The bypass plan

Heparin is the primary anticoagulant used during cardiac surgery to prevent thrombosis due to cardiopulmonary bypass (CPB)–related activation of the hemostatic system. The efficacy of heparin in the operating room is generally determined by activated clotting time (ACT) point-of-care tests performed throughout the procedure. In an effort to transition to the Hemochron Elite which requires approximately 1/10th the sampling volume of blood, we conducted a prospective study in 260 pediatric patients undergoing CPB. ACT tests were performed during CPB with a total of 260 pre-bypass and 1,117 on-bypass ACT values recorded. All samples were run simultaneously on both ACT devices. Several therapeutic cut-off possibilities ranging from >380 to >480 seconds were evaluated to ascertain the ACT level on the Elite device which best correlated with results from the Response device. Linear regression was used to determine correlation. The correlation between the two methods was moderate with a Pearson r of .6 and .4 for pre-bypass bolus ACT values and on-bypass ACT values, respectively. As the therapeutic ACT cut-off values were lowered from 480 to 380 seconds on the Elite device relative to the Response device (>480 seconds) for the on-bypass heparin samples, more patients would be under-dosed (incidence rising from 1 to 2%) and fewer patients would be overdosed (incidence decreasing from 32 to 5%) and the percent correlation between devices increased from 67 to 93%. A similar trend was observed with the pre-bypass heparin bolus samples. There was no significant effect of temperature on the ACT values comparing both devices. A therapeutic ACT value of >400 seconds for CPB with the Hemochron Elite device reasonably approximates a therapeutic ACT value of >480 seconds on the Hemochron Response device in our congenital cardiac surgery practice. Transitioning to the Elite device significantly reduces the overall sampling volume required for ACT monitoring during cardiac surgery.

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Failure to oxygenate during cardiopulmonary bypass; treatment options and intervention algorithm

Matte,

Regan,

Gadille

et al. 2024

J Extra Corpor Technol

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Membrane oxygenator failure remains a concern for perfusion teams. Successful outcomes for this low-frequency, high-risk intervention are predicated on having written institutional protocols for both the oxygenator change-out procedure as well as how often the procedure is practiced by staff perfusionists. A recent review of peer-reviewed journal articles, textbooks and online resources revealed a lack of a unified intervention algorithm for failure to oxygenate during cardiopulmonary bypass (CPB). While an oxygenator change-out procedure may still be considered the gold standard for a confirmed device failure, temporizing measures exist that, in select cases, can afford time to the clinical team and even obviate the need for an oxygenator change-out procedure. We now consider the venous piggyback technique sourcing blood from the venous limb of the circuit a first-line intervention to afford enhanced patient safety while the clinical team decides on required interventions when oxygenator failure presents during CPB.

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The bypass plan

Cited by 4 publications

References 121 publications

Management of Pediatric Cardiopulmonary Bypass

Management of Pediatric Cardiopulmonary Bypass

Transition from Hemochron Response to Hemochron Signature Elite Activated Clotting Time Devices in a Congenital Cardiac Surgery Practice

Failure to oxygenate during cardiopulmonary bypass; treatment options and intervention algorithm

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