Goal Directed Perfusion Is Not Associated with a Decrease in Acute Kidney Injury in Patients Predicted to Be at High Risk for Acute Renal Failure after Cardiac Surgery.

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.

Development of an Electronic Medical Record for Extracorporeal Membrane Oxygenation and Its Role in a Multidisciplinary Team.

As the extracorporeal membrane oxygenation (ECMO) program at our institution has grown and our staffing model has evolved into a multidisciplinary team, our method of ECMO charting has also evolved, using an electronic medical record (EMR) with electronic checklists, progress notes, and remote access. Using our EPIC charting platform, version 1 of our EMR was implemented in 2015. It has been revised three times, and remote access deemed necessary to properly support our staff and patients. Our current, yet still evolving, remotely accessible, ECMO EMR incorporates hourly charting and protocol-based checklists for procedures such as initiation of support, shift handoffs, circuit checks, and patient transport. Perfusionists are required to fill out thrice daily progress notes, notes for bedside/operating room procedures, and patient transport. We present a format for centers looking to implement a comprehensive EMR for ECMO patients. An expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.