Citrate does not change viscoelastic haemostatic assays after cardiopulmonary bypass.

Context: Viscoelastic hemostatic assays (VHA) are commonly used to identify specific cellular and humoral causes for bleeding in cardiac surgery patients. Cardiopulmonary bypass (CPB) alterations to coagulation are observable on VHA. Citrated VHA can approximate fresh whole blood VHA when kaolin is used as the activator in healthy volunteers. Some have suggested that noncitrated blood is more optimal than citrated blood for point-of-care analysis in some populations. Aims: To determine if storage of blood samples in citrate after CPB alters kaolin activated VHA results. Settings and Design: This was a prospective observational cohort study at a single tertiary care teaching hospital. Methods and Material: Blood samples were subjected to VHA immediately after collection and compared to samples drawn at the same time and stored in citrate for 30, 90, and 150 min prior to kaolin activated VHA both before and after CPB. Statistical Analysis Used: VHA results were compared using paired T-tests and Bland-Altman analysis. Results: Maximum clot strength and time to clot initiation were not considerably different before or after CPB using paired T-tests or Bland-Altman Analysis. Conclusions: Citrated samples appear to be a clinically reliable substitute for fresh samples for maximum clot strength and time to VHA clot initiation after CPB. Concerns about the role of citrate in altering the validity of the VHA samples in the cardiac surgery population seem unfounded.

Minimizing reperfusion injuries: successful resuscitation using eCPR after cardiac arrest on a post-operative Norwood patient.

In patients with hypoplastic left heart syndrome (HLHS), the left ventricle is too small to circulate adequate oxygenated blood. If left untreated, HLHS is fatal.A 3-staged palliative procedure ultimately leading to a single ventricle physiology is the preferred management strategy for HLHS in most pediatric cardiac centers in the United States. In this report, a 1-month-old infant developed cardiac arrest 3 weeks after undergoing a Norwood procedure as an initial palliation for HLHS. After 151 minutes of cardio-pulmonary resuscitation (CPR) with intermittent, but non-sustainable return of spontaneous circulation, extracorporeal cardio-pulmonary resuscitation (eCPR) was used. Utilizing the carotid artery and internal jugular vein for cannulation, we connected our extracorporeal membrane oxygenation (ECMO) circuit to the patient. To minimize reperfusion injury, immediate cooling, arterial/venous shunting, minimal calcium, and hemodilution strategies were used. Once paCO2/pvCO2 gradients were minimized, we instituted sweep gas and gradually increased fiO2 as pH normalized. The patient was successfully weaned from ECMO and discharged, eCPR was used successfully in the resuscitation of this patient and reperfusion injuries were minimized despite prolonged CPR.