Potential Danger of Pre‐Pump Clamping on Negative Pressure‐Associated Gaseous Microemboli Generation During Extracorporeal Life Support—An In Vitro Study

Wang, Shigang; Chin, Brian J.; Gentile, Frank T.; Kunselman, Allen R.; Palanzo, David A; Ündar, Akif

doi:10.1111/aor.12540

Cited by 12 publications

(15 citation statements)

References 17 publications

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“…In our study, the applied negative pressure depends on the rotational speed of the centrifugal pump as well as on the (dynamic) restriction of the inflow. These findings are in accordance with previously published results . The highest MB activity (number + gas volume) was observed after the static restriction of the inflow line.…”

Section: Discussionsupporting

confidence: 93%

“…Hypovolemia in ECLS therapy is normally accompanied by rhythmic occlusion of the inflow cannula due to recurrent drainage of the total blood volume in the blood vessel (eg, vena cava/caval vein) and subsequent suction to the vessel’s wall. Another reason for hypobaric MB formation is the (static) complete or partial occlusion of the inflow cannula due to iatrogenic manipulation or nursing errors . In order to simulate these conditions, we added a standard roller pump (type 10‐00‐00, Sorin Group S.p.A.) to the system and removed one roll.…”

Section: Methodsmentioning

confidence: 99%

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Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies

et al. 2019

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Occurrence of microbubbles (MB) is a major problem during venoarterial extracorporeal life support (ECLS) with partially severe clinical complications. The aim of this study was to establish an in vitro ECLS setup for the generation and detection of MB. Furthermore, we assessed different MB elimination strategies. Patient and ECLS circuit were simulated using reservoirs, a centrifugal pump, a membrane oxygenator, and an occluder (modified roller pump). The system was primed with a glycerin solution of 44%. Three different revolution speeds (2500, 3000, and 3400 rpm) were applied. For MB generation, the inflow line of the pump was either statically or dynamically (15 rpm) occluded. A bubble counter was used for MB detection. The effectiveness of the oxygenator and dynamic bubble traps (DBTs) was evaluated in regard to MB elimination capacities. MB generation was highly dependent on negative pressure at the inflow line. Increasing revolution speeds and restriction of the inflow led to increased MB activity. The significant difference between inflow and outflow MB volume identified the centrifugal pump as a main source. We could show that the oxygenator’s ability to withhold larger MB is limited. The application of one or multiple DBTs leads to a significant reduction in MB count and overall gas volume. The application of DBT can significantly reduce the overall gas volume, especially at high flow rates. Moreover, large MB can effectively be broken down for faster absorption. In general, the incidence of MBs is significantly dependent on pump speed and restriction of the inflow. The centrifugal pump was identified as a major source of MB generation.

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Section: Discussionsupporting

confidence: 93%

Section: Methodsmentioning

confidence: 99%

Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies

et al. 2019

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“…It was observed in this study that the negative pressure at the inlet of the Rotaflow pump head was usually significantly higher than the venous line pressure measured close to the venous cannula. High negative pressure in the venous line may cause a large number of gaseous microemboli and macro-bubbles in the circuit during an ECLS run (12). Not only is it dangerous for air bubbles to be delivered to the patient, but if large amounts of macro-bubbles get into the centrifugal pump head it may reduce pump efficiency and increase vibration and noise.…”

Section: Discussionmentioning

confidence: 99%

Hemodynamic Evaluation of Avalon Elite Bi‐Caval Dual Lumen Cannulas and Femoral Arterial Cannulas

et al. 2018

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Translational research is a useful tool to provide scientific evidence for cannula selection during extracorporeal life support (ECLS). The objective of this study was to evaluate four Avalon Elite bi‐caval dual lumen cannulas and nine femoral arterial cannulas in terms of flow range, circuit pressure, pressure drop, and hemodynamic energy transmission in a simulated adult ECLS model. A veno‐venous ECLS circuit was used to evaluate four Avalon Elite bi‐caval dual lumen cannulas (20, 23, 27, and 31 Fr), and a veno‐arterial ECLS circuit was used to evaluate nine femoral arterial cannulas (15, 17, 19, 21, and 23 Fr). The two circuits included a Rotaflow centrifugal pump, a Quadrox‐D adult oxygenator, and 3/8 in ID tubing for arterial and venous lines. The circuits were primed with lactated Ringer’s solution and packed human red blood cells (hematocrit 40%). Trials were conducted at rotational speeds from 1000 to 5000 RPM (250 rpm increments) for each Avalon cannula, and at different flow rates (0.5–7 L/min) for each femoral arterial cannula. Real‐time pressure and flow data were recorded for analysis. Small caliber cannulas created higher circuit pressures, higher pressure drops and higher M‐numbers compared with large ones. The inflow side of Avalon dual lumen cannula had a significantly higher pressure drop than the outflow side (inflow vs. outflow: 20 Fr‐100.2 vs. 49.2 mm Hg at 1.1 L/min, 23 Fr‐93.7 vs. 41.4 mm Hg at 1.6 L/min, 27 Fr‐102.3 vs. 42.8 mm Hg at 2.6 L/min, 31 Fr‐98.1 vs. 44.7 mm Hg at 3.8 L/min). There was more hemodynamic energy lost in the veno‐arterial ECLS circuit using small cannulas compared to larger ones (17 Fr vs. 19 Fr vs. 21 Fr at 4 L/min—Medtronic: 71.0 vs. 64.8 vs. 60.9%; Maquet: 71.4 vs. 65.6 vs. 62.0%). Medtronic femoral arterial cannulas had lower pressure drops (Medtronic vs. Maquet at 4 L/min: 17 Fr‐121.7 vs. 125.0 mm Hg, 19 Fr‐71.2 vs. 73.7 mm Hg, 21 Fr‐42.9 vs. 47.4 mm Hg) and hemodynamic energy losses (Medtronic vs. Maquet at 4 L/min: 17 Fr‐43.6 vs. 44.4%, 19 Fr‐31.0 vs. 31.4%, 21 Fr‐20.8 vs. 22.4%) at high flow rates when compared with the Maquet cannulae. The results for this study provided valuable hemodynamic characteristics of all evaluated adult cannulas with human blood in order to guide ECLS cannula selection in clinical practice. Use of larger cannulas are suggested for VV‐ and VA‐ECLS.

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“…Higher negative pressures in the venous line may cause cavitation resulting in hemolysis and trauma to the surrounding tissue. These forces may also increase the risk of gaseous microemboli . Therefore, attempts should be made to reduce negative pressure in the venous line.…”

Section: Introductionmentioning

confidence: 99%

“…These forces may also increase the risk of gaseous microemboli. 2,[8][9][10] Therefore, attempts should be made to reduce negative pressure in the venous line. Unfortunately, there are no clear guidelines on venous line pressure, and ideal venous cannulae and venous line lengths have not been established.…”

mentioning

confidence: 99%

Impact of cannula size and line length on venous line pressure in pediatric VA‐/VV‐ECLS circuits

2019

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The objective of this study was to do an in vitro evaluation of venous line pressure using different venous line lengths and venous cannula sizes in pediatric venoarterial extracorporeal life support (VA‐ECLS) and venovenous ECLS (VV‐ECLS) circuits. The pediatric VA‐ECLS circuit consisted of a Xenios i‐cor diagonal pump, a Maquet Quadrox‐i pediatric oxygenator, a Medtronic Biomedicus arterial cannula, a Biomedicus venous cannula, and 1/4″ ID arterial and venous tubing. The pediatric VV‐ECLS circuit was similar, except it included a Maquet Avalon ELITE bi‐caval dual lumen cannula. Circuits were primed with lactated Ringer’s solution and packed red blood cells (hematocrit 40%). Trials were conducted at various flow rates (VA‐ECLS: 250–1250 mL/min, VV‐ECLS: 250–2000 mL/min) using different venous tubing lengths (2, 4, and 6 feet) and cannula sizes (VA‐ECLS: A8Fr/V10Fr, A10Fr/V12Fr and A12Fr/V14Fr, VV‐ECLS: 13Fr, 16Fr, 19Fr, 20Fr and 23Fr) at 36°C. Real‐time pressure and flow data were recorded for analysis. The use of a small‐caliber venous cannula significantly increased the venous line pressure in the 2 pediatric circuits (P < 0.01). Shorter venous tubing lengths significantly reduced the venous line pressure at high flow rates (P < 0.01). The VV‐ECLS circuit had larger negative pre‐pump pressure drops (7.2 to −102.2 mm Hg) when compared to the VA‐ECLS circuit (0.7 to −60.7 mm Hg). Selecting an appropriate venous cannula and a shorter venous tubing when feasible may significantly reduce the pressure drop of the venous line in pediatric VA‐ECLS and VV‐ECLS circuits and improve venous drainage.

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Potential Danger of Pre‐Pump Clamping on Negative Pressure‐Associated Gaseous Microemboli Generation During Extracorporeal Life Support—An In Vitro Study

Cited by 12 publications

References 17 publications

Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies

Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies

Hemodynamic Evaluation of Avalon Elite Bi‐Caval Dual Lumen Cannulas and Femoral Arterial Cannulas

Impact of cannula size and line length on venous line pressure in pediatric VA‐/VV‐ECLS circuits

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