Acute respiratory failure (ARF) strikes an estimated two million people in the United States each year, with care exceeding US$50 billion. The hallmark of ARF is a heterogeneous injury, with normal tissue intermingled with a large volume of low compliance and collapsed tissue. Mechanical ventilation is necessary to oxygenate and ventilate patients with ARF, but if set inappropriately, it can cause an unintended ventilator-induced lung injury (VILI). The mechanism of VILI is believed to be overdistension of the remaining normal tissue known as the 'baby' lung, causing volutrauma, repetitive collapse and reopening of lung tissue with each breath, causing atelectrauma, and inflammation secondary to this mechanical damage, causing biotrauma. To avoid VILI, extracorporeal membrane oxygenation (ECMO) can temporally replace the pulmonary function of gas exchange without requiring high tidal volumes (VT) or airway pressures. In theory, the lower VT and airway pressure will minimize all three VILI mechanisms, allowing the lung to 'rest' and heal in the collapsed state. The optimal method of mechanical ventilation for the patient on ECMO is unknown. The ARDSNetwork Acute Respiratory Management Approach (ARMA) is a Rest Lung Approach (RLA) that attempts to reduce the excessive stress and strain on the remaining normal lung tissue and buys time for the lung to heal in the collapsed state. Theoretically, excessive tissue stress and strain can also be avoided if the lung is fully open, as long as the alveolar re-collapse is prevented during expiration, an approach known as the Open Lung Approach (OLA). A third lung-protective strategy is the Stabilize Lung Approach (SLA), in which the lung is initially stabilized and gradually reopened over time. This review will analyze the physiologic efficacy and pathophysiologic potential of the above lung-protective approaches.

Small increases in serum creatinine postoperatively reflect an acute kidney injury (AKI) that likely occurred during cardiopulmonary bypass (CPB). Maintaining adequate oxygen delivery (DO2) during CPB, known as GDP (goal-directed perfusion), improves outcomes. Whether GDP improves outcomes of patients at high risk for acute renal failure (ARF) is unknown. Forty-seven adult patients undergoing cardiac surgery with CPB utilizing GDP with Cleveland Clinic Acute Renal Failure Score of 3 or greater were compared with a matched cohort of patients operated upon using a flow-directed strategy. CPB flow in the GDP cohort was based on a DO2 goal of 260 mL/min/m2. Serum creatinine values were used to determine whether postoperative AKI occurred according to AKIN (Acute Kidney Injury Network) guidelines. We examined the distribution of all variables using proportions for categorical variables and means (standard deviations) for continuous variables and compared treatment groups using t tests for categorical variables and tests for differences in distributions for continuous and count variables. We used inverse probability of treatment weighting to adjust for treatment selection bias. In adjusted models, GDP was not associated with a decrease in AKI (odds ratio [OR]: .97; confidence interval [CI]: .62, 1.52), but was associated with higher odds of ARF (OR: 3.13; CI: 1.26, 7.79), mortality (OR: 3.35; CI: 1.14, 9.89), intensive care unit readmission (OR: 2.59; CI: 1.31, 5.15), need for intraoperative red blood cell transfusion (OR: 2.02; CI: 1.26, 3.25), and postoperative platelet transfusion (OR: 1.78; CI: 1.05, 3.01) when compared with the historic cohort. In patients who are at high risk for postoperative renal failure, GDP was not associated with a decrease in AKI when compared to the historical cohort managed traditionally by determining CPB flows based on body surface area. Surprisingly, the GDP cohort performed significantly worse than the retrospective control group in terms of ARF, mortality, intensive care unit readmission, and RBC and platelet transfusions.

Standards and guidelines for cardiopulmonary bypass have been established by various professional societies. They serve as an instrument to guide safe and effective patient care. We conducted a survey of practicing perfusionists in Kenya to learn about their background, education, current clinical practice and about their knowledge, and attitude regarding standards and guidelines. Two multiple-choice surveys were distributed to all known practicing perfusionist in Kenya using SurveyMonkey (San Mateo, CA). Multiple-choice questions related to professional background, training, annual procedure volume, staffing models, clinical practices, the use of safety devices, and the use of checklists were included in the questionnaires. The survey also inquired about familiarity with American and European perfusion practice standards and guidelines and opinions on establishing standards in Kenya. Responses were received from 12 perfusionists practicing at 10 centers. Professional backgrounds included anesthesia nursing, clinical officers, and critical care nursing. Sixty-seven percent (8/12) received formal training and 33% (4/12) trained primarily through clinical instruction. Of those that received formal training, 63% (5/8) received 1-2 years of training, 25% (2/8) <1 year but more than 6 months, and 12.5% (1/8) received 6 months of formal training. The median clinical experience was 5 years (range 1-22). The median annual case load was 54 (range 0-100). Use of safety devices was reported as follows: level sensor 75% (9/12), air bubble detector 17% (2/12), one-way vent valves 67% (8/12), continuous venous oxygen saturation monitoring 25% (3/12), and gas supply analyzers 33% (4/12). More than one-third of the respondents had no knowledge of the American and European perfusion practice standards, and nearly two-thirds were aware of or had read them. This survey provides contextual information about perfusion practice in Kenya in 2021. There was consensus among perfusionists to develop standards and practice guidelines for Kenya.

The conduct of cardiopulmonary bypass in neonatal, infant, and pediatric patients continuously evolves as new devices and innovative techniques are introduced. Since 1989, periodic pediatric perfusion surveys have been conducted to ascertain practice patterns involving demographics, equipment, and perfusion techniques. The goal of this current project is to provide an updated perspective on international pediatric and congenital perfusion practice since the last survey conducted in 2016. In July 2021, a 100-question perfusion survey was distributed to 284 pediatric cardiac surgery centers using a secure web browser-based data application. Each center was given a unique survey hyperlink to ensure one response per institution and to monitor the response rate. Centers were given 1 month to complete the survey and electronic reminders were sent weekly to nonrespondents. After the survey was closed, information from completed surveys was exported to a software program for analysis. Responses were received from 153 of 284 pediatric centers for a response rate of 54%. Sixty respondents (39%) were from North American (NA) centers while 93 respondents (61%) were from non-North American (NNA) centers. The vast majority of centers use a roller head arterial pump (93%), hollow fiber oxygenators with open reservoirs (86%), and integrated arterial line filters (73%). The use of modified ultrafiltration was reported by 76% of centers. Ninety-two percent of centers reported the use of selective antegrade cerebral perfusion for aortic arch repairs. The N + 1 staffing model was most prevalent (52%), followed by two perfusionists per case (33%). Periodic surveys continue to be a useful modality in assessing regional variation in pediatric perfusion practice. This survey marked the first time the majority of responses came from non-North American institutions. Identifying these practice patterns may aid in the development of, and adherence to, regional standards and guidelines. This would foster the reduction of variation in practice and potentially improve patient safety.

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Cardiopulmonary bypass provides the surgical team with the most controlled environment to perform the precise anastomoses needed for a successful coronary artery bypass graft operation. It not only promotes the most stable surgical field, but it utilizes a range of techniques that benefit both the surgeon and the patient. This chapter aims to provide the surgical team with an outline of cardiopulmonary bypass circuit components and an overview of common technical issues that diminish the adequacy of perfusion, and to direct the team to resources available in order to achieve evidence-based clinically safe cardiopulmonary bypass.

New cardiopulmonary bypass device techniques emerge and are reported in the scientific literature. The extent to which they are actually adopted into clinical practice is not well known. Since 1989, we have periodically surveyed pediatric cardiac centers to ascertain practice patterns. In December 2016, a 186-question perfusion survey was distributed to pediatric cardiac surgery centers all over the world using a Web-based survey tool. Responses were received from 93 North American (NA) centers (the United States and Canada) and 67 non-NA (NNA) centers, representing 19,645 cumulative annual procedures in NA and 27,776 in NNA centers on patients <18 years. Wide variation in practice was evident across geographic regions. However, the most common pediatric circuit consisted of a hard-shell (open) venous reservoir, an arterial roller pump, and a hollow-fiber membrane oxygenator with a separate or integrated arterial filter. Compared with our previous surveys, there was increased utilization of all types of safety devices. The use of an electronic perfusion record was reported by 50% of NA centers and 31% of NNA centers. There was wide regional variation in cardioplegia delivery systems and cardioplegia solutions. Seventy-nine percent of the centers reported the use of some form of modified ultrafiltration. The survey demonstrated that there remains variation in perfusion practice for pediatric patients. Future surveys will be useful to evaluate the adoption of emerging perfusion practice guidelines.

THE USE of cardiopulmonary bypass has enabled the delivery of complex cardiovascular surgical procedures. Cardiopulmonary bypass (CPB), at its best, involves a highly technical process that is executed carefully through a complex interaction among a surgeon, an anesthesiologist, and a cardiovascular perfusionist. More than a decade ago, early practice was to review the literature and summarize best practices based on the published evidence that began to appear in the literature.1Bartels C Gerdes A Babin-Ebell J et al.Cardiopulmonary bypass: Evidence or experience based?.J Thorac Cardiovasc Surg. 2002; 124: 20-27Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 2Murphy GS Hessel 2nd, EA Groom RC Optimal perfusion during cardiopulmonary bypass: An evidence-based approach.Anesth Analg. 2009; 108: 1394-1417Crossref PubMed Scopus (226) Google Scholar, 3Shann KG Likosky DS Murkin JM et al.An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response.J Thorac Cardiovasc Surg. 2006; 132: 283-290Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar We were coauthors of one such review that has been highly cited in the literature.2Murphy GS Hessel 2nd, EA Groom RC Optimal perfusion during cardiopulmonary bypass: An evidence-based approach.Anesth Analg. 2009; 108: 1394-1417Crossref PubMed Scopus (226) Google Scholar More recently, professional societies have convened expert panels to write clinical practice guidelines based on evidence using a more rigorous and structured methodology. The Institute of Medicine defines clinical practice guidelines as “statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”4Graham R Mancher M Wolman DM et al.Clinical practice guidelines we can trust. National Academies Press, Washington, DC2011Crossref Google Scholar Some of the first guidelines in anesthesiology were undertaken by the Society of Thoracic Surgeons (STS) and were related to technical surgical procedures and device implants such as valve replacements and repairs or pacemaker implants. Some of the early guidelines were related to surgical care and CPB. In 2007, guidelines related to blood management and transfusion for cardiac surgery were written with collaboration from the Society of Cardiovascular Anesthesiologists (SCA), and an update to these guidelines was written in 2011, which included collaboration with the American Society of Extracorporeal Technology’s (AmSECT’s) International Consortium for Evidence Based Perfusion Committee. The STS, SCA, and AmSECT also have collaborated on guidelines for anticoagulation and temperature management during CPB. Guidelines provide clinicians with actionable evidence informed by expert opinion. The recently published 2019 European Association for Cardio-Thoracic Surgery (ECTS)/European Association for Cardiothoracic Anaesthesiology (EACTA)/European Board for Cardiovascular Perfusion guideline on CPB in adult cardiac surgery, is a timely, well-informed collaborative document that includes an exhaustive structured review of the related literature, and where evidence is lacking, expert consensus from all 3 disciplines is provided.5Kunst G Milojevic M Boer C et al.2019 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery.Br J Anaesth. 2019; 123: 713-757Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar To promote wide dissemination, the guideline was copublished with permission in the British Journal of Anaesthesia, the European Journal of Cardio-Thoracic Surgery, and the Interactive CardioVascular and Thoracic Surgery journal. Many of our colleagues in North America took notice of this work and are reading it with great interest. The authors of the guidelines are a multidisciplinary, world class group comprising European surgeons, anesthesiologists, perfusionists, and an epidemiologist. The guideline was written following the EACTS practice guideline writing instructions. This methodology was modeled after the handbook for guideline writing by the American College of Cardiology (ACC) and American Heart Association (AHA). It is important to note that the EACTS framework uses slightly different definitions for the levels of evidence and classification. Some of the more important differences between the ACC/AHA and EACTS classifications were pointed out by Baker et al. in their recent editorial.6Baker RA Nikolic A Onorati F et al.2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery: A tool to better clinical practice.Eur J Cardiothorac Surg. 2020; 57: 207-209Crossref PubMed Scopus (5) Google Scholar However in both cases, the stated aim is to provide well-balanced, objective, and unbiased multidisciplinary recommendations that will be embraced by clinicians and encourage decision- making that endorses patient care on the basis of the best available science and expert opinion. Another benefit of this work is that it identifies areas for which currently there is low evidence and that may perhaps attract future investigation. The 2019 EACTS/EACTA/European Board for Cardiovascular Perfusion guideline is unique in that the focus is entirely on CPB and its use in cardiac surgery. The STS/SCA/AmSECT guideline group has taken the approach of topical guidelines related to CPB and spans the entire episode of care for cardiac surgery patients. It is not surprising that many of the EACTS guidelines are strikingly similar, in some cases nearly verbatim, to the STS/SCA/AmSECT published work. Some of the content likewise derived from standards and practice guidelines published by organizations such as AmSECT (http://www.amsect.org/p/cm/ld/fid=1617),7American Society of ExtraCorporeal Technology. Standards and clinical practice guidelines. Available at: http://www.amsect.org/p/cm/ld/fid=1617. Accessed April 22, 2020.Google Scholar Australian and New Zealand College of Anaesthetists (http://www.anzca.edu.au/documents/ps27-2015-guidelines-for-major-extracorporeal-perf.pdf),8Australian and New Zealand College of Anaesthetists. Guidelines for major extracorporeal perfusion. Available at: http://www.anzca.edu.au/documents/ps27-2015-guidelines-for-major-extracorporeal-perf.pdf. Accessed April 22, 2020.Google Scholar and the Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland (https://assets.website-files.com/5da4ad68b9d5374c5a54c71d/5da743ffa1b0aaa1cb7351e0_SCPS%20-%20Standards%20Of%20Practice%20-%202019.pdf).9Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland. Standards of practice. Society documents. Available at: https://assets.website-files.com/5da4ad68b9d5374c5a54c71d/5da743ffa1b0aaa1cb7351e0_SCPS%20-%20Standards%20Of%20Practice%20-%202019.pdf. Accessed April 22, 2020.Google Scholar Although these prior guidelines and standards generally are referenced in the EACTS work, the authors would have done well to reference the previously published guidelines and standards that relate to their specific recommendations, where applicable. This would have added strength to their recommendations, particularly those that lack high-level evidence. The European guideline provides, by our count, 113 recommendations. Forty-three (38%) are class I, 32% class IIa, 19% class IIb, and 10% class III (Fig 1). Notably and unfortunately, only about 6% are supported by class A evidence, whereas 50% are supported by class B evidence and 44% by class C evidence. Of the 43 class I indications, although most are reasonable and should be followed, only 4 are supported by class A evidence and 4 by class B evidence (Fig 2). This deficiency of high-level evidence to support many of the practices of CPB is acknowledged by the authors of these European guidelines and has been noted previously by others.1Bartels C Gerdes A Babin-Ebell J et al.Cardiopulmonary bypass: Evidence or experience based?.J Thorac Cardiovasc Surg. 2002; 124: 20-27Abstract Full Text Full Text PDF PubMed Scopus (56) Google ScholarFig. 2Level of evidence.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Included in this editorial are 4 tables (Table 1, Table 2, Table 3, Table 4) in which we list their class I, IIa, IIb, and III recommendations and compare them with those in other documents. Referenced documents include the 2017 AmSECT Standards and Guidelines,7American Society of ExtraCorporeal Technology. Standards and clinical practice guidelines. Available at: http://www.amsect.org/p/cm/ld/fid=1617. Accessed April 22, 2020.Google Scholar the Australian and New Zealand College of Anaesthetists Guidelines for Major Extracorporeal Perfusion,8Australian and New Zealand College of Anaesthetists. Guidelines for major extracorporeal perfusion. Available at: http://www.anzca.edu.au/documents/ps27-2015-guidelines-for-major-extracorporeal-perf.pdf. Accessed April 22, 2020.Google Scholar the Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland Standards of Practice: Society Documents,9Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland. Standards of practice. Society documents. Available at: https://assets.website-files.com/5da4ad68b9d5374c5a54c71d/5da743ffa1b0aaa1cb7351e0_SCPS%20-%20Standards%20Of%20Practice%20-%202019.pdf. Accessed April 22, 2020.Google Scholar an evidence-based review of the practice of CPB in adults,3Shann KG Likosky DS Murkin JM et al.An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response.J Thorac Cardiovasc Surg. 2006; 132: 283-290Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar the STS/SCA/AmSECT 2011 Updated Transfusion Guideline,10Ferraris VA Brown JR Despotis JG et al.2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (905) Google Scholar the STS/SCA/AmSECT Anticoagulation Guideline,11Shore-Lesserson L Baker RA Ferraris VA et al.The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of ExtraCorporeal Technology: Clinical practice guidelines-anticoagulation during cardiopulmonary bypass.Anesth Analg. 2018; 126: 413-424Crossref PubMed Scopus (14) Google Scholar the STS/SCA/AmSECT Temperature Management Guideline,12Engleman R Baker RA Likosky DS et al.Clinical practice guidelines for cardiopulmonary bypass—temperature management during cardiopulmonary bypass.Ann Thorac Surg. 2015; 100: 748-757Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar the AHA/ACC Scientific Statement Safety in Cardiac Surgery,13Wahr J Prager R Abernathy J et al.AHA scientific statement patient safety in the cardiac operating room: Human factors and teamwork. A scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1669Crossref PubMed Scopus (159) Google Scholar and the International Consortium for Evidence Based Perfusion (ICEBP) review regarding attenuating inflammation related to CPB.14Landis RC Brown JR Fitzgerald D et al.Attenuating the systemic inflammatory response to adult cardiopulmonary bypass: A critical review of the evidence base.Extra Corpor Technol. 2014; 46: 197-211PubMed Google Scholar Exact wording between recommendations may vary and direct comparison need to be undertaken with caution.Table 1Class I RecommendationsLevel of Evidence⁎Level of evidence assigned by the European Association for Cardio-Thoracic Surgery/European Association for Cardiothoracic Anaesthesiology/European Board for Cardiovascular Perfusion guidelines.AmSECT 20177American Society of ExtraCorporeal Technology. Standards and clinical practice guidelines. Available at: http://www.amsect.org/p/cm/ld/fid=1617. Accessed April 22, 2020.Google ScholarANZCA8Australian and New Zealand College of Anaesthetists. Guidelines for major extracorporeal perfusion. Available at: http://www.anzca.edu.au/documents/ps27-2015-guidelines-for-major-extracorporeal-perf.pdf. Accessed April 22, 2020.Google ScholarGB9Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland. Standards of practice. Society documents. Available at: https://assets.website-files.com/5da4ad68b9d5374c5a54c71d/5da743ffa1b0aaa1cb7351e0_SCPS%20-%20Standards%20Of%20Practice%20-%202019.pdf. Accessed April 22, 2020.Google ScholarShann3Shann KG Likosky DS Murkin JM et al.An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response.J Thorac Cardiovasc Surg. 2006; 132: 283-290Abstract Full Text Full Text PDF PubMed Scopus (190) Google ScholarSafety (AHA/ACC)13Wahr J Prager R Abernathy J et al.AHA scientific statement patient safety in the cardiac operating room: Human factors and teamwork. A scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1669Crossref PubMed Scopus (159) Google ScholarTransfusion 201110Ferraris VA Brown JR Despotis JG et al.2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (905) Google ScholarTemperature12Engleman R Baker RA Likosky DS et al.Clinical practice guidelines for cardiopulmonary bypass—temperature management during cardiopulmonary bypass.Ann Thorac Surg. 2015; 100: 748-757Abstract Full Text Full Text PDF PubMed Scopus (52) Google ScholarAnticoagulation11Shore-Lesserson L Baker RA Ferraris VA et al.The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of ExtraCorporeal Technology: Clinical practice guidelines-anticoagulation during cardiopulmonary bypass.Anesth Analg. 2018; 126: 413-424Crossref PubMed Scopus (14) Google ScholarInflammation14Landis RC Brown JR Fitzgerald D et al.Attenuating the systemic inflammatory response to adult cardiopulmonary bypass: A critical review of the evidence base.Extra Corpor Technol. 2014; 46: 197-211PubMed Google Scholar1.It is recommended that perfusionists complete a formal period of training in an approved educational training program.CY S2.1Y 1.2, 3.2Y 3.1Y2.It is recommended that perfusionists achieve certification by successfully completing an examination of skills and knowledge. The certification shall be maintained by the demonstration of an appropriate level of continued professional development, minimum caseload, and professional standards.CY S2.1Y 3.2Y 3.2Y3.It is recommended that perfusion departments are structured around a quality management framework approved by the institution.CY S17.1Y 3.3.2Class I Level CClass IIa Level B4.It is recommended that each perfusion department has written standard operating procedures for the conduct of CPB.CY S1.1YY 13.15.It is recommended that the perfusion department is adequately staffed, equipped, and resourced.CY S15, 16.1YY 10.1, 10.26.It is recommended that verbal communication among team members in the operating room is standardized and always acknowledged.CY S3.1, 3.2,Y 5.2.3.4Class I Level B7.Reporting and systematically analyzing errors or untoward events, including outcomes dissemination for shared learning, are recommended.CY 3.3.3Y 15.0Class I Level CPart IV. Heart-lung machine hardware1.It is recommended that pressure monitoring devices are used on the arterial line and cardioplegia delivery systems during CPB.CY S6.1, 7.2, 7.4Y 4.2.5.12.A bubble detector is recommended during CPB procedures on all inflow lines.CY 6.2Y 4.2.63.It is recommended to use a level sensor during CPB procedures utilizing a (hard-shell) reservoir.CY 6.3Y 4.2.4.14.It is recommended to have backups for vital systems of the heart-lung machines available at all times.CY S18.4Y 4.25.It is recommended to have a maintenance plan for CPB equipment.CY S18.2Y 4.16.Continuous arterial line pressure monitoring (preoxygenator and postoxygenator) in the CPB circuit is recommended.CY S.2 (Post)Y 4.2.5.1 (Pre and post)7.Continuous oxygenator arterial outlet temperature monitoring is recommended.CY S6.4Y 4.2.8.4Class I Level C8.It is recommended to continuously monitor SvO2 and HCT levels during CPB.BY S7.7, 7.10Y 4.2.7.19.Monitoring of blood gas analyses through regular intervals or continuous observation is recommended during CPB.CY S7.6Y10.It is recommended to objectively report, adequately record, and properly analyze all adverse events related to CPB practice in an efficient and timely manner.CY 3.3.311.It is recommended that continuous piped supplies of oxygen, air, and carbon dioxide are delivered and controlled during CPB with backup cylinder supplies available.CY S6.10Y 4.2.212.When a supply system for volatile anesthetics is used, a scavenging system at the outlet of the oxygenator is recommended.CY S6.8Y 4.2.2.513.Validated decontamination and maintenance procedures for HCUs are recommended.CY 18.114.It is recommended that HCUs be placed outside operating rooms to prevent the contaminated air from entering the surgical field.C15.It is recommended that the perfusionist collect data concerning the conduct of perfusion via a clinical registry or database and use such data to actively participate in institutional and departmental quality assurance and improvement programs.BY S17.1, 17.2Y 3.3.3Part V. CPB: Disposables1.It is recommended that there is a preoperative agreement between the perfusionist and surgeon on the choice of the size and type of venous and arterial cannulae in order to provide an adequate and safe venous return and an appropriate arterial flow tailored to the needs of the patient and the procedure.CY S3.12.Microporous membrane oxygenators are recommended as the first choice for use in CPB.BPart VI. Preparation for CPB1.It is recommended to use an institution-approved pre-CPB checklist during the set-up of and before initiating CPB.CY S5.2 G5.2Y 5.4.4Class I Level B2.It is recommended that completion of the perfusion checklist is acknowledged during the surgical safety checklist “time out” procedure.C3.A preoperative assessment of the patient is recommended in preparation for CPB.CY S3.1Y 5.2.3.3YClass I Level APart VII. Procedures during CPB1.It is recommended that CO2 flush of the CPB circuit before priming be established as the standard of care to reduce GME.B2.Retrograde and antegrade autologous primings are recommended as part of a blood conservation strategy to reduce transfusions.AY G13.1Class IIb Level B3.In the absence of individual heparin dosing tools, it is recommended that ACT tests be performed at regular intervals based on institutional protocols and that heparin doses must be given accordingly.CS8.1, 8.3Y 5.3.1Class I Level C4.It is recommended to adjust the MAP during CPB with the use of arterial vasodilators (if MAP >80 mmHg) or vasoconstrictors (if MAP <050 mmHg), after checking and adjusting the depth of anesthesia and assuming sufficiently targeted pump flow.AY S11.1, 11.25.It is recommended that vasoplegic syndrome during CPB be treated with a1-adrenergic agonist vasopressors.C6.It is recommended that the pump flow rate be determined before the initiation of CPB based on the BSA and the planned temperature.CY S10.17.GDT is recommended to reduce the rate of postoperative complications and length of hospital stay.AY S9.1 G9.28.It is recommended that an approved venous reservoir be used for assisted venous drainage.C9.It is recommended that the venous line pressure be monitored when using assisted venous drainage.CY S6.110.It is recommended that PRBCs be transfused during CPB if the Hb value is <06.0 g/dL.CClass IIa Level C11.It is recommended that antithrombin concentrate be used instead of FFP to treat antithrombin deficiency to improve heparin sensitivity.BClass I Level A12.It is recommended that patient-centered myocardial protective strategies be used based on clinical condition and procedural complexity rather than on the use of a fixed institutional cardioplegic solution.C13.It is recommended that a set-up CPB circuit be available at all times for emergency procedures.CY G14.214.After the patient is weaned from CPB, it is recommended that the CPB circuit be kept functional until the patient’s chest has been closed.CY F14.1Y 5.2.4.2Part VIII. Separation from CPB1.The use of a checklist before the weaning process is recommended to enhance team performance and augment patient safety.CY G5.22.Positive inotropic and/or vasopressor agents are recommended as a first-line treatment to reduce mortality rates in patients with hemodynamic instability.A3.Retransfusion of the residual volume of the CPB circuit at the end of the procedure is recommended as a part of a blood management program to minimize allogeneic blood transfusions.CY S13.1, G13.1Class IIa Level CAbbreviations: ACT, activated clotting time; ACC, American College of Cardiology; American Heart Association; AMSect, American Society of ExtraCorporeal Technology; ANZCA, Australian and New Zealand College of Anaesthetists; BSA, body surface area; CO2, carbon dioxide; CPB, cardiopulmonary bypass; FFP, fresh frozen plasma; GB, Great Britain; GDT, goal directed hemodynamic therapy; GME, gaseous microemboli; Hb, hemoglobin; HCT, hematocrit; HCU, heater cooler unit; MAP, mean arterial pressure; PRBC, packed red blood cell; SvO2, mixed venous oxygen. Level of evidence assigned by the European Association for Cardio-Thoracic Surgery/European Association for Cardiothoracic Anaesthesiology/European Board for Cardiovascular Perfusion guidelines. Open table in a new tab Table 2Class IIa RecommendationsLevel of Evidence⁎Level of evidence assigned by the European Association for Cardio-Thoracic Surgery/European Association for Cardiothoracic Anaesthesiology/European Board for Cardiovascular Perfusion guidelines.AmSECT 20177American Society of ExtraCorporeal Technology. Standards and clinical practice guidelines. Available at: http://www.amsect.org/p/cm/ld/fid=1617. Accessed April 22, 2020.Google ScholarANZCA8Australian and New Zealand College of Anaesthetists. Guidelines for major extracorporeal perfusion. Available at: http://www.anzca.edu.au/documents/ps27-2015-guidelines-for-major-extracorporeal-perf.pdf. Accessed April 22, 2020.Google ScholarGB9Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland. Standards of practice. Society documents. Available at: https://assets.website-files.com/5da4ad68b9d5374c5a54c71d/5da743ffa1b0aaa1cb7351e0_SCPS%20-%20Standards%20Of%20Practice%20-%202019.pdf. Accessed April 22, 2020.Google ScholarShann3Shann KG Likosky DS Murkin JM et al.An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response.J Thorac Cardiovasc Surg. 2006; 132: 283-290Abstract Full Text Full Text PDF PubMed Scopus (190) Google ScholarSafety (AHA/ACC)13Wahr J Prager R Abernathy J et al.AHA scientific statement patient safety in the cardiac operating room: Human factors and teamwork. A scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1669Crossref PubMed Scopus (159) Google ScholarTransfusion 201110Ferraris VA Brown JR Despotis JG et al.2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (905) Google ScholarTemperature12Engleman R Baker RA Likosky DS et al.Clinical practice guidelines for cardiopulmonary bypass—temperature management during cardiopulmonary bypass.Ann Thorac Surg. 2015; 100: 748-757Abstract Full Text Full Text PDF PubMed Scopus (52) Google ScholarAnticoagulation11Shore-Lesserson L Baker RA Ferraris VA et al.The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of ExtraCorporeal Technology: Clinical practice guidelines-anticoagulation during cardiopulmonary bypass.Anesth Analg. 2018; 126: 413-424Crossref PubMed Scopus (14) Google ScholarInflammation14Landis RC Brown JR Fitzgerald D et al.Attenuating the systemic inflammatory response to adult cardiopulmonary bypass: A critical review of the evidence base.Extra Corpor Technol. 2014; 46: 197-211PubMed Google ScholarPart III. Training, education, and service delivery1.Simulation in perfusion should be considered to improve quality of care and patient safety.C2.Recording and submitting activity and outcomes to a regional database or registry should be considered, and these data should be used for quality assurance and improvement.BY G17.1Part IV. Heart-lung machine hardware1.It should be considered that pump flow is confirmed by ultrasonic measurement on the arterial line.C2.Electronic automated data recording of perfusion parameters should be considered in a perfusion program.BY S4.1To limit trauma to blood elements, limited use of cardiotomy suction and avoidance of air entrainment into the cardiotomy and venting lines should be considered.BClass I Level B3.The use of a separated cardiotomy reservoir should be considered to decrease the deleterious effect of SMB.BB4.The use of centrifugal pumps should be considered for expected longer CPB times.CPart V. CPB: Disposables1.The use of any biocompatible coating to reduce postoperative complications should be considered.BY G13.1Class IIa Level BPart VII. Procedures during CPB1.MiECC should be considered over standard conventional CPB systems to reduce blood loss and the need for transfusion.BClassI Level A2.MiECC should be considered over standard conventional CPB systems to increase the biocompatibility of ECC.B3.A combination of MiECC features, such as coating, centrifugal pump, separation of cardiotomy suction blood, and use of closed systems, should be considered to improve conventional CPB.C4.ACT >480 s during CPB should be considered in CPB with uncoated equipment and cardiotomy suction. The required target ACT used depends on the type of equipment used.CClass IIa, Level C5.Individualized heparin and protamine management should be considered to reduce postoperative coagulation abnormalities and bleeding complications in cardiac surgery with CPB.B8.4, 8.5Class IIb, Level B6.Protamine overdosing should be avoided in order to reduce postoperative coagulation abnormalities and bleeding complications in cardiac surgery with CPB.B8.5Class IIa, Level C7.In patients with contraindications to heparin and/or protamine usage and in need of a surgery requiring CPB, anticoagulation with bivalirudin should be considered.B8.1Class I Level AClass IIa, Level B8.Alpha-stat acid-base management should be applied in adult cardiac surgery with moderate-to-mild hypothermia because neurologic and neurocognitive outcomes are improved.BClass I Level A9.Maintenance of a normal pH (7.35-7.45) andavoidance of hyperchloremic acidosis should be considered to reduce the risk of postoperative complications.B10.In patients with vasoplegic syndrome refractory to a1- adrenergic agonist vasopressors, alternative drugs (vasopressin, terlipressin, or methylene blue) should be used, alone or in combination with a1-agonists.B11.The adequacy of the pump flow rate during CPB should be checked based on oxygenation and metabolic parameters (SvO2, O2ER, NIRS, VCO2, and lactates).BY G10.212.The pump flow rate should be adjusted according to the arterial oxygen content in order to maintain a minimal threshold of DO2 under moderate hypothermia.BY G9.213.Pulsatile perfusion may reduce postoperative pulmonary and renal complications and should be considered in patients at high risk for adverse lung and renal outcomes.B14Volatile anesthetics should be considered during CPB.B15The oxygenator exhaust concentration of volatile anesthetic agents during CPB should be at least the same as that before CPB (if used as the sole anesthetic agent), except during rewarming, when it should be increased.C4.2.8.516Oxygenator exhaust concentrations of volatile agents should be monitored during CPB.B17Doses of intravenous anesthetics and opioids, except remifentanil, during maintenance of CPB should be at least the same as before CPB (if used as the sole anesthetic agent).B18Short-acting neuromuscular blocking agents should be considered in cardiac anesthesia.B19Blood cardioplegia should be considered in selected patients to reduce hemodilution, bleeding complications, and transfusion requirements.B20Biocompatible modifications of circuits should be considered to protect the lungs from inflammatory responses and provide less oxidative stress.BB21PEEP during CPB should be considered in order to protect the lungs.B22Discarding shed blood should be considered.BClass I Level B23Processing and secondary filtration of red blood cells should be considered to decrease the deleterious effects of reinfused shed blood.B24Perfusionists should be adequat

The American Society of Extracorporeal Technology Board of Directors, consistent with the American Society of Extracorporeal Technology's safe patient care improvement mission, charged the International Board of Blood Management to write a knowledge and skill certification examination for healthcare personnel employed as adult extracorporeal membrane oxygenation (ECMO) specialists. Nineteen nationally recognized ECMO subject-matter experts were selected to complete the examination development. A job analysis was performed, yielding a job description and examination plan focused on 16 job categories. Multiple-choice test items were created and validated. Qualified ECMO specialists were identified to complete a pilot examination and both pre- and post-examination surveys. The examination item difficulty and candidate performance were ranked and matched using Rasch methodology. Candidates' examination scores were compared with their profession, training, and experience as ECMO specialists. The 120-item pilot examination form ranked 76 ECMO specialist candidates consistent with their licensure, ECMO training, and clinical experience. Forty-three registered nurses, 28 registered respiratory therapists, four certified clinical perfusionists, and one physician assistant completed the pilot examination process. Rasch statistics revealed examination reliability coefficients of .83 for candidates and .88 for test items. Candidates ranked the appropriateness for examination items consistent with the item content, difficulty, and their personal examination score. The pilot examination pass rate was 80%. The completed examination product scheduled for enrollment in March 2020 includes 100 verified test items with an expected pass rate of 84% at a cut score of 67%. The online certification examination based on a verified job analysis provides an extramural assessment that ranks minimally prepared ECMO specialists' knowledge, skills, and abilities (KSA) consistent with safe ECMO patient care and circuit management. It is anticipated that ECMO facilities and ECMO service providers will incorporate the certification examination as part of their process improvement, safety, and quality assurance plans.

Luiz Fernando Caneo1, MD, PhD; Gregory Matte2, CCP, LP, FPP; Robert Groom3, PhD; Rodolfo A. Neirotti4, MD, PhD, FEACTS; Paulo Manuel Pêgo-Fernandes5, MD, PhD; Juan Alberto C. Mejia6, MD, PhD; Fernando Augusto Marinho dos Santos Figueira7, MD; Élio Barreto de Carvalho Filho8, MSc; Fábio Murilo da Costa8, Sintya Tertuliano Chalegre9,10, MSc; Renato Abdala Karam Kalil11, MD, MSc, PhD; Rui M. S. Almeida12, MD, MSc, PhD; on behalf of DECAM/SBCCV13 and SBCEC14

Use of autotransfusion systems to collect, wash, and concentrate shed blood during surgical procedures is a widely used method for reducing postoperative anemia and the need for blood transfusions. The aim of this study was to evaluate the CATSmart Continuous Autotransfusion System wash program performance with small (200 or 700 mL) and large volumes (1,000 mL) of shed blood and to determine non-inferiority of the CATSmart to the C.A.T.S plus system. Human whole blood was collected in citrate phosphate dextrose, diluted, and divided into two aliquots to be processed as a pair using the C.A.T.S plus and CATSmart systems with their corresponding wash programs: low-volume, high quality/smart, or emergency wash. Final packed red cell product was analyzed for red blood cell (RBC), white blood cell, and platelet counts; hemoglobin; hemolysis; RBC recovery rates; and elimination of albumin, total protein, and potassium. The mean hematocrit (HCT) after processing with CATSmart and C.A.T.S plus systems were 59.63% and 57.71%, respectively. The calculated overall RBC recovery rates on the CATSmart and C.A.T.S plus systems were 85.41% and 84.99%, respectively. Elimination of albumin (97.5%, 98.0%), total proteins (97.1%, 97.5%), and potassium (92.1%, 91.9%) were also calculated for the CATSmart and C.A.T.S plus systems. The CATSmart and C.A.T.S plus systems both provided a high-quality product in terms of HCT, protein elimination, and hemolysis rates across the range of tested shed blood volumes and all wash programs. The study was able to confirm the CATSmart is non-inferior to the C.A.T.S plus system.

Thank you, Ben. I appreciate the opportunity to speak today and be part of this symposium. I do not have any relationships, financial or other conflicts of interest related to this topic, however, I do want to disclose that I am the default speaker or “weakest link” on this program today. Six months ago, when Ben and I started to talk about this session, we had a “dream team” of speakers in mind for this session. And we were able to deliver all of them today except one. Dr. Filip de Somer had planned on being here, but several weeks ago, we learned that he would not be able to attend and I am a substitute for him today. I’ll be presenting on goal-directed therapy and reviewing two important papers on that topic, one authored by Filip. I also acknowledge the work of John St. Onge from Maine Medical Center. John leads our efforts related to goaldirected therapy and it is his effort that has secured our ability to measure goal-directed perfusion (GDP) parameters at our center and he is the thought leader at our center on GDP. My aim today is to use the audience response system (ARS) to gain some context knowledge on practices of those represent in this room, specifically the things that you measure to determine adequacy of perfusion. I will review several key historic references on adequacy of perfusion. But for the most part, I will review two landmark GDP studies, one from Marco Ranucci published in the Annals of Thoracic Surgery in 2005 (1) and the second by de Somer published in Critical Care Medicine in 2011 (2). These two studies have been important catalysts to the growing interest in goal-directed therapy during cardiopulmonary bypass. Finally, I will share practical applications of this concept that we’re using at my center. So here is an ARS question. Do you measure venous oxygen saturation levels during cardiopulmonary bypass continuously, intermittently, or do not measure (Figure 1)? Okay. That’s not too surprising. The majority of us are using an inline monitor to monitor the venous saturation during bypass. And here’s the next question. Do you routinely measure carbon dioxide production index (VCO2 index; Figure 2)? This is measured at the exhaust for the oxygenator. Studies have shown that it is a good parameter related to metabolic requirement. It appears that 90% of those of us in this room do not use that technology. Do you routinely measure venous PO2 levels during adult cardiopulmonary bypass (Figure 3)? All right. Thank you. That technology is available continuously. It’s interesting that a third of us don’t measure venous partial pressures of oxygen. Early studies looked at venous PO2 and arterial to venous PO2 differences, as a measure of adequacy of perfusion. The next question, is about routine measurement of serum lactate levels during cardiopulmonary bypass (CPB) in your adult patients (Figure 4). It is apparent that more than half of us are not measuring lactates routinely in adult patients. I suspect that lactate measurement is more routinely measured for pediatric patients. You know, one of the studies that Dr. Rivers referred to was by Demers and colleagues, which showed that the critical level seems to be greater than 4 mmol/L, where there’s a sharp increase in mortality and morbidity in patients that experience a lactate greater than—greater than four during cardiopulmonary bypass (3). Professor Ranucci also looked at metabolism and anaerobic metabolism during bypass and how that relates to oxygen delivery. And in this paper published in 2006, he showed that 260 mL/min/m seems to be a critical level of oxygen delivery where lactate increases and anaerobic metabolism is quite substantial (4). Address correspondence to: Robert C. Groom, CCP, FPP, Cardiac Surgery, Maine Medical Center, 22 Bramhall St., Portland, ME 04102. E-mail: groomr@mmc.org

I’ve been asked to address the question, “Could clinical outcome registries bring us closer to consensus on the question, what is the best solution for myocardial protection?” I don’t have any financial relationships related to this subject that would constitute a conflict of interest. However, I must confess that I am really biased and want to believe registry data can inform us on practice questions like this one. Furthermore, I want to acknowledge Elaine Olmstead, an analyst for the Northern New England Cardiovascular Study Group. She provided analytical support for this presentation (Table 1). As many of the presenters have shared, there is not a lot of high-level evidence to support the use of the various cardioplegia solutions and protection techniques. Linda told us, they changed their technique at Columbia from 4:1 blood cardioplegia to 1:4 del Nido with very little scientific evidence. Think about that, it is a radical change to go from a mostly blood to mostly crystalloid, administered every 15–20 minutes to a re-administration every 90 minutes, that is radical. So the question is, in the absence of other scientific evidence, would a registry help? My experience with registries stems from my participation in a regional consortium, The Northern New England Cardiovascular Disease Study Group (NNE). The study group is composed of clinicians from eight cardiac centers that collaborate to develop and exchange information concerning the treatment of cardiovascular disease. It is a regional, voluntary, multi-disciplinary group of clinicians, hospital administrators, and health-care research personnel who seek “to improve continuously the quality,” safety, effectiveness, and cost of medical interventions in cardiovascular disease. We have registries for cardiac surgery, interventional cardiology, and anesthesia. We meet three times a year to learn from one another. The NNE group is actually meeting today in Hanover, NH. While I am pleased to be here today, I regret that I am not able to be with my colleagues at the study group meeting in Hanover. The aim of my presentation will be to discuss some of the challenges related to making inferences about cardioplegia solution or myocardial protection techniques from registry data. So what’s a registry? A registry is an organized system to collect uniform data, clinical and other, to evaluate specific outcomes for a population. If you want to learn more about registries, the Agency for Healthcare Research and Quality (AHRQ) has published a very comprehensive pamphlet on registries (1). The AHRQ pamphlet states that a registry can be used to describe the natural history of a disease, to determine clinical effectiveness or costeffectiveness of health-care products and services, or to measure or monitor the safety and harm, and/or measure quality of care. It would seem then that a registry is a suitable tool for questions about myocardial protection. There are currently three perfusion registries that collect myocardial protection data; The NNE Perfusion Registry was established in 1995 and has over 63,000 procedures. The Perfusion Down Under Registry (PDU) began collecting records in 2006, and now has about 20,000 records (R.A. Baker, personal communication, 2015) and the PERForm registry was started in 2010 and has collected 32,000 procedure records to date (D.S. Likosky, personal communication, 2015) (Table 1). The NNE Registry cardioplegia variables are shown in Table 2. We record a number of process variables including, if a cross clamp was used or not and the cross clamp time. We look at the type of cardioplegia solution that was used, the induction, dose temperature, the maintenance dose temperature, the routing, which is quite variable among centers that participate in our registry. We collect the longest period between cardioplegia doses. For coronary artery bypass cases we record, if the anastomoses Address correspondence to: Robert C. Groom, CCP, FPP, Maine Medical Center Cardiac Surgery, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. E-mail: groomr@mmc.org

Cardiac surgeons traveling to East Africa on humanitarian surgical missions treat a large number of people of all ages with rheumatic heart disease. A patient with severe mitral stenosis with pulmonary edema in the second trimester of pregnancy was treated successfully with closed mitral commissurotomy in a hospital in rural Kenya. An operation from the late 1940s may regain prominence more than 70 years later in areas of the world with a high incidence of rheumatic heart disease and limited cardiology and cardiac surgery resources. (C) 2016 by The Society of Thoracic Surgeons