Aspirated blood contaminated by tissue contact is the most important activator of the coagulation system and the principal cause of hemolysis during cardiopulmonary bypass. Contact with a foreign surface is not a main variable in the procoagulant effect of bypass. Mimicking the outer cell membrane structure resulted in decreased platelet activation and decreased blood loss.
Phosphorylcholine coating had a favourable effect on blood platelets, which is most obvious after studying the changes during cardiopulmonary bypass. A steady increase of TXB2 and betaTG was observed in the control group, whereas plateau formation was observed in the phosphorylcholine group. Clinically, this effect may contribute to reduced blood loss and less thromboembolic complications. Complement activation is lower in the coated group.
An extracorporeal circuit consisting of an oxygenator especially designed for neonatal use and appropriately sized tubing, with an average total priming volume of 205 ml, was used on 80 infants undergoing cardiac surgery for congenital heart-disease. The priming volume and foreign surface area of the circuit were determined. The influence of low priming volumes on the use of blood products and the management of cardiopulmonary bypass was studied. No whole blood or platelets were used in this study. The mean volume of packed red blood cells used over the hospital stay was 202 +/- 67 ml. The mean volume of fresh frozen plasma (FFP) used until the second postoperative day was 62 +/- 72 ml. The mean total blood loss until the second postoperative day was 15.8 +/- 9.2 ml/kg. The priming volume of the extracorporeal circuit was 62% lower than values commonly reported in the literature. The low priming volume had a strong influence on the use of platelets and FFP and to a lesser extent on the use of packed red blood cells.
Protein adsorption onto polymers remains a problem. In recent years, several protein-repellent PVC tubings have been developed. Although several studies report the interaction between plasma coagulation proteins and PVC, few address the interaction with other plasma proteins. Two commercial brands of untreated medical grade PVC tubing, phosphorylcholine-coated PVC tubing, triblock-copolymer (polycaprolactone-polydimethylsiloxane-polycaprolactone)-treated PVC tubing and poly-2-methoxyethylacrylate (PMEA)-coated tubing were exposed for 60 minutes to human plasma. A broad spectrum of plasma proteins was found on all tubing. The adsorbed albumin to total protein ratio is lower than the similar ratio in plasma while alpha1 and alpha2 globulins are over-represented in the protein spectrum. On PMEA tubing, not only alpha globulins, but also beta and gamma globulins, are found in high concentrations in the adsorbed protein. PMEA tubing and uncoated PVC tubing of brand B had a higher amount of protein adsorbed compared against all other tubing (p < 0.05). There were no statistical differences in protein adsorption between the triblock-copolymer-treated tubing, the phosphorylcholine-coated tubing and the uncoated PVC tubing of brand A. The average thickness of the protein layer was 23 nm. Plasma protein adsorption still exists on uncoated and protein-repellent tubing and can initiate a systemic inflammatory reaction.
Despite major improvements in perfusion techniques over the past 50 years, it is still not possible to formulate a clear definition of what is meant by optimal perfusion. In part this is due to the lack of sufficient evidence-based data and in part because of the complex pathophysiology that takes place during cardiac surgery with cardiopulmonary bypass. To find an answer we need to understand the exact mechanism of the inflammatory reaction triggered by the cardiopulmonary bypass. However, it is clear that further improvement of the cardiopulmonary bypass components alone will be sufficient. Only a combined strategy can further improve cardiopulmonary bypass-related morbidity and mortality. Such a combined strategy will embrace perfusion techniques as well as a pharmacological approach. It will also require a continuous monitoring of the microcirculation. The latter will not only allow to rapidly sense changes in the quality of perfusion but, even more important, also make it possible to intervene at the moment of deterioration. Recent research shows that such an approach has positive an impact on cardiopulmonary bypass-related morbidity postoperatively.
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