“SINERGIA MÁS ALLÁ DE LOS LÍMITES,
ACELERANDO LA INNOVACIÓN”
COMO ESTRATEGIA PARA REDUCIR EL USO DE
TRANSFUSIONES SANGUINEAS EN CIRUGÍA CARDIACA
Prescripción de la oxigenación
Terumo Group Website
Estudio de caso
3D Animation video 2
Circuitos de perfusión de acuerdo a las necesidades de su paciente
Disminución de los costos hospitalarios
Reducción de la hemodilución y transfusiones sanguíneas
Estudios reportan significativa disminución en el uso de productos sanguíneos en las instituciones y servicios de cirugía cardiaca, ahorrando alrededor de $558,450 usd por año.
Optimización de los resultados en los pacientes
Disminución de los costos hospitalarios
La Prescripción de la Oxigenación ™es una estrategia única de Terumo que ayuda a los perfusionistas a reconocer y manejar las necesidades de oxigenación y las necesidades sanguíneas de los pacientes con mayor precisamente.
Basados en los cálculos del área de superficie corporal de los pacientes, un numero significativo de estos, podría beneficiarse al usar oxigenadores diseñados de acuerdo a su talla. Los cuales le ofrezcan solución a sus necesidades metabólicas mientras disminuyen la hemodilución y el riesgo asociado a la circulación extracorpórea.
Estudios han demostrado que, controlando la hemodilución a través del uso de dispositivos que requieran bajo volumen de primado, se observa una reducción considerable de unidades de productos sanguíneos. Por esta razon, Terumo le ofrece la posibilidad de escoger tres diferentes tamaños dentro de la familia de Capiox FX, para el mayor beneficio de sus pacientes y sus resultados.
1. Ferraris, et al, 2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical
Practice Guidelines. Ann Thorac Surg 2011, 91:944-982.
2. Bker, R., et al. (2013). American Society of ExtraCorporeal Technology Standards and Guidelines For perfusión practice.
3. Lahanas, T., et al. (2013). A retrospective comparison of blood tranfusión requirements during cardiopulmonary bypass with two differents small
adult oxygenator. Perfusión. July 2013, 28 (4).
4. Bronson,S., et al. Prescriptive patient Extracorporeal Circuit and Oxygenator Sizing reduces Hemodilution and allgeneic Blood Product
Transfusion during Adult Cardiac Surgey. JECT. 2013:45:167-72
5. Shann, et al. An evidence- based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control,
hemodilution, (and the inflammatory response. J Thorac Cardiovasc Surg 2016; 132:283-290.
6. Preston, et al. Clinical Gaseous microemboli Assessment of an Oxygenator with Integral Arterial Filter in the Pediatric population. JECT
7. Gomez, et al. Evaluation of air handling in a new geration neonatal oxygenator with integral arterial filter. Perfusión 2019;24 (2)107-112.
Sean Murtha, CCP, Director of Perfusion Services at Memorial Regional Hospital and Joe DiMaggio Children's Hospital in Hollywood, Florida, enjoys sharing the results and discoveries of his team's journey to improve patient outcomes. Since 2007, the perfusion team has instituted many changes to reduce donor blood exposure to patients undergoing open heart surgery. Mr. Murtha believes the most significant changes are:
selecting the oxygenator membrane and perfusion circuit size based on patient size
using a more efficient retrograde autologous prime (RAP) procedure based on a smaller circuit prime volume
Perfusionists recognize that RAP can be more effective with smaller circuits. Mr. Murtha has developed an awareness of the ratio of circuit prime volume to patient blood volume and how much blood volume is needed for effective RAP. He describes net RAP efficiency as achieving the highest percent RAP efficiency with the lowest percent patient RAP/AAP (antegrade autologous priming) volume. A smaller circuit prime volume makes RAP more efficient and easier to accomplish.
Mr. Murtha's net RAP efficiency formula is: Total RAP/AP Volume divided by Circulating Volume equals Percent RAP Efficiency (higher numbers are most efficient).
"Choosing a circuit size in proportion with patient size is more efficient," Mr. Murtha adds. "We see it all the time: the smaller patient can't tolerate large blood loss during RAP and AAP, and anesthesia just gives back fluids. If anesthesia is not giving fluids back, we maintain higher hematocrit. You can start to see how you can easily reduce hemodilution."
The Memorial Regional Hospital team switched to a low prime volume circuit for patients less than 2.1 M2 — which includes the CAPIOX® FX15 Oxygenator with integrated arterial filter. According to Mr. Murtha, these small patients don't need an oxygenator that flows up to eight liters per minute with its associated high prime volume. In down-sizing the circuit, the perfusion team documented that using RAP and AAP techniques along with the FX15 Oxygenator:
decreased circulating prime volume from 1,100 mL to 654 mL — a 41% reduction
reduced the patient's exposure to circulating prime volume to 273 mL after RAP/AAP
required only 381 mL of the patient's blood volume to achieve an effective RAP/AAP
"We determined 381 mL was our most effective RAP because it's the most volume we can remove from the patient based on our circuit configuration," Mr. Murtha says. "It's about net RAP efficiency, and we now achieve a very high efficiency. It's highly likely perfusionists will find much higher hematocrits by just changing circuit design and techniques to match the patient's size.
Prior to selecting the new oxygenator and smaller perfusion circuit, Mr. Murtha had already spent two years analyzing his team's data and makin incremental improvements. In 2007, his hospital's Cardiovascular Committee charged the Perfusion and Anesthesia teams with reducing blood
transfusions. The clinicians:
implemented an evidence-based blood transfusion protocol based on STS (Society of Thoracic Surgeons) recommendations
reduced tubing lengths in the perfusion circuit to minimize circuit volume
established a protocol to reduce hemodilution involving RAP and AAP techniques
The Cardiovascular Committee held all clinicians accountable to optimize patient care, and therefore Anesthesia became more conservative about giving fluid volume to stabilize the patient. "We tried to set a standard so all anesthesiologists managed the fluid volume in the same way," Mr. Murtha recalls. "With our focus on protocol driven care, everybody became accountable. And everybody got behind it when we started seeing the results."
Mr. Murtha concludes: "You really can optimize cardiac surgery. You just have to start collecting data to see where you're at, and see where you can make your improvements."
For more information:
Visit the Prescriptive Oxygenation webpage
Order the 2010 Optimizing Blood Management CDROM
The benefits of self-venting technology as a continuous gaseous
Most oxygenator manufacturers integrate arterial filters and oxygenators — offering better technology to improve patient care.
The new integrated arterial filters offer the same functionality of a traditional filter — trap particulate and purge gaseous microemboli (GME). But some, like the CAPIOX® FX Oxygenator, accomplish these functions in simple but innovative ways.
In a 2008 published study that ranked gaseous microemboli separation performance, Riley wrote, "Arterial line filters are arguably the most important component in the cardiopulmonary bypass circuit to protect the patient from gaseous macro- and microemboli originating in the perfusion circuit." 1
Methods to remove GME from the circuit with integrated arterial filters varies. First-generation designs simply attach the arterial filter to the oxygenator. These first-generation designs use the traditional vent to purge air to the venous reservoir.
The CAPIOX FX Oxygenator is unique because of its self-venting function which removes GME through the microporous hollow fibers — it does not require purging through a vent port.
A 32 micron screen filter surrounds the fiber layer of the CAPIOX FX Oxygenator. Particulate microemboli in the blood are trapped in the filter mesh while gaseous emboli remain inside the oxygenator and in contact with the hollow fibers.
During bypass, the blood-side pressure is higher than that of the gas-side pressure of the inner lumen of the hollow fiber. Driven by the pressure differential, gaseous emboli enter the inner lumen of the microporous hollow fibers. Once the emboli enter the inner lumen, they are eliminated via the gas outlet.
The self-venting method of GME elimination separates the emboli from the blood in the circuit rather than returning them to the venous reservoir for removal.
"The self-venting method of GME elimination separates the emboli from the blood in the circuit rather than returning them to the venous reservoir for removal."
As De Somer wrote in a published study, "Since the advent of cardiopulmonary bypass, the generation and elimination of gaseous and solid microemboli have been a concern." 2
First-generation integrated arterial filters use a vent (or purge) port to remove the GME. If microemboli enter the perfusion circuit, they are trapped by the arterial filter, and then exit from the vent (purge) port with blood flow shunted to the venous reservoir.
Clinical concerns of purging through a vent port:
"The design of the Terumo CAPIOX FX Oxygenator with its integrated filter optimizes the performance of the hollow fibers to self-vent gaseous microemboli," says Carl Freytag, Senior Clinical Specialist, Terumo Cardiovascular Group.
Figure 1 shows a concept of the self-vent function.
Figure 1: Illustration of self-venting purge through the oxygenator hollow fiber.
"The integrated screen filter efficiently traps the gaseous microemboli, maintaining them in close proximity to the large surface area of micro-pores of the hollow fibers," Carl adds. "The blood-side to gaseous-side positive pressure gradient effectively drives the emboli through the micro-pores to the gas-side of the hollow fibers for immediate removal from the cardiopulmonary bypass circuit.
“It is a simple bubble movement through the hollow fiber's micro-pores," he adds.
Although the self-venting method of microemboli removal in the CAPIOX FX Oxygenator is different than a traditional purge, clinical studies have shown it to be just as effective. 3, 4 More important, removing GME via the gas phase helps eliminate GME from the circuit rather than recirculating them to the venous reservoir.
1. Riley, J. Arterial Line Filters Ranked for Gaseous Micro-Emboli Separation Performance: An In Vitro Study. J Extra Corpor Technol. 2008;
2. De Somer, F. Impact of Oxygenator Characteristics on Its Capability to Remove Gaseous Microemboli. J Extra Corpor Technol. 2007;
3. Preston, et al. Clinical Gaseous Microemboli Assessment of an Oxygenator with Integral Arterial Filter in the Pediatric Population. J Extra
Corpor Technol. 2009; 41:226-230.
4. Gomez, et al. Evaluation of air handling in a new generation neonatal oxygenator with integral arterial filter. Perfusion. 2009; 24(2):107-112.