Bicarb Alternatives: Sodium Acetate & Balanced Crystalloids

Editor’s Note:   Authorization for the contributions below were obtained from each contributor via email.  Please see comments section… THAM A a Buffer Tham Description Tham Solution (tromeThamine injection) is a sterile, non-pyrogenic 0.3 M solution of tromeThamine, adjusted to a pH of approximately 8.6 with glacial acetic acid. It is administered by intravenous injection, by […]

Management of weaning from cardiopulmonary bypass after cardiac surgery

Editor’s Note: Oddly enough, I was searching for some information regarding observed hypotensive states post CPB- associated with pump blood reinfusion, when I came upon this very cogent and well written article.  So I diverted my attention for the time being, to sharing this resource. Ill get back to the previous search later 🙂 Enjoy […]

Why is my Patient Bleeding? A Snapshot of Hemostasis, Part II

Click on image to view source article Editor’s Note: We have all revisted this pathway intensively throughout our careers, and of course, we have all been clinically challenged by open-heart cases that test our fundamental understanding of coagulation theory in real time, at a level that certainly reflects a fairly deep dive into esoteric hematology. So i am keeping it simple, and found […]

The ‘Third Space’–Fact or Fiction?

“While I was familiar with the concept of “third spacing”, I needed to clarify the implied “first”, and “second” spaces.” Editor’s Note: Back quite a while ago, I was really into publications, and the academic side of cardiac perfusion and education.  Part of what we do involves some major fluid shifts within the patient as […]

Aortic Stenosis

Aortic Stenosis Rheumatic heart disease and calcification deposits due to age (senile calcific aortic stenosis) are the most common pathologic conditions associated with aortic stenosis.  Congenital malformations such as a bicuspid aortic valve with a small annulus, or unicuspid valve usually develop symptoms at an early age but occasionally surface in later years.  Calcification of […]

Cardiac Blood Flow & O2 Consumption

“The major vessels of the coronary circulation are the left main coronary that divides into left anterior descending and circumflex branches, and the right main coronary artery.” Source: Cardiovascular Physiology Concepts Richard E. Klabunde, PhD The major vessels of the coronary circulation are the left main coronary that divides into left anterior descending andcircumflex branches, and the right main coronary artery. […]

Myocardial Ischemia: The Best Timing for Engaging CPB for Revascularization

Editors Note: Having been in the field for awhile, and being an STS data coordinator, the timing of surgery for patients suffering from an acute evolving myocardial infarction (AEMI) has always intrigued me. The STS data form is very specific in tracking these intervals, and I am naturally curious as to what the impact on […]

A Unique Case Review:

Authored by Steve Sutton, LP, CCP Editor’s Note: Steve Sutton is well known and highly regarded into today’s Perfusion community.  He is a strong proponent for advancing Perfusion education and in pursuing that goal,  he has given numerous presentations at some of the most  premier Perfusion meetings held each year. Along with his dedication to […]

Adequacy of Perfusion:

Adequacy of Perfusion:  By Steve Sutton, LP, CCP Editor’s Note: Steve Sutton is well known and highly regarded into today’s Perfusion community.  He is a strong proponent for advancing Perfusion education and in pursuing that goal,  he has given numerous presentations at some of the most  premier Perfusion meetings held each year. Along with his […]

And Then Comes Sunday …

24 Hours… of ECMO New Beginnings   (To view the entire “Day In The Life” series Click Here) Jesse Shipman struggles to do a stretch during a therapy session with occupational therapist Megan Taylor at TrustPoint Hospital in Lubbock, Texas Tuesday, June 12, 2011. (Miranda Grubbs/ Lubbock Avalanche-Journal) To view the entire “Day In The […]

CNS & CPB

CNS & CPB The major postoperative neurological complication associated with open-heart surgery and cardiopulmonary bypass is stroke, which is defined as a sudden onset of a focal deficit of the central nervous system lasting longer than 24 hours.  While this clinical finding occurs in approximately 1-5% of cardiac surgery patients, 70% of cerebrovascular sequelae occur […]

Intracardiac Pressures

Intracardiac Pressures = Right ventricular systolic pressure Right ventricular systolic pressure (RVSP) can be easily assessed in most subjects who present some degree of tricuspid regurgitation. The velocity recorded across the regurgitant jet corresponds to the right ventricular-right atrial gradient (RV-RA ΔP), so that, this value added to mean right atrial pressure (RAP) represents the […]

Intracardiac Shunts

Principles of Intracardiac Shunts Significant hypoxemia can result from right-to-left intracardiac shunting through a patent foramen ovale, an atrial septal defect or a ventricular septal defect. Pulmonary embolus, congenital heart disease and pericardial tamponade are well-recognized causes of right-to-left shunting. With the continued presence of a congenital defect of the cardiac septum or great vessels […]

Mitral Insufficiency

Mitral Insufficiency Six anatomical components must mesh synchronously to insure proper function of the mitral valve.  Disruption of the kinetic interrelationship between the left ventricular wall, the left atrial wall, valve leaflets, annulus, chordae tendineae, and papillary muscles, may lead to dysfunction of the valve.  Chronic mitral valve insufficiency (regurgitation) most often results from rheumatic […]

Right Ventricular Function

Right Ventricle The right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk. It is triangular in form, and extends from the right […]

Letters To ‘Surfers: From China: Pediatric Priming Solutions ?

(Click Image to Enlarge) Editor’s Note: I got this question regarding pediatric priming protocols from a perfusionist in China. My pediatric experience is limited to ECMO- so I defer to the more experienced pediatric perfusionists out there to help formulate an informed response 🙂 Leave your answers or suggestions in the “Comments” section plz? Frank […]

Cold Agglutinins

Literature: Click image to view source article Cold Agglutinins in Cardiac Surgery: Management of Myocardial Protection and Cardiopulmonary Bypass CAs are autoantibodies to RBC antigens [3], which can causesystemic thrombosis and hemolysis. The cause of these CAs maybe primary/idiopathic, or more commonly, secondary to an infectiveprocess (eg, mycoplasma, human immunodeficiency virus) or alymphoproliferative disorder [2]. […]

Heparin: Factors Affecting & it’s Effects [Reprint]

HEPARIN ONSET: Maximal at 1 minute past atrial delivery: Measured at radial artery.  Note:  10-20% reduction in svr without affecting c.o. and or h.r. LUNG VS MUCOSAL: Mucosal requires larger doses- but can be reversed with 25-30% less protamine:  greater postoperative blood loss associated with mucosal heparin- speculated to result from lower molecular weight & […]

The A1C : “Say Hello To My Little Friend…”

Glycosylated Hemoglobin Called also hemoglobin A1c. Hemoglobin A with a glucose moiety attached to the amino terminal valine of the beta chain. This type of hemoglobin is made at a slow constant rate during the life span of the erythrocyte. Increased levels correlate with glucose intolerance in diabetes. With adequate insulin treatment, levels return to […]

Malignant Hyperthermia

Editor’s Note: Just a brief primer on Malignant Hyperthermia, should the need ever arise to place a patient on CPB who has been diagnosed with this condition. It is an unusual co-morbidity and should be approached and treated with an abundance of clinical respect and caution.  Any insight or recommendations from readers would be greatly […]

Ventricular Hypertrophy & Perfusion

LVH :  Photo by:  Srinivas Rao @ Gruppo dei Perfusionisti!!! Ventricular Hypertrophy & Perfusion Subendocardial Q Determinants While subendocardial and sub-epicardial layers have the same determinants for blood flow, subendocardial layers are at greater risk from ischemia and infarction.  The deeper subendocardium is subjected to greater wall tension which then expresses as a metabolic requirement […]

Sickle Cell Anemia & CPB

I.    DESCRIPTION: Sickle Cell hemoglobinopathy is a single gene recessive disorder that involves an abnormality of the hemoglobin (Hgb) molecule.  This disorder causes the red cell to sickle under certain circumstances.  A sickled cell cannot undergo normal respiratory functions and they interfere with normal blood circulation. Sickle cell disease is genetic and a patient may […]

Heparin: Factors Affecting & it’s Effects

HEPARIN ONSET: Maximal at 1 minute past atrial delivery: Measured at radial artery.  Note:  10-20% reduction in svr without affecting c.o. and or h.r. LUNG VS MUCOSAL: Mucosal requires larger doses- but can be reversed with 25-30% less protamine:  greater postoperative blood loss associated with mucosal heparin- speculated to result from lower molecular weight & […]

A Thesis from Japan [ 8 ] Pediatric Q Rates ?

Presentation authored by:  Hiroyuki Kuromitsu (Hiro) Editor’s Note: Hiro Kuromitsu is very active as a Japanese perfusionist, and has been an on-line FaceBook friend for quite some time.  He will be presenting a paper on Pediatric Flow Rates / CPB at the 21st Annual Meeting of the Asian Society for Cardiovascular and Thoracic Surgery in […]

Deep Hypothermia: Antegrade & Retrograde Cerebral Perfusion

Editor’s Note: Deep Hypothermic Circulatory Arrest (DHCA), is a concept discussed here in this forum, as well as a significant perfusion event when it comes to the horizon. Obviously an issue for aortic dissections, transections, or congenital malformations that require a surgical approach and repair that can only be accomplished by intermittent or momentary cessation […]

Deep Hypothermia: Rapid Cooling & Nitroglycerine

Editor’s Note: Deep Hypothermic Circulatory Arrest (DHCA), is a concept discussed here in this forum, as well as a significant perfusion event when it comes to the horizon. Obviously an issue for aortic dissections, transections, or congenital malformations that require a surgical approach and repair that can only be accomplished by intermittent or momentary cessation […]

Slow Motion Calm: Stress During Open-Heart Surgery…

Cardiac Surgeon, William Springer-  running a half marathon. Editor’s Note: Have you ever noticed that when you are in a serious situation on bypass- or things start to go awfully wrong, that time seems to slow a bit, and you are actually accomplishing the tasks needed to fix the situation much faster than you perceive […]

The “Hot Shot” : A Layman’s Approach to Myocardial Protection

A Salient Point from a Perfusionist: “I will give one good example of how a warm/hot shot worked for us. We finished up a normal 4 banger and before doing the proximals with the cross clamp on we routinely give a short hot shot, actually its room temperature shot, but I digress. The clamp was […]

CO2 Embolisms & What Not …

Editor’s Note: We encounter CO2 in the operating room every day.  With the advent of so many new OR procedures requiring the use of scopes, mini-incisions, and endoscopic approaches for things like saphenous vein grafting, robotic surgeries, and on and on, the CO2 tank is as necessary and recognizable as an oxygen tank. There are […]

Subendocardial Blood Flow Determinants

Editor’s Note: Subendocardial Blood Flow Determinants While subendocardial and sub-epicardial layers have the same determinants for blood flow, subendocardial layers are at greater risk from ischemia and infarction.  The deeper subendocardium is subjected to greater wall tension which then expresses as a metabolic requirement 10-20% greater than the more superficial epicardium. Higher oxygen demand and […]

Refining Extracorporeal Support Strategy: Oxygen Pressure Field Theory IX

OPFT Part IX:   Using OPFT to Refine Extracorporeal Support Strategy. The anion gap is the difference in the measured cations and the measured anions in serum, plasma, or urine. The magnitude of this difference (i.e. “gap”) in the serum is often calculated in medicine when attempting to identify the cause of metabolic acidosis. If the […]

Interpretation of the Anion Gap: Oxygen Pressure Field Theory VIII

OPFT Part VIII:  Interpreting the Anion Gap The anion gap is the difference in the measured cations and the measured anions in serum, plasma, or urine. The magnitude of this difference (i.e. “gap”) in the serum is often calculated in medicine when attempting to identify the cause of metabolic acidosis. If the gap is greater […]

The Anion Gap: Oxygen Pressure Field Theory VII

OPFT Part VII:  The Anion Gap The anion gap is the difference in the measured cations and the measured anions in serum, plasma, or urine. The magnitude of this difference (i.e. “gap”) in the serum is often calculated in medicine when attempting to identify the cause of metabolic acidosis. If the gap is greater than […]

Microvascular Redistribution: Oxygen Pressure Field Theory VI

Part VI:  Microvascular  Redistribution (Click Image to View Online Power Point Presentation) Authored by:  Gary Grist,  BS, RN, CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here Mr Gary Grist delivered a seminar on this topic at The Missouri Perfusion Society 16th Annual Meeting titled “Beyond The Fick Equation”  on June […]

The Role of Carbon Dioxide: Oxygen Pressure Field Theory V

Part V:  The Role of Carbon Dioxide Which of these unlikely bypass candidates- ” Ain’t Gonna Make It? “ Authored by:  Gary Grist,  BS,  CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here Carbon Dioxide Pressure Field Theory The term Oxygen Pressure Field Theory is a misnomer if the perfusionist is […]

Axial Gradients: Oxygen Pressure Field Theory IV

Part IV:  Axial Gradients Authored by:  Gary Grist,  BS, RN, CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here Axial Gradients To review, Oxygen Pressure Field theory states that there is an oxygen pressure field established in the tissues around each capillary where oxygen is present in varying concentrations from as […]

Perfused Capillary Density: Oxygen Pressure Field Theory III

Part III:  Perfused Capillary Density Authored by:  Gary Grist,  BS, RN, CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here Perfused Capillary Density The development of a lethal corner is dependent on the ratio of the capillary X-section to the cylinder X-section and/or a change in oxygen consumption.  The ability of […]

The Lethal Corner: Oxygen Pressure Field Theory II

Part II:  The Lethal Corner Authored by:  Gary Grist,  BS, RN, CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here The Lethal Corner The Krogh cylinder predicts a wide range of tissue pO2 values called an oxygen pressure field surrounding individual capillaries. As the relationship between the capillary and its surrounding […]

Oxygen Pressure Field Theory I

Oxygen Pressure Field Theory. Authored by:  Gary Grist,  BS, RN, CCP, LCP    To View all of Gary Grist”s Posts Regarding OPFT-  click here INTRODUCTION: I would like to begin a perfusion discussion of a subject about which most perfusionists know nothing.  Yet, in my opinion, it is vital to the basic understanding of perfusion science.  […]

ICPB: A Stroke Window

The 1st Stroke Window … Gauging & Avoiding & Being Smart About it… Bump up the age, notice the increased cerebral vascular issues, mix in a low body weight, a little calcium (in terms of deposits- here and there), a stiffened aorta, a low hemoglobin, and perhaps a significant hemodilutional drop once on bypass, and […]

Methemoglobin (METHB)

I.    DESCRIPTION: Methemoglobin (METHB) is a condition by which oxygen molecules cannot bind to hemoglobin thus the patient presents with a distinct cyanosis.  The cyanosis occurs due to an  altered hemoglobin ion from the reduced form to the oxidized ferric molecule.  This molecule is not capable of binding to or releasing oxygen. The  distinct cyanosis […]

Fetal-Hemoglobin (HbF)

“The left shift of the oxyhemoblobin dissociation curve in the presence of significant quantities of HbF indicates that there is a propensity for low delivery of oxygen to tissues.” I.    DESCRIPTION: Fetal-hemoglobin (HbF) is an abnormal hemoglobin which is characterized by the presence of 2 alpha and 2 gamma chains in its structural configuration.  HbF […]

The Role of Nitric Oxide in Myocardial Ischemia / Reperfusion

(Click above to view source article) ABSTRACT = Objective: The role of nitric oxide (NO) in myocardial ischemia/reperfusion is controversial. While some studies have shown cardioprotective effects of NO, others suggested that increased myocardial NO release secondary to ischemia may contribute to reperfusion injury. However, the impact of cardioplegia-induced myocardial ischemia/reperfusion on the activity of […]

Survey Results: Graft Preservation During Heart Transplant

Photograph by Dario Fichera:  Click Image to view Facebook Profile. Editors Note: I contacted Mr. Morton regarding permission to reprint the results of this survey.  I thank him for this opportunity.  It was initially submitted to AMSECT via PERFLIST. Graft Preservation During Heart Transplant Authored by:  John Morton, BS, CCP “I would like to thank […]

MicroCircuits & Rapping : [Reprint]

MicroCircuits & Rapping (Click Here if you want to skip to a list of posts) In the last 15 months, our institution decided to get aggressive about reducing our transfusion rate, and the numbers of patients that had postoperative bleeding issues. Originally our aim was to reduce the circuit size and use the integrated microcircuits […]