Pretreatment with an intravenous lipid emulsion increases plasma eicosapentanoic acid and downregulates leukotriene b4, procalcitonin, and lymphocyte concentrations after open heart surgery in infants.

BACKGROUND: The effect of providing a lipid emulsion containing medium-chain triglyceride (MCT), soybean oil, and fish oil in critically ill infants is not widely studied. This study investigated lipid emulsion effects on plasma phospholipids and immune biomarkers. MATERIALS AND METHODS: Thirty-two infants undergoing cardiopulmonary bypass (CPB) and dependent on parenteral nutrition (PN) were randomized to receive either soybean oil (control, n = 16) or a 50:40:10 mixture of MCT, soybean oil, and fish oil (treatment, n = 16). PN was administered for 3 days preoperatively and 10 days postoperatively. Fatty acids, procalcitonin (PCT), leukotriene B4 (LTB4), and lymphocytes were quantified at baseline, before surgery, and days 1, 7 and 10 after surgery. RESULTS: PCT was significantly lower in the treatment vs control group 1 day postoperatively (P = .01). The treatment group exhibited a lower ω-6 to ω-3 ratio (P = .0001) and a higher ω-3 concentration at all postoperative study periods (P = .001). Treatment resulted in higher (P < .05) plasma phospholipid eicosapentaenoic acid (EPA) on days 7 and 10, while α-linolenic acid, arachidonic acid, and docosahexaenoic acid remained constant. An increase in plasma phospholipid EPA concentration was associated with a decrease in plasma phospholipid LTB4 concentration (P < .05). On postoperative day 10, treatment infants with high Pediatric Risk of Mortality III scores exhibited a 45% lower lymphocyte concentration (P < .05). CONCLUSION: These findings suggest that treating infants undergoing CPB with a lipid emulsion containing ω-3 improves fatty acid status and results in a lower inflammatory response after surgery. Overall, this alternative ω-3-enriched lipid emulsion may benefit clinical outcomes of critically ill infants after cardiac surgery.

The new role of the perfusionist in adult extracorporeal life support.

Adult and pediatric extracorporeal life support (ECLS) has been transformed by the European(1) and Australian( 2) experiences with a reduction of the circuit to its most basic form (Figure 1). Many factors have converged at this point in time to allow us to offer this support. The availability in the U.S.A. of an advanced oxygenator (Quadrox(D)) (Maquet Inc., Bridgewater, NJ), long-term centrifugal pumps and circuit coatings offers us the means to provide ECLS. The other equally important factor is the intensivist trained in extracorporeal therapies. Once the intensive care unit registered nurse (ICU RN) is trained to safely and effectively manage both the patient and ECLS circuit, this support may be offered. The perfusionist is in an unique position to educate and mentor the ICU RN in ECLS. There is, perhaps, no one in a better position to explain this equipment and its uses in an interdisciplinary-oriented pediatric and adult ECLS program than a perfusionist.

Portable rapid response extracorporeal life support: a center's 20-year experience with a registered nurse-run program.

If advanced cardiac life support therapy fails to revive a patient, extracorporeal life support (ECLS) becomes a critical bridge that maintains total systemic circulation and oxygenation during cardiac arrest or severe respiratory failure and allows time to establish a treatment plan. Improved patient outcomes depend on a shorter time period from the start of advanced cardiac life support to the initiation of ECLS. An in-house critical care nurse response team facilitates rapid initiation of ECLS, often in less than 20 minutes, at any time in any area of the hospital. Since 1986, Sharp Memorial Hospital has placed 176 patients on ECLS, using a registered nurse team with a survival rate greater than 30 days of 27.7%. The system used for rapid and mobile initiation of ECLS maintains perfusion to the vital organs via a centrifugal flow pump, using a hollow-fiber membrane oxygenator and percutaneous cannulas. Team members prime the system while the ECLS-trained first-response physicians place cannulae. All elements of program development, team education, and ongoing program maintenance are critical to successful outcomes for patients.

Innovative solutions: development and implementation of a tight blood glucose management protocol: one community hospital's experience.

Blood glucose monitoring and control are an important component of nursing care for the critically ill patient. This article discusses the efforts of one community hospital in the development of a tight blood glucose management protocol for cardiopulmonary bypass patients.

Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery.

OBJECTIVE: To assess whether a nurse led, flow monitored protocol for optimising circulatory status in patients after cardiac surgery reduces complications and shortens stay in intensive care and hospital. DESIGN: Randomised controlled trial. SETTING: Intensive care unit and cardiothoracic unit of a university teaching hospital. PARTICIPANTS: 174 patients who underwent cardiac surgery between April 2000 and January 2003. INTERVENTIONS: Patients were allocated to conventional haemodynamic management or to an algorithm guided by oesophageal Doppler flowmetry to maintain a stroke index above 35 ml/m2. RESULTS: 26 control patients had postoperative complications (two deaths) compared with 17 (four deaths) protocol patients (P = 0.08). Duration of hospital stay in the protocol group was significantly reduced from a median of nine (interquartile range 7-12) days to seven (7-10) days (P = 0.02). The mean duration of hospital stay was reduced from 13.9 to 11.4 days, a saving in hospital bed days of 18% (95% confidence interval -12% to 47%). Usage of intensive care beds was reduced by 23% (-8% to 59%). CONCLUSION: A nurse delivered protocol for optimising circulatory status in the early postoperative period after cardiac surgery may significantly shorten hospital stay.

Bypass injury: implications of cardiopulmonary bypass.

Despite significant advances made in cardiac surgery over the last 2 decades, the process of bypassing the heart and lungs or cardiopulmonary bypass (CPB) continues to precipitate physiologic insults that have an impact on a patient's ability to recover from open-heart surgery. This article explores some of these potential insults and reviews some of the interventions used to neutralize the impact of CPB.

Anesthetic and perfusion issues in contemporary pediatric cardiac surgery.

As the fields of pediatric cardiology and cardiac surgery advance in complexity and in accountability for clinical and economic outcomes, several issues traditionally associated with the operating room are becoming important to physicians, nurses, and respiratory therapists who take care of children after cardiac surgery. The article discusses the concepts of "fast track" cardiac surgery, regional anesthetic techniques, coagulopathies and bleeding after cardiopulmonary bypass, intraoperative ultrafiltration, and mechanical circulatory assist devices.

Extracorporeal circuit sterility after 168 hours.

One of the most important tasks of the perfusionist is the proper assembly of the extracorporeal circuit (ECC) prior to the initiation of cardiopulmonary bypass (CPB). The ECC is usually assembled, primed and debubbled 30 minutes to one hour prior to the patient entering the operating room. But there are occasions when the ECC may have been set up and the previously scheduled procedure cancelled. Perfusionists in this situation have found themselves in a quandary; dispose of the ECC because of required nursing compliance and the sterility question, or keep it and use it later because of the economic impact on the "bottom line". Some hospitals may have satisfactorily answered the question of ECC sterility after 24 hours without observation, but the few reported papers regarding this issue, and our desire to save these circuits, inspired us to find out if they were in fact sterile after having been open for a long period of time. The purpose of this study was to evaluate ECC sterility using an open reservoir oxygenator, over a time period of seven days. After obtaining 792 bacterial cultures from three sites within the ECC, the study was terminated. There were no positive bacterial cultures during the study period. Assuming there is no deliberate contamination, pump circuits assembled in an unused operating room can be maintained sterile for a period of seven days.

Cardiopulmonary support in the intensive care unit.

The cardiopulmonary support system is an extracorporeal device that allows for rapid cardiopulmonary support of the critically ill patient in the intensive care unit. It provides immediate and complete support of cardiac and pulmonary functions to maintain perfusion to vital organs in patients who are severely physiologically compromised (eg, in cardiogenic shock, adult respiratory distress syndrome or pulmonary edema). Successful cardiopulmonary support requires systemic anticoagulation, percutaneous venous and arterial cannulation and careful monitoring by the critical care team to maintain adequate tissue perfusion and oxygenation. Although patient mortality can occur secondary to bleeding, embolism or sepsis, this technique provides life-sustaining circulatory and respiratory support until definitive treatment can be initiated.

Percutaneous cardiopulmonary bypass support: a new approach to high-risk angioplasty.

Percutaneous cardiopulmonary bypass is a new technique for supporting systemic blood flow during high-risk coronary angioplasty procedures. This mechanical alternative, unlike traditional methods, is not limited by dependency on adequate left ventricular stroke volume. Percutaneous cardiopulmonary bypass support offers new and demanding challenges in the care of this high-risk group of patients.