Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Positioning document of the Spanish Association of Perfusionists in 2020. Organization and care management model for perfusion in Spain

Perfusion is a specialized healthcare area within the nursing field that deals with the application of technology for organ perfusion necessary in the treatment of disorders and diseases that require it, mainly in the cardiocirculatory system. The continuous and rapid advances in the diagnosis and treatment of diseases justify the need to carry out an update of the main defining and organizational aspects of perfusion, related to the practice and quality of care in the profession, with the training program of this area of specialization, continuing education, and accreditation processes, among others. This document, prepared by experts in perfusion and cardiovascular surgery, represents the opinion of the Spanish Association of Perfusionists, in collaboration and support of the Spanish Society of Cardiovascular and Endovascular Surgery, and updates the main aspects of perfusion in our country.

Oxygen delivery during cardiopulmonary bypass and acute kidney injury: Preliminary Study

Objective: to assess the relationship between oxygen delivery during cardiopulmonary bypass and the incidende of acute kidney injury in the immediate postoperative period of patients undergoing cardiac surgery, as well as to identify possible risk factors. Methods: A retrospective observational study of patients undergoing cardiac surgery scheduled between May 2016 and February 2018 was carried out in which the M-M4 System was used for online blood gases. Patients with preoperative diagnosis of chronic renal failure were excluded. For the oxigen delivery, the average of all M4 records was made. Results: 133 patients (35.3% women) with a mean age of 64.9 ± 10.9 years were studied. The incidence of acute kidney injury was 18.8% (AKI I: 12%; AKI II: 3%; AKI III: 3.8%). There was no correlation between acute kidney injury and O2 delivery (251 ± 43 vs 247 ± 52, ns), if there was a difference when patients needed renal replacement therapy (251 ± 43 vs 198 ± 18, p = 0.04). There was a significant increase risk in diabetes; HTA; pulmonary arterial hypertension; chronic atrial fibrilation; red blood cell concentrate and blood products administration in the operating room; redo for bleeding; high lactic acid and glycemia post cardiopulmonary bypass; prolonged pump and ischemia times; and combined surgery. Conclusions: There was no direct relationship between O2 delivery and acute kidney injury, although there was a significantly lower O2 delivery in patients who needed postoperative renal replacement therapy.

Optimal perfusion: Review based on recent scientific evidence

Introduction: Throughout the history of extracorporeal circulation there have been several controversial aspects regarding the management of the different physiological, hemodynamic and technical variables. In this review we will synthesize recent scientific evidence of what we call "optimal perfusion". Method: The bibliographic search was carried out in the Cochrane and MEDLINE databases using the PubMed search engine, where the main term was “optimal perfusion” combining it with MeHS terms such as “cardiopulmonary bypass”, “cardiac surgery”, “acute kidney injury” and “goal directed perfusion”. Results: 168 references were obtained, of which 61 were selected for later analysis and synthesis. The main blood pressure remains one of the parameters with less consensus, especially in high-risk patients. The incidence of acute renal failure after cardiac surgery associated with extracorporeal circulation has undergone a notable change thanks to the management of physiological variables or the so-called goal directed perfusion. With these strategies it has been possible to update and review the critical hematocrit in order to ensure a constant and optimal oxygen supply at all times and avoid tissue hypoperfusion and its incidence in global morbidity. Conclusions: The parameters referred to as "optimal" are under continuous review and analysis and, together with the advances in active and real-time monitoring of the delivery and consumption parameters, have changed management in our daily clinical practice.

Anticoagulation management in neonatal and pediatric ECMO

Introduction: Despite significant advances in the materials, components and techniques used for extracorporeal life support in recent years, the management of anticoagulation in ECMO remains controversial, the objective of this protocol is to develop an update for anticoagulation and its control for infants ECMO. Development: Unfractionated heparin is the drug of choice for anticoagulation in ECMO. The heparin dose used in pediatrics have been mostly adapted from the experience in adults without a corresponding validation, as well as limiting the absence of randomized clinical trials in children. After the assessment of the patient and a possible correction of coagulopathies, prior to establishment of ECMO, as well as decide the administration of a heparin bolus of 50-100 IU/kg of body weight at the time prior to cannulation. At 5-10’ of beginning ECMO a ACT control is made, if the value is greater than 300 sg, ACT is repeated at 30-60’. Once the ACT is less than 300, an infusion starts between 10-20 IU/kg/h, in the absence of major bleeding. Controls will be carried out every 30’ to stabilize the ACT in the chosen range. For the control, the ACT will be used, mainly, and the APTT, with better results the higher the child's age, although the anti-Xa test is the only laboratory test that shows a strong correlation with the heparin dose administered in ECMO.

Analysis of online gas monitoring CDI 500® and SYSTEM M-M4®. Are they comparable tools for clinical perfusion practice?

Objective: to compare the data obtained from the CDI500® and Spectrum M4® to assess the reliability of the results and their impact on cardiopulmonary bypass. Methods: a prospective observational study of patients undergoing cardiac surgery with CPB was conducted between January-2017 and February-2018. The data provided by CDI and M4 was collected. Arterial and venous blood gases taken from Radiometer ABL90 Flex® were used as control. With the first sample, the data of both analyzers were adjusted. A minimum of two samples and a maximum of four were made. Results: 100 patients and 292 samples (32% women) with a mean age of 65.2 ± 11.5 years were studied. The parameters of the CDI and M4 practically did not present significant differences after the first adjustment, and without affecting the clinical practice, except in the bicarbonate and the excess of base where CDI does not adjust to the values. The analysis was done with the Bland/Altman charts, the PCO2 and PO2 were better measured by the CDI while Hto, Hb and SvO2 by M4, which was corroborated comparing the error percentages less than ± 5% in both systems, the significant differences being in the five parameters. Conclusions: both systems provide reliable data, although they require a previous calibration. The M4 allows direct evaluation of data to help a goal directed perfusion.

Hemodynamic and functional effectiveness of the patient undergoing pulmonary thromboendarterectomy

Objective: to evaluate the hemodynamic and functional effectiveness of the patient undergoing thromboendarterectomy. Methods: a descriptive study of series of cases in postoperative patients of thromboendarterectomy from 2002 to 2016 with complete records was carried out. The data collection was done with an "ex profeso" sheet of 10 demographic items, 2 of somatometry, 6 hemodynamics, 1 functional, 6 gasometric and 9 of perfusion conduction, with open and dichotomous responses. For the data analysis, descriptive statistics, U Mann-Whitney tests and Kaplan-Meier survival analysis were applied; the significance was set at p <0.05. Results: 25 patients were studied, male prevalence (68%), age 43 ± 18 years. The cardiopulmonary bypass time was 222 ± 73 min. and the aortic clamp of 121 ± 71 min; in 80%total circulatory arrest was performed for periods of 20 min and reperfusion times of 10 min between each one. 20% of the patients were managed with selective cerebral perfusion. Thromboendarterectomy decreased pulmonary vascular resistance (p <0.0001) and mean pulmonary arterial pressure (p = 0.001) and increased cardiac output (p = 0.009), PaO2 (p = 0.035) and SaO2 (p = 0.015). 72% improved the functional class from III-IV to I-II. There was mortality of 20% associated to persistence of pulmonary arterial hypertension and the three-year survival was 80%. Two patients required ECMO A-V both successful. Conclusion: Thromboendarterectomy is the treatment of choice for patients with chronic pulmonary thromboembolism, significantly improving hemodynamic and functional parameters, reflected in their quality of life and survival.

Neurological monitoring as a safety system in patients undergoing cardiac surgery with cardiopulmonary bypass

Objective: to evaluate the adequate cerebral perfusion in patients who underwent cardiac surgery with cardiopulmonary bypass. Methods: an observational, analytical, prospective and multicentric study was conducted. All adults patients scheduled for cardiac surgery with cardiopulmonary bypass were included, with hospital admission at least the day before the intervention, with a negative Pfeiffer test, without communication problems, and with informed consent. Cerebral monitoring with Masimo ROOT 03® was used with encephalogram measurement (4 channels), cerebral oximetry and anesthetic depth. As a pre and postoperative cognitive assessment instrument we used the Pfeiffer test. Results: 19 patients with a mean age of 64.8 ± 11.5 years were included. The postoperative Pfeiffer test showed no cognitive impairment in 78.9% of the cases. While the remaining 21.1% had mild cognitive impairment (1 patient had ischemic damage). In this group, all were valvular patients, older than 65 years of age, and had maximum glycemias greater than 180 mg/dL. In 75% of the patients with cognitive impairment, the baseline SrO2 was less than 57%, there was sustained hypotension at sometime during surgery and it had a decrease of more than 20% of its basal SrO2. Conclusions: Continuous brain monitoring (electroencephalogram, cerebral oxygen saturation, anesthetic depth, suppression rate) during cardiac surgery with cardiopulmonary bypass is a reliable, valid and necessary safety measure to improve the quality of perfusion and surgical patient care.

Goal Directed Perfusion: Bibliographical Review

Objective: The aim of this study is to synthesize the existing evidence on Goal Directed Perfusion Methods: The search for the existing evidence was made in the MEDLINE databases, using the PubMed search engine. The initial search term was “goal directed perfusion.” In order to narrow the search, MeHS terms such as “cardiac surgery” and “cardiopulmonary bypass” were used together with the initial term and the Boolean operator AND. Results: At first, 238 references were obtained, combined whit “cardiac surgery” there were 49 references and finally whit “cardiopulmonary bypass” 21. We read 23 articles. Levels of oxygen delivery (DO2i) > 272 ml/min/m2, minimize hemodilution an maintain hematocrit values > 26% decrease acute kidney injury. A carbon dioxide production VCO2 i > of 60 ml/min/m2 and DO2i/VCO2i < 5 are predictors of hyperlactatemia. The mixed venous oxygen saturation (SvO2) and the oxygen extraction rate (ERO2) are better predictors of transfusion during extracorporeal circulation than hemoglobin value. The majority of the bibliography refers to adult surgery, but the application of GDP to the pediatric perfusion is beginning. Conclusion: The improvement of “optimal” perfusion, considered the gold standard, towards goal directed perfusion is already in use. Many hospitals are incorporating online monitoring of the new perfusion parameters in order to apply a specific perfusion to each patient as well as his metabolic needs during extracorporeal circulation.