Development of the Adult ECMO Specialist Certification Examination.

The American Society of Extracorporeal Technology Board of Directors, consistent with the American Society of Extracorporeal Technology's safe patient care improvement mission, charged the International Board of Blood Management to write a knowledge and skill certification examination for healthcare personnel employed as adult extracorporeal membrane oxygenation (ECMO) specialists. Nineteen nationally recognized ECMO subject-matter experts were selected to complete the examination development. A job analysis was performed, yielding a job description and examination plan focused on 16 job categories. Multiple-choice test items were created and validated. Qualified ECMO specialists were identified to complete a pilot examination and both pre- and post-examination surveys. The examination item difficulty and candidate performance were ranked and matched using Rasch methodology. Candidates' examination scores were compared with their profession, training, and experience as ECMO specialists. The 120-item pilot examination form ranked 76 ECMO specialist candidates consistent with their licensure, ECMO training, and clinical experience. Forty-three registered nurses, 28 registered respiratory therapists, four certified clinical perfusionists, and one physician assistant completed the pilot examination process. Rasch statistics revealed examination reliability coefficients of .83 for candidates and .88 for test items. Candidates ranked the appropriateness for examination items consistent with the item content, difficulty, and their personal examination score. The pilot examination pass rate was 80%. The completed examination product scheduled for enrollment in March 2020 includes 100 verified test items with an expected pass rate of 84% at a cut score of 67%. The online certification examination based on a verified job analysis provides an extramural assessment that ranks minimally prepared ECMO specialists' knowledge, skills, and abilities (KSA) consistent with safe ECMO patient care and circuit management. It is anticipated that ECMO facilities and ECMO service providers will incorporate the certification examination as part of their process improvement, safety, and quality assurance plans.

An in-vitro comparison between Hemobag and non-Hemobag ultrafiltration methods of salvaging circuit blood following cardiopulmonary bypass.

Ultrafiltration of the residual cardiopulmonary bypass circuit blood has become one of the most advantageous procedures to maximize autologous whole blood recovery and coagulation management in cardiovascular surgery. In this in-vitro study, the Hemobag technique (HB) was compared to the most common non-Hemobag method (NHB) of hemoconcentrating residual circuit blood. The residual bovine blood from 10 identical extracorporeal circuits was processed by the recirculating HB technique or by a venous reservoir NHB concentration method. Blood component concentrations and hemolysis levels were measured before and after processing. The HB method yielded significantly higher hemoglobin, hematocrit, fibrinogen, albumin, and total protein levels in the final product. There was no significant difference in final product platelet and white blood cell counts, or hemolysis index. HB processing times were substantially shorter at all residual circuit volumes tested. The HB technique resulted in significantly less wasted red blood cells at the end of processing. The recirculating HB method to process residual extracorporeal circuit blood is consistent and superior to the most common single pass concentrating method.

State-of-the-art blood management in cardiac surgery.

Blood has been described as the most precious and personal substance in the world. Current directions in cardiac surgery are moving away from transfusing donor "Allogeneic" blood products, and towards improving methods of saving and preserving the patient's own "autologous" blood. Nothing else comes close to the natural healing abilities and homeostasis that one's own whole blood offers. No substitute, whether it is human or artificial, will ever work as well with fluid shifts, hemostasis and homeostasis. News reports today commonly feature severe blood shortages and research documenting recognized transfusion risks such as how older stored blood can put heart surgery patients at increased risk and others that point to the morbidity and mortality associated with its use. Therefore the medical community is moving towards more effective blood utilization by minimizing the exposure to donated blood. Current techniques are saving as much as possible of the patient's own blood that might otherwise be mismanaged or lost during surgery. Techniques, such as Ultrafiltration, that quickly concentrate and reinfuse whole blood back to the patient are the best choice. Admission to discharge hemovigilance requires a concerted multidisciplinary team effort with multimodal tools available in the coagulation armamentarium to effectively avoid this form of organ transplant. Improving outcomes and reducing morbidity and mortality in cardiac surgery takes place at the microcirculatory capillary level and with control of Hemostasis. Cardiac teams need to effectively communicate and minimize blood loss and hemodilution and reverse it, for state of the art blood management in Cardiac surgery.

On-line autotransfusion waste calculator.

Cell concentrating and washing techniques are widely accepted and believed to be beneficial to cardiac surgery patients. During cell processing, platelets, proteins, and clotting factors are wasted as the plasma is washed away by saline. Beneficial and costly plasma constituents are sacrificed for the sake of removing potentially harmful drugs, debris, and naturally activated cells and chemical mediators. An interactive Microsoft Excel spreadsheet was designed to input patient and autotransfusion system (ATS) reservoir blood values, processed centrifugal bowl data, and hospital allogeneic blood product concentration and cost information. The spreadsheet calculates the number of wasted platelets, grams of protein, and milligrams of fibrinogen. The calculator further estimates the number of units and cost of allogeneic blood products needed to replace the wasted blood components. The simulation allows for variable levels of platelet activation and protein removal during centrifugal cell processing. Specific case scenarios may be simulated with the calculator. If a known volume of residual extracorporeal circuit blood with a known hematocrit, platelet count, and protein concentration is diverted to the ATS reservoir to be processed and washed after bypass, the number of units of fresh frozen plasma, platelet packs, and albumin concentrate needed to replace the wasted proteins and platelets may be calculated. When typical end-bypass patient and blood bank product values are input, the cost to replace the wasted blood components in 1550 mL of residual circuit blood with allogeneic blood products is about US $2097. There are risks and costs associated with replacing the platelets, proteins, and clotting factors wasted during cell washing compared with other techniques such as whole blood ultrafiltration.

A new practical technique to reduce allogeneic blood exposure and hospital costs while preserving clotting factors after cardiopulmonary bypass: the Hemobag.

Recent data independently linking allogeneic blood use to increased morbidity and mortality after cardiopulmonary bypass (CPB) warrants the study of new methods to employ unique and familiar technology to reduce allogeneic blood exposure. The Hemobag allows the open-heart team to concentrate residual CPB circuit contents and return a high volume of autologous clotting factors and blood cells to the patient. Fifty patients from all candidates were arbitrarily selected to receive the Hemobag (HB) therapy. A retrospective control group of 50 non-Hemobag (NHB) patients were matched to the HB group patient-by-patient for comparison according to surgeon, type of procedure, age, body surface area (BSA), body weight and CPB time. Many efforts to conserve blood (Cell Saver and ANH) were employed in both groups. Post-CPB cell washing of circuit contents was additionally employed in the control group. There were no significant differences between the HB and NHB groups in regard to patient morphology, pre-op cell concentrations, distribution of surgeon or procedures (41% valve, 16% valve/coronary artery bypass graft (CABG), balance CABG), pump and ischemic times and Bayes National Risk scores. The average volume returned to the patient from the HB was 817+/-198 mL (1 SD). Average processing time was 11 min. The Hemobag contained an average platelet count of 230+/-80 K/mm3, fibrinogen concentration of 413 +/- 171 mg/dl, total protein of 8.0+/-2.8 gm/dl, albumin of 4.4+/-1.2 gm/dl and hematocrit of 43+/-7%. Factor VII, IX and X levels in three HB contents averaged 259% greater than baseline. Substantial reductions were achieved in both allogeneic blood product avoidance and cost to the hospital with use of the HB. Infusion of the Hemobag concentrate appears to recover safely substantial proteins, clotting factor and cell concentration for all types of cardiac procedures, maintaining the security of a primed circuit.