1. PRICE SULTAN CARDIAC CENTER TECHNIQUE FOR MODIFIED ULTRAFILTERATION ABDULHADI AL JALI CHIEF PERFUSIONIST PRINCE SULTAN CARDIAC CENTER

2. Introduction n Prince Sultan Cardiac Center Modified Ultra filtration Technique is not very much different from the Modified Ultrafilteration already known to all of you or to most of you except in the technique.

3. n Hemofiltration started back to the early 1900’s as a means of removing fluid edematous patients when they are with renal failure. In 1970’s hemofilteration started to be implemented during open heart surgery

4. n In 1980’s hemofilteration started to be used routinely for all patients undergoing open heart surgery as a means of volume control in those that had been over hydrated

5. n Today, hemofilteration, or hemoconcentration, has found widespread application as a means of volume control and blood preservation in cardiac surgery on adults as well as children's.

6. n Special variations of hemofilteration are used with children undergoing open heart surgery however. Some of these are called ultrafilteration, modified ultrafilteration (MUF) and Zero balance ultrafilteration (ZBUF).

7. Prince Sultan Cardiac Center Technique for modified ultra filtration (PSCCMUF n It is not very much different as I said before from what is known to all of you or most of you except in the technique. The following diagram shows this technique

10. Prince Sultan Cardiac Center Cardioplegia/Modified Ultra filtration Circuit Modified Ultra filtration Configuration

11. Procedure for this technique 1. No additional capital equipment necessary. 2. Disposable consists of custom hemoconcentrator pack and a hemoconcentrator. 3. MUF tubing and hemoconcentrator should be primed before use 4. Just prior to termination of bypass MUF circuit should be prime with blood from the oxygenator ang recerculated into the venous reservoir negative pressure not greater than (-150mmgh)shpuld be applied to the filtrate outlet.

12. 5. Once the patient is off by-pass the surgeon will connect the cardioplegia line to the venous connector. 6. While the patient is still hepranized the perfusionist will begin ultra filtrating the patient using the cardioplegia pump on. NOTE: The perfusionist should watch the pressure within the circuit. Negative pressure may cause cavitations at the aortic cannula

13. 7. A target flow for the MUF pump is 15-30ml/kg/min. 8. Once the MUF pump is running, the arterial pump should be turned on. This way you will be able to concentrate the residual pump volume and prevent patient from becoming hypovolemic. NOTE: In order to remove volume from the patient, MUF pump flow should be more than the arterial pump flow.

14. 9. By adjusting the relative flow rates between the two pumps, per fusionist will maintain appropriate systemic pressure and filling pressure. 10. This procedure will continue until all residual pump volume has been displaced with crystalloid, or the surgeon specifies the time.(10- 15min)

15. 11. Upon completion of MUF, the canola is removed and protamine is given. 12. Oxygenator heat exchanger should remain on throughout the procedure to maintain the temperature. 14. By-pass can be initiated at any time. The perfusionist needs only to turn off the MUF pump and open the venous line. (Pump should remain primed at all times.)

16. 15. To correct hypotension caused by hypovolimia, slowdown the MUF pump or stop completely. To correct hypertension caused by hypervolemia, slowdown the arterial pump or stop completely.

17. Advantage of this technique n Total control of the shunted flow n Total control of the TMP. n No extra pump needed. Cardioplegia pump will be used. n Control of the temperature. n Easy control of the cardioplegia pump because it is next to the main pump.

18. n Perfusionist can hemoconcentrat during bypass because there is a connection between the hemofilter outlet and the venous reservoir.

19. CONCOLUSION In conclusion I would like to say that every center can develop their own technique in any way suitable to them as long as it is easy to apply and enables the perfusionist to provide the surgeon or the anesthetist with with all answers to their expected question regarding MUF.