European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept.

The Pediatric Cardiac Anesthesia (PCA) fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is evaluated critically by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Effect of modified ultrafiltration on bivalirudin elimination and postoperative blood loss after on-pump coronary artery bypass grafting: assessment of different filtration strategies.

OBJECTIVE: Bivalirudin has a short elimination half-life of approximately 25 to 30 minutes, but no antidote is available. We assessed the effect of four different strategies of modified ultrafiltration after cardiopulmonary bypass on the bivalirudin elimination and postoperative blood loss. METHODS: Five groups of seven patients undergoing elective "on-pump" coronary artery bypass grafting were enrolled in this controlled randomized investigation. The filtration strategies varied with regard to the filtration flow, the filtrate volume, the addition of vacuum suction to the filter system, and the performance of hemodiafiltration. Filtration was started after weaning from cardiopulmonary bypass (CPB). The cumulative postoperative blood drainage at 12 hours was recorded. RESULTS: Bivalirudin half-life in the control group was 0.6 +/- 0.11 hours, and the blood loss was 958 +/- 472 mL. Hemofiltration with a constant flow of 300 mL/m(2) body surface area/min and a filtrate volume of 3000 mL reduced the elimination half-life significantly to 0.47 +/- 0.11 hours. Adding the process of dialysis to hemofiltration resulted in a half-life of 0.52 +/- 0.04 hours and reduced the 12-hour postoperative blood loss significantly, compared to the control group, to 444 +/- 220 mL. The other strategies failed to augment the bivalirudin elimination and postoperative drainage effectively. CONCLUSION: Zero-balanced modified hemodiafiltration without addition of vacuum suction is effective in improving the elimination of bivalirudin after CPB and reducing the postoperative blood loss. Zero-balanced hemodiafiltration should be considered for the augmented elimination of bivalirudin in complex surgical procedures with a high risk of bleeding complications. However, larger investigations are warranted to confirm these results.

Assessment of hemostatic activation during cardiopulmonary bypass for coronary artery bypass grafting with bivalirudin: results of a pilot study.

OBJECTIVE: Bivalirudin has been successfully used as a replacement for heparin during on-pump coronary artery bypass grafting. This study was conducted to assess the effects of the currently suggested protocol for bivalirudin on hemostatic activation during cardiopulmonary bypass with and without cardiotomy suction. METHODS: Ten patients scheduled for coronary artery bypass grafting were enrolled. Bivalirudin was given with a bolus of 50 mg in the priming solution and 1.0 mg/kg for the patient, followed by an infusion of 2.5 mg . kg(-1) . h(-1) until 15 minutes before the conclusion of cardiopulmonary bypass. Cardiopulmonary bypass was performed with a closed system in 5 patients with and in 5 patients without the use of cardiotomy suction. Blood samples were obtained before and after cardiopulmonary bypass. D-dimers, fibrinopeptide A, prothrombin 1 and 2 fragments, thrombin-antithrombin, and factor XIIa were determined. RESULTS: Values for factor XIIa remained almost unchanged in both groups, indicating a minor effect of contact activation. In patients without cardiotomy suction, post-cardiopulmonary bypass values for D-dimers, fibrinopeptide A, prothrombin 1 and 2 fragments, and thrombin-antithrombin were not significantly increased compared with pre-cardiopulmonary bypass values. In patients with cardiotomy suction, values obtained for these parameters had significantly increased compared with pre-cardiopulmonary bypass values and the values obtained in the group without cardiotomy suction after cardiopulmonary bypass. CONCLUSIONS: With this protocol, hemostatic activation during cardiopulmonary bypass was almost completely attenuated when cardiotomy suction was avoided. Cardiotomy suction results in considerable activation of the coagulation system and should therefore be restricted and replaced by cell saving whenever possible.

An assessment of different filter systems for extracorporeal elimination of bivalirudin: an in vitro study.

IMPLICATIONS: Bivalirudin is a new, direct thrombin inhibitor. We investigated the extracorporeal elimination rate of different hemofilters and one plasmapheresis filter for bivalirudin. Our data show that bivalirudin can be effectively eliminated via hemofiltration and plasmapheresis, although there were significant differences in the elimination rates among the filter systems investigated.