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Objective Many children with a congenital heart defect undergo surgical correction requiring cardiopulmonary bypass (CPB). One sixth of these patients take an angiotensin-converting enzyme inhibitor (ACEi) for heart failure treatment. The effect of ACE inhibition on the fibrinolytic and inflammatory response in children undergoing CPB is unknown. In adults, ACE inhibition attenuates the increase in plasminogen activator inhibitor-1 (PAI-1) following CPB whereas the effect on the interleukin (IL)-6 response is uncertain. This study tests the hypothesis that preoperative ACE inhibition attenuates postoperative PAI-1 and IL-6 expression following CPB in children. Design Single center prospective randomized non-blinded study. Setting University-affiliated pediatric hospital. Patients Children undergoing elective surgical correction of a congenital heart defect requiring CPB and taking an ACEi. Interventions Children were randomized to continue ACEi until the morning of surgery (ACEi group, N=11) or to discontinue therapy 72 hours prior to surgery (No ACEi group, N=9). Measurement and Main Results Blood samples were collected at baseline before CPB, at 30min of CPB, upon arrival to the ICU, and on postoperative day 1 (POD1). Baseline bradykinin concentrations were significantly higher and ACE activity significantly lower in the ACEi group compared to the no ACEi group (P=0.04 and P=0.001 respectively). PAI-1 antigen increased 15-fold following CPB and peaked on POD1 (from 4.6±1.2 to 67.7±9.5 ng/ml; P<0.001). POD1 PAI-1 antigen correlated significantly with CPB time (r2=0.40, P=0.03) and was significantly lower in the ACEi group compared to the no ACEi group (P=0.03). The pro-inflammatory markers IL-6 and IL-8, as well as the anti-inflammatory marker IL-10, increased significantly following CPB (all P<0.001). IL-6 concentrations were significantly higher in the ACEi group following CPB (P=0.02) even after controlling for potential confounding factors such as age, CPB time and transfusion volume. Conclusion ACE inhibition attenuates the increase in postoperative PAI-1 but enhances the IL-6 response in children undergoing CPB.

The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence due to smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT membership and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists and serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this manuscript is to summarize the process of development, the content, and recommended utilization of AmSECT’s Standards and Guidelines for Pediatric and Congenital Perfusion Practice.

Objective: In this study we assessed differences in intraoperative blood loss using flow cytometry in patients undergoing total hip replacement under general (GA) or spinal anesthesia (SA). Patients and Methods: After approval of the ethics committee and written informed consent, 42 patients (ASA I–III) undergoing elective total hip replacement were included in this study. All perioperative data were recorded with an anesthesia information management system. Therefore, standardized electronic anesthesia record charts were configured according to the study protocol. Red cell volume was measured with sodium fluorescein using flow cytometry before induction of anesthesia and at the end of the surgical procedure. Surgical blood loss was determined with the calculated loss of red blood cells and the mean of all intraoperatively measured hematocrit levels. Results: Data of all 42 patients (18 GA, 24 SA) were evaluated. The electronic charts contained complete data sets of the patients’ biometric data, laboratory parameters, and surgery times. The study revealed no significant differences (p < 0.05) between the groups for intraoperative blood loss determined by flow cytometry (GA 1,688 ± 921 ml, SA 1,581 ± 1,052 ml), mean body temperature (GA 35.5 ± 0.5 °C, SA 35.6 ± 0.4 °C), average mean arterial blood pressure (GA 90 ± 7 mm Hg, SA 89 ± 9 mm Hg), and duration of surgery (GA 125 ± 46 min, SA 120 ± 40 min). Conclusions: The controversially discussed influence of anesthesia technique on intraoperative blood loss in total hip replacement could not be confirmed by this study. GA as well as SA are equivalent techniques in hip surgery regarding circulatory parameters and body temperature.