Efficacy and safety of strategies to preserve stable extracorporeal life support flow during simulated hypovolemia

Simons, Antoine P.; Lindelauf, Anouk A. M. A.; Ganushchak, Yuri M.; Weerwind, PW

doi:10.1177/0267659113502833

Cited by 5 publications

(5 citation statements)

References 20 publications

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“…Correct exploitation of centrifugal pumps under these conditions requires measurement and control of pressure before the pump. 23 , 26 – 28 However, the pressure in the venous line that can be recognized in clinical practice as safe is not clearly defined. In contrast, the allowable pressures at the inlet for industrial pumps in contrast to “medical” pumps are defined and are an obligatory part of their documentation in terms of NPSHr.…”

Section: Discussionmentioning

confidence: 99%

Is there a “safe” suction pressure in the venous line of extracorporeal circulation system?

Ganushchak

Korver

2020

Perfusion

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Successes of extracorporeal life support increased the use of centrifugal pumps. However, reports of hemolysis call for caution in using these pumps, especially in neonatology and in pediatric intensive care. Cavitation can be a cause of blood damage. The aim of our study was to obtain information about the cavitation conditions and to provide the safest operating range of centrifugal pumps. A series of tests were undertaken to determine the points at which pump performance decreases 3% and gas bubbles start to appear downstream of the pump. Two pumps were tested; pump R with a closed impeller and pump S with a semiopen impeller. The performance tests demonstrated that pump S has an optimal region narrower than pump R and it is shifted to the higher flows. When the pump performance started to decrease, the inlet pressure varies but close to −150 mmHg in the test with low gas content and higher than −100 mmHg in the tests with increased gas content. The same trend was observed at the points of development of massive gas emboli. Importantly, small packages of bubbles downstream of the pump were registered at relatively high inlet pressures. The gaseous cavitation in centrifugal pumps is a phenomenon that appears with decreasing inlet pump pressures. There are a few ways to increase inlet pump pressures: (1) positioning the pump as low as possible in relation to the patient; (2) selecting appropriate sized venous cannulas and their careful positioning; and (3) controlling patient’s volume status.

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Section: Discussionmentioning

confidence: 99%

Is there a “safe” suction pressure in the venous line of extracorporeal circulation system?

Ganushchak

Korver

2020

Perfusion

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Section: Discussionmentioning

confidence: 99%

“…36,37,46 We found that the inclusion of a compliance chamber (Better Bladder) in the venous line serves not only as an effective bubble-trap, but also decreases pressure fluctuations and de novo formation of gas bubbles in the venous line. [33][34][35] The concept of minimized systems requiring the patient to be used as a reservoir oblige a particular differentiated volume management. This poses challenges in the clinical application of minimized CPB systems.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, sub-atmospheric venous line pressures can provoke de-gassing, with resultant large amounts of gaseous microemboli. [33][34][35] This, together with the limited effectiveness of minimized systems at removing gaseous emboli, can cause severe complications. 36,37 Another limitation of minimized systems is the absence of cardiotomy suction, which can lead to excessive blood loss via a cell saver device.…”

Section: Introductionmentioning

confidence: 99%

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Versatile minimized system - a step towards safe perfusion

et al. 2015

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A growing body of evidence indicates the superiority of minimized cardiopulmonary bypass (CPB) systems compared to conventional systems in terms of inflammatory reactions and transfusion requirements. Evident benefits of minimized CPB systems, however, do not come without consequences. Kinetic-assisted drainage, as used in these circuits, can result in severe fluctuations of venous line pressures and, consequently, fluctuation of the blood flow delivered to the patient. Furthermore, subatmospheric venous line pressures can cause gaseous microemboli. Another limitation is the absence of cardiotomy suction, which can lead to excessive blood loss via a cell saver. The most serious limitation of minimized circuits is that these circuits are very constrained in the case of complications or changing of the surgery plan. We developed a versatile minimized system (VMS) with a priming volume of about 600 ml. A compliance chamber in the venous line decreases peaks of pressure fluctuations. This chamber also acts as a bubble trap. Additionally, the open venous reservoir is connected parallel to the venous line and excluded from the circulation during an uncomplicated CPB. This reservoir can be included in the circulation via a roller pump and be used as a cardiotomy reservoir. The amount and rate of returned blood in the circulation is regulated by a movable level detector. Further, the circuit can easily be converted to an open system with vacuum-assisted venous drainage in the case of unexpected complications. The VMS combines the benefits of minimized circuits with the versatility and safety of a conventional CPB system. Perfusionists familiar with this system can secure an adequate and timely response at expected and unexpected intraoperative complications.

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“…However, studies concentrated on the elimination of already existing gaseous bubbles and not on their avoidance. We [ 2 ] and others [ 12 ] have already demonstrated that excessive negative pressures in the venous line play a major role in the production of gaseous microemboli. The observed pressure differences were primarily due to volume depletion and underline the need for an appropriate and sensitive sensor for detecting it.…”

Section: Discussionmentioning

confidence: 99%

Counteracting negative venous line pressures to avoid arterial air bubbles: an experimental study comparing two different types of miniaturized extracorporeal perfusion systems

et al. 2015

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BackgroundBecause of its low rate of clinical complications, miniaturized extracorporeal perfusion systems (MEPS) are frequently used in heart centers worldwide. However, many recent studies refer to the higher probability of gaseous microemboli formation by MEPS, caused by subzero pressure values. This is the main reason why various de-airing devices were developed for today’s perfusion systems. In the present study, we investigated the potential benefits of a simple one-way-valve connected to a volume replacement reservoir (OVR) for volume and pressure compensation.MethodsIn an experimental study on 26 pigs, we compared MEPS (n = 13) with MEPS plus OVR (n = 13). Except OVR, perfusion equipment was identical in both groups. Primary endpoints were pressure values in the venous line and the right atrium as well as the number and volume of air bubbles. Secondary endpoints were biochemical parameters of systemic inflammatory response, ischemia, hemodilution and hemolysis.ResultsOne animal was lost in the MEPS + OVR group. In the MEPS + OVR group no pressure values below −150 mmHg in the venous line and no values under -100 mmHg in right atrium were noticed. On the contrary, nearly 20 % of venous pressure values in the MEPS group were below −150 and approximately 10 % of right atrial pressure values were below -100 mmHg. Compared with the MEPS group, the bubble counter device showed lower numbers of arterial air bubbles in the MEPS + OVR group (mean ± SD: 13444 ± 5709 vs. 1 ± 2, respectively; p < 0.001). In addition, bubble volume was significantly lower in the MEPS + OVR group than in the MEPS group (mean ± SD: 1522 ± 654 μl vs. 4 ± 6 μl, respectively; p < 0.001). The proinflammatory cytokine interleukin-6 and biochemical indices of cardiac ischemia (creatine kinase, and troponin I) were comparable between both groups.ConclusionsThe use of a miniaturized perfusion system with a volume replacement reservoir is able to counteract excessive negative venous line pressures and to reduce the number and volume of arterial air bubbles. This approach may lead to a lower rate of neurological complications.

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Efficacy and safety of strategies to preserve stable extracorporeal life support flow during simulated hypovolemia

Abstract: In contrast to a reserve-driven pump control strategy combined with a VBC device, flow and pressure servo control for ELS show evident deficits in preserving stable and safe ELS flow during hypovolemia.

Cited by 5 publications

References 20 publications

Is there a “safe” suction pressure in the venous line of extracorporeal circulation system?

Is there a “safe” suction pressure in the venous line of extracorporeal circulation system?

Versatile minimized system - a step towards safe perfusion

Counteracting negative venous line pressures to avoid arterial air bubbles: an experimental study comparing two different types of miniaturized extracorporeal perfusion systems

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