1. Modified Ultrafiltration in Adults: Should We All Be Doing It? Kenneth G. Shann, CCP Assistant Director, Perfusion Services Senior Advisor, Performance Improvement Montefiore Medical Center New York, NY

2. Disclosure No Relationships to Disclose

3. Outline Describe the technique of MUF Discuss the recent guideline recommendation and supporting literature regarding MUF in adults Discuss the logistical challenges related to the MUF technique

4. Modified Ultrafiltration (MUF) Performed after CPB before protamine Blood is drained from the venous line into the reservoir Using the cardioplegia pump, blood is pumped out of the aorta and retrograde down the arterial line Blood passes through the hemoconcentrator and heat exchanger and back to right atrium

5. MUF Ann Thorac Surg 1994;58:573-4

6. Modified Ultrafiltration (MUF) 10 – 15 mL/kg/min up to 500mL/min Performed for 10 to 20 minutes Volume status of patient is monitored closely Volume removed through ultrafiltration is replaced with volume from CPB circuit When venous reservoir is empty blood is chased with crystalloid Substances with molecular weight < 65,000 daltons are removed

7. Transfusion Guidelines Ann Thorac Surg 2007;83:S27– 86

8. Transfusion Guidelines Ann Thorac Surg 2011;91:944– 82

9. Supporting Literature European Journal of Cardio-thoracic Surgery 30 (2006) 892—897

10. Supporting Literature Circulation. 2001;104[suppl I]:I-253-I-259

11. Supporting Literature Circulation. 2001;104[suppl I]:I-253-I-259

12. Supporting Literature J Ayub Med Coll Abbottabad 2007;19(4)

13. Supporting Literature J Thorac Cardiovasc Surg 2011;141:1298-304

14. Cannulation for adult procedures Modifications to CPB circuit Associated risks – air embolism, hypothermia, hypotension Increased cost? Time commitment (10 – 20 minutes after CPB) Logistical Challenges of MUF

15. Peer-reviewed literature supports the use of MUF in adult patients Recent STS/SCA/ICEBP Transfusion Guidelines recommend the use of MUF in adult patients to conserve blood transfusion and reduce bleeding Despite supporting literature, routine use of MUF in adult patients is uncommon Where do we go from here? Conclusions