion and 12 non-dispersion) adult arterial CPB cannulae in a clear perspex chamber using a Levitronix CentriMag. Pump speed was set to achieve flow rates of 3.0 and 5.0 L min with each cannula. The fluid (water glycerol at 60 40% by mass) was seeded with tracer particles which were tracked using 20 image pairs under continuous flow conditions. The maximum velocity CONCLUSION Due to lower exit velocities and subsequent jet forces on the aortic wall dispersion cannulae may cause less damage to endothelial tissue and should be used for atherosclerotic aortas. This study may assist the surgeon in choosing the best cannula for patient and operation type based on the hydrodynamic performance of the cannula. 46 JUNE 2016 www.anzcp.org AIR TRANSMISSION COMPARISON OF TWO ADULT ARTERIAL FILTERS AF-100 VS. CB351 AN IN-VITRO STUDY Kieron C Potger Darryl Mcmillan Mark Ambrose. Cardiopulmonary Perfusion & Autotransfusion Unit Royal North Shore Hospital Sydney INTRODUCTION Arterial filters are commonly incorporated within the extracorporeal circuit to minimise cerebral injury by capturing particulate matter and microbubbles. We clinically use the Affinity CB351 arterial filter. The new Affinity AF100 (BB851) arterial filter has a smaller prime volume (100 mL vs. 212 mL) and smaller screen pore size (30 m vs. 38 m). Our aim was to determine if the AF-100 was as safe as the CB351 in terms of relative microbubble transmission of introduced air. A COMPARISON OF 4 INTEGRATED ARTERIAL FILTER OXYGENATORS ABILITY TO HANDLE GME Ferguson James CCP Chief Perfusionist at Phoenix Perfusion Services Phoenix Arizona OVERVIEW This presentation begins with a detailed review of the origins of GME and its effects on patients. Best practices to attenuate GME in the conventional extracorporeal circuit are discussed. Literature about integrated arterial filters prior to 2013 are referenced. The presentation concludes with Mr. Ferguson s study evaluating 4 oxygenators with integrated arterial filters and their ability to handle GME. The four commercially available oxygenators that were studied were Affinity Fusion from Medtronic Synthesis from Sorin Capiox FX15 from Terumo and Quadrox-I from Maquet. Testing was conducted in vitro with bovine blood and GME was measured with an EDAC bubble detector. Data was collected for total embolic load total volume total emboli 40 microns total emboli 40 and clearance time. The different oxygenators were listed as manufacturer 1...to manufacturer 4 (Affinity Fusion). The results demonstrated that Affinity Fusion has the least amount of total embolic load total volume and total emobli 40 microns however was second to Quadrox in the amount of time it took to clear the air from the system. METHODS A recirculating in-vitro circuit primed with warmed blood was used to compare both arterial filters. Microbubbles were detected using a GAMPT BC100 Doppler in the arterial filter inflow and outflow line. While at 3 L min and 5 L min pump flow rates measurements were taken one minute prior and for three minutes after bolusing 30 mL air proximal to the venous reservoir. KEY TAKEAWAYS Affinity Fusion was ranked number one by the investigators for overall GME handling capabilities compared to the other 3 competitor devices. RESULTS Both arterial filters transmitted microbubbles during air injection. Both arterial filters proportion of bubble volume transmitted increase with higher flows. Both arterial filters transmit a similar number of bubbles. However the AF-100 transmits smaller sized bubbles and consequently less total bubble volume. CONCLUSION The results of this in-vitro study show that the transmission of introduced air by the AF-100 arterial filter is not more than the CB351 arterial filter over a range of flow rates suggesting that it is as safe in terms of air handling. JUNE 2016 www.anzcp.org 47 WHEN THERE S NO ROOM FOR DOUBT A comprehensive menu of tests in a single portable platform Lactate Haematology Chemistries and Electrolytes POINT OF CARE Endocrinology The i-STAT System range of diagnostic tests Blood Gases Coagulation Cardiac Markers i-STAT System PORTABLE BLOOD ANALYSER BE THERE. BE CONFIDENT. CHOOSE TRANSFORMATIONTM 48 FOR JUNEIN VITRO DIAGNOSTIC USE ONLY. ALL PRODUCTS NOT AVAILABLE IN ALL REGIONS 2015 Abbott. All rights reserved. 2016 www.anzcp.org LEADERSHIP DEVELOPMENT NEGOTIATING IN AND OUT OF THE OR Kieron C Potger Darryl Mcmillan Mark Ambrose. Cardiopulmonary Perfusion & Autotransfusion Unit Royal North Shore Hospital Sydney SESSION OBJECTIVES To discuss leadership strategies with a focus on effective negotiating techniques to efficiently achieve goals and objectives. The delegates will be introduced to scenarios illustrating successful project management including the elements of planning execution monitoring and closing. Why should I care What are you talking about How do I negotiate Simulated negotiation scenarios Jane Ottens CCP Giovanni Cecere CCP Kenneth G. Shann CCP The Next Annual Scientific Meeting will be held in Townsville in October 2016 JUNE 2016 www.anzcp.org 49 CALENDAR of EVENTS JUNE 2016 22-25 The New Orleans Conference Practices in Cardiac Surgery & Extracorporeal Technologies Ritz Carlton New Orleans LA http www.theneworleansconference.com AUGUST 2016 17-20 Perfusion Downunder The Heritage Queenstown Queenstown New Zealand SEPTEMBER 2016 16-18 27th Annual ELSO Conference in conjunction with AmSECT s Pediatric and Congenital Perfusion Committee Manchester Grand Hyatt San Diego CA 21-24 Quality and Outcomes Sheraton New Orleans Hotel New Orleans LA OCTOBER 2016 1-5 30th EACTS (European Association for Cardio-Thoracic Surgery) Annual Meeting Centre Convencions Internacional de Barcelona Barcelona Spain http www.eacts.org annual-meeting 21-22 Belgian Society for ExtraCorporeal Technology 15th International Symposium on Perfusion Royal Library Meeting Center http www.belsect.be symp2016 21-23 Canadian Society of Clinical Perfusion Annual General Meeting Sofitel Montreal Golden Mile Montreal Qeubec https www.cscp.ca Professionals Events Annual-General-Meeting OCTOBER 2016 27-29 33rd ANZCP Annual Scientific Meeting Rydges Southbank Convention Center Townsville Australia NOVEMBER 2016 24-25 Scandinavian Paediatric Perfusion Meeting Grand Hotel Lund Sweden http www.rhppc.dk Nov 30 - Dec 2 2nd Annual Latin American ELSO Conference Cancun International Convention Center Cancun Mexico DECEMBER 2016 8-11 12th Annual International Meeting Pediatric Cardiac Intensive Care Society Loews Miami Beach Miami FL http www.pcics.org meetings upcoming APRIL 2017 April 29-May 3 AmSECT 55th International Conference in Collaboration with AATS (American Association for Thoracic Surgery) Boston MA MAY 2017 5-6 ANZCP IMoB meeting (Intraoperative management of Blood) Amora Hotel Sydney NSW 50 JUNE 2016 www.anzcp.org 12 TH PERFUSION DOWNUNDER WINTER MEETING 18-20th August 2016 Heritage Hotel Queenstown New Zealand www.perfusiondownunder.com Perfusion Downunder is an exciting annual meeting designed to promote original prospective research into the effects of perfusion management on patient outcomes. KEYNOTES Joyce Wahr Professor of Anaesthsia University of Minnesota Minneapolis USA FACULTY Rinaldo Bellomo Melbourne AUS Steven Horton Melbourne AUS Alan Merry Auckland NZ Paul Myles Melbourne AUS Sara-Jane Allen Auckland NZ David Sidebotham Auckland NZ Rob Baker Adelaide AUS Richard Newland Adelaide AUS Michael McDonald Melbourne AUS Tim Willcox Auckland NZ THEMES Teamwork and good practice Fine tuning the Metabolism of the cardiac patient The changing face of Paediatric CPB Managing the unintended Error and a lot more Masterclass for Clinicians Statistics and Publishing Tim Jones Paediatric Surgeon Birmingham Children s Hospital Birmingham UK REGISTRATION To find out more details regarding the Conference including attendance fees accommodation options booking contacts and registration please visit www.perfusiondownunder.com or contact Bernardette Tackney on Ph 64 21 319 014 Email btackney perfusiondownunder.com Proudly Sponsored By SPONSORED BY JUNE 2016 www.anzcp.org 51 INSPIRE TM Optimized perfusion Because no two of your patients are the same. INSPIRETM is part of the integrated HeartLinkTM System and offers a low (DOV) Dynamic Operating Volume to reduce hemodilution and (AKI) Acute Kidney Injury occurrence. Single or Dual Chamber Reservoir Low Dynamic Operating Volume (DOV) PH.I.S.I.O. PC coating Integrated arterial filter Effective Gaseous Micro Emboli (GME) control Superior handling of gaseous micro emboli (GME) lowers the risk of cognitive dysfunctions. www.livanova.com 52 JUNE 2016 www.anzcp.org