Abstract:The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.
Hypoplastic left heart syndrome (HLHS) is a rare and severe congenital cardiac defect. Approximately 1000 infants are born with HLHS in the United States every year. Healthcare collaboratives over the last decade have focused on sharing patient experiences and techniques in an effort to improve outcomes. In 2010, cardiologists and patient families joined together to improve the care of HLHS patients by forming the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC). Sixty-six of the approximately 110 institutions caring for patients with HLHS in the United States and Canada are now members of NPC-QIC. In 2017, cardiovascular perfusionists joined the collaborative as another specialty involved in the care of HLHS patients. Perfusionists and cardiac surgeons developed the collaborative's first conduct of perfusion survey for the Norwood Stage 1 procedure, specifically targeting the provision of cardiopulmonary bypass for patients with HLHS. This manuscript discusses the results of this survey, unveiling a significant variance in the conduct of perfusion for this patient population.
Background: Providing adequate metabolic support is the principal concern during cardiopulmonary bypass (CPB) with different strategies utilized to enhance oxygen delivery to the patient. Modifying temperature, hematocrit (Hct) and cardiac index (CI) during CPB are primary techniques which aid in this effort. Based upon surgeon preference, the study institution employs differing perfusion strategies (PS) during congenital cardiac surgery requiring CPB. One method utilizes a 2.4 L/min/m 2 CI and nadir Hct of 28% (PS1) and the other a 3.0 L/ min/m 2 CI with a nadir Hct of 25% (PS2). Methods: Cardiopulmonary bypass cases during which the PS1 or PS2 strategies were applied were retrospectively examined, finding no significant difference in pre-CPB lactate, maximum lactate on CPB or maximum change in lactate on CPB. Results: While the post-CPB lactate was statistically significantly higher in the PS2 group (p=0.024), the magnitude of difference (0.15 mmol/L) was small. Conclusions: This study illustrates that, when oxygen delivery or tissue perfusion is suspected as the primary cause of lactate production during CPB, increasing the CI to a 3.0 rather than a 2.4 CI may be more advantageous than packed red blood cell administration.
Correlation between the use of hypobaric oxygenation and GME counts suggests hypobaric oxygenation could play a significant role in the reduction of GME.
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