Presentation on theme: "2011 International Pediatric Perfusion Survey"— Presentation transcript:
1 2011 International Pediatric Perfusion Survey Kenneth G. Shann, CCP; David Fitzgerald, CCP; Brian Harvey, CP; Brian Mejak, CCP; Donald S. Likosky, PhD; Luc Puis, ECCP; Robert A. Baker, PhD, CCP(Aust); Robert C. Groom, CCPBrian Mejak, CCPColorado Children’s HospitalAurora, ColoradoPerfusion Safety & Best Practices in PerfusionOctober 5-8, 2011Grand Hyatt San AntonioSan Antonio, Texas
2 Goals of the international pediatric perfusion survey Measure variation in program demographics, equipment and techniques.2. Enable clinicians to compare their own program to that of centers in and outside of North America.4. Identify areas of research necessary to validate trends in pediatric perfusion.** Previous pediatric perfusion surveys of North America by Groom et al. every 5 years
3 Presentation contents Methods.2. Results.Research related to results.Many questions are relative to adult practice.International –all countries.Center caseload (<100, , , >250)Compare the U.S./Canada results to new countries to the survey.
4 ICEBP Pediatric Perfusion Survey Work Group Robert Groom, CCP Maine Medical Center, Portland, MaineKenneth Shann, CCP Montefiore Medical Center, Bronx, New YorkDavid Fitzgerald, CCP INOVA Health System, Fairfax, VirginiaBrian Harvey, CP Montefiore Medical Center, Bronx, New YorkBrian Mejak, CCP Children’s Hospital Colorado, Denver, ColoradoDonald Likosky, PhD Dartmouth College, Lebanon, New HampshireRobert Baker, PhD, CCP Flinders University, Adelaide, AustraliaLuc Puis, ECCP UZ Brussels, ASZ Aalst, Brussels-Aalst, Belgium
5 Survey Methods Seventeen regional perfusionists were contacted. 1. Leaders for geographic areas.2. addresses.3. Language barriers.4. Pilot surveys.C Thuys H Itoh V IiyinM Helena H Darban E VandenandeA Ritu N Cross D LongroisF Merkel M Davis L LindholmC Gruenwald R Munoz C BrabantT Frey B MejakContact information for 299 active programs representing 34 countries.
6 Survey Methods I. 107 questions - 21 Demographics - 42 Techniques - 21 Circuit Design- 23 PharmacologyII. Survey Monkey web based program1. English2. Spanish3. French4. Portuguese5. JapaneseIII. Five waves of s (December 2010-May 2011).
7 Demographics. Countries represented. Europe Belgium Denmark-1Germany Italy-6Netherlands-3 Portugal-1Sweden-2United Kingdom-3AsiaJapan-7Oman-1Saudi Arabia-2Lebanon-1North AmericaCanada-4El Salvador-1Mexico-3United States-89South AmericaArgentina-1Brazil-3Columbia-4Ecuador-1Paraguay-1Peru-1Australia and OceaniaAustralia-4New Zealand-1154 Surveys received (52% response rate)24 countries (71% of countries surveyed)
8 Demographics. Caseload Total (patients < 18 years old).
9 Demographics. Centers based on caseload size. Number of centersn=147
11 Demographics. How many perfusionist per pediatric case Demographics. How many perfusionist per pediatric case? Center size experience.n=20n=8n=12n=35
12 Centers grouped by caseload Gas supply oxygen analyzer Circuit design. Safety devices.Centers grouped by caseloadn=147One way valve in vent lineGas supply oxygen analyzerLevel detectorBubble detector
13 Techniques. Modified ultrafiltration usage by center size. Center size by yearly caseload
14 Demographics. Electronic perfusion charting. Arguments for using EMR.U.S. federal mandates by 2014 (fines could be levied).Assist in reconstruction of cases (poor outcome or lawsuits).Quality improvement program1.Reduce variability amongst perfusionists1.1 Stammers et al. Perfusion quality improvement and the reduction of clinical variability. JECT ;41:P48-P58.n= 154
15 Circuit Design. Arterial line filter usage. Clinical non-randomized retrospective gas emboli study comparing FX15 (integrated ALF) vs. RX15 and separate ALF using the EDAC (emboli detection and classification) Quantifier.Gas Emboli RemovedNumber Removed Volume Removed SignificanceRX15 circuit % % NSFX15 (integrated) % % NSPrime Reduction when using FX15 (integrated ALF)1/4 x 3/8 circuit Less 56 mL3/8 x 3/8 circuit Less 183 mLPreston et al. Clinical gaseous microemboli assessment of an oxygenator with integral arterial line filter in the pediatric population. JECT ;41:
16 Circuit Design. Arterial Line Filter. 92.9%93.5%93.5%n=144Neonates Infants Pediatrics
17 Circuit design. Retrograde autologous priming. Prospective randomized trial in which patients were randomized to CPB with or without retrograde autologous priming (n=60).Lowest Hct Intraop transfusion Transfusion entire stayNo RAP 20% + 3% 23% (7 patients) % (16 patients)RAP 22% + 3% 3% (1 patient) % (8 patients)Significance p = p = p = 0.03Rosengart et al. Retrograde autologous priming for cardiopulmonary bypass: A safe and effective means of decreasing hemodilution and transfusion requirements. J Thorac Cardiovasc Surg. 1998;115:
18 Techniques. Retrograde autologous priming. Why is usage so low?What percentage of cases do you RAP?Circuits need to be redesigned.Unfamiliar technique.
19 Techniques. Vacuum assisted venous drainage. Benefits of VAVD:Allows use of smaller diameter venous lines and venous cannula1Allows oxygenator/reservoir to be moved closer to operative field1.VAVD drainage at -40 mmHg did not significantly increase gaseous microemboli activity when compared with gravity siphon venous drainage at 4 LPM.21 Darling et al. Experimental use of an ultra-low prime neonatal cardiopulmonary bypass circuit utilizing vacuum -assisted venous drainage. JECT. 1998;30(4):184-9.2 Jones et al. Does vacuum-assisted drainage increase gaseous microemboli during cardiopulmonary bypass? Ann Thorac Surg. 2002; 74(6):n=154
20 Techniques. Hematocrit management. Randomized 21.5% vs. 27.8% hematocrit levels for low flow/DHCA.Low hematocrit group (21.5%).Higher serum lactate after 60 minutes of CPB.Decreased cardiac index.Greater % of increase in total body water on 1st post operative day.Worse scores on Psychomotor Development Index at one year of age (2 SD below average).Jonas et al. The influence of hemodilution on outcome after hypothermic cardiopulmonary bypass: Results of a randomized trial in infants. J Thor Cardiovasc Surg. 2003;126:
21 Techniques. Hematocrit management. Randomized trial 24.8% vs. 32.6% hypothermic low flow CPB.Lower hematocrit group (24.8%)More positive intraoperative fluid balance.dTGA (24.8%) had a significantly longer hospital stay.Lower cerebral oxygen saturation at 10 minutes of cooling and onset of low flow.At one year, the treatment groups had similar scores on the Psychomotor and Mental Development Indexes.Newburger et al. Randomized trial of hematocrit 25% vs. 35% during hypothermic cardiopulmonary bypass in infant heart surgery. J Thor Cardiovasc Surg. 2008;135:
22 Techniques. Minimal acceptable hematocrit. During CPB.n=154Termination.Range 24-48% Range 14-40%Range 17-34% Range 16-34%
24 Circuit Design. Oxygenator/reservoir type. U.S. and CanadaOthersn= 86*** No bubblers in use by respondents.n=62
25 Techniques. Do you wash packed blood cells before adding them to the prime?
26 Pharmacology.AntifibrinolyticsAntithrombin on bypass?
27 Techniques. Modified ultrafiltration usage –North American data only.
28 Techniques. Modified ultrafiltration revisited. Benefits of MUF are well documented.Improved left ventricular functionRise in blood pressure, rise in hematocritDecrease in percent rise in total body waterNaik, Knight, Elliott. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation. 1991;84(5 suppl):III
29 What has changed since 1991????1. Minimal acceptable Hematocrit in 1994 for DHCA……………..19.1%.Minimal acceptable Hematocrit in 2011for DHCA/low flow……24.9%.Average prime volume circa 1994??? around 750 mL.Average prime volume 2011 (our survey)……325.3 mL (range mL)Retrograde autologous priming-40%.Vacuum assisted venous drainage-61%.Integrated arterial line filters-22.9%.Use of MUF benefits needs to be revisited due a lot of techniques/technology introduced since 1991 to reduce prime volume, increase hematocrit levels, and decrease the inflammatory response.
30 Techniques. Cardioplegia. CustodialK+Del Nido 1:4Combination of 2
31 Techniques. Are there regional differences in cardioplegia?
32 Additional research needed? Can it be used with adults? Techniques. Why the change to 1:4 Del Nido cardioplegia?Formula: Amount ConcentrationPlasmalyte A Injection pH ,000 mLMannitol mL 20%Magnesium Sulfate mL 50%Sodium Bicarbonate mL 1 mEq/mLLidocaine mL 1%Potassium Chloride mL 2 mEq/mLBenefits of Del Nido solutionPediatric/neonatal hearts, especially those exposed to hypoxia, are more sensitive to Ca2+ induced injury during ischemia and reperfusion than adult hearts.The Lidocaine acts as a Na+ channel blocker.MgSO4 acts as a Ca++ antagonist.1 Both assist in reducing action potential development and reduce excitability.1 O’Brien et al. Pediatric Cardioplegia Strategy Results in Enhanced Calcium Metabolism and Lower Serum Troponin T. Ann Thorac Surg 2009;87:1517–24 .1 to 3 hours without redosing-varies amongst centers.Less blood to prime.Additional research needed? Can it be used with adults?
33 Challenges Length of survey and complexity of questions. Language barrier.Assurance of confidentiality across borders (International and interstate).China, India, and Africa
34 Future surveys to include more countries. MUF and cardioplegia. Conclusions.Compare your practice and me at for reference information.Future surveys to include more countries.MUF and cardioplegia.4. ICEBP working hard to include many of these variables in the STS database to compare against outcomes.
35 Thank you !!!!Perfusion Safety & Best Practices in Perfusion Conference Planning CommitteeICEBP Pediatric Perfusion SubcommitteeKenny ShannBob GroomDave FitzgeraldBrian HarveyDonny LikoskyLuc PuisRob BakerSpecial thanks to all the perfusionists for completing the survey.