Perfusion Electronic Record Documentation Using Epic Systems Software.

This paper describes the design and use of Epic Systems software for documentation of perfusion activities as part of the patient electronic medical record. The University of Wisconsin Hospital and Clinics adapted the Anesthesia software module and developed an integrated perfusion/anesthesia record for the documentation of cardiac and non-cardiac surgical procedures. This project involved multiple committees, approvals, and training to successfully implement. This article will describe our documentation options, concepts, design, challenges, training, and implementation during our initial experience.

Effects of modified ultrafiltration on coagulation as measured by the thromboelastograph.

Hemodilution during cardiopulmonary bypass (CPB) continues to be a cause of morbidity associated with coagulation dysfunction, bleeding, and allogeneic blood transfusion. Clot formation and strength have been shown to impact bleeding and transfusions. Strategies to reduce hemodilution may be negated based on the course of the cardiac procedure itself. Modified ultrafiltration (MUF) is commonly used in pediatric cardiac surgery; however, it is not well accepted in adult surgery. This study aimed to evaluate clot formation and strength, bleeding, and transfusions in adult subjects undergoing MUF. Nineteen subjects having primary coronary artery bypass, aortic, or mitral valve surgeries were recruited and randomized to having MUF (n = 10) or no-MUF (n = 9) performed after the termination of CPB. Five time points for data collection were designated: T1, baseline/induction; T2, termination CPB; T3, post-MUF; T4, post-protamine; T5, 24 hours postoperative. Subjects randomized to MUF had 1505 +/- 15.8 mL of effluent removed, and no-MUF subjects had the CPB remnants processed with a cell salvage device. There was no statistical difference seen in 24-hour chest tube output, thromboelastograph values, or allogeneic transfusions at any time point between MUF and no-MUF subjects. There was a significant difference between MUF and no-MUF in the number of autologous cell salvage units processed (1.3 +/- .48 vs. 2.9 +/- .78, p = .0013) and end of procedure net fluid balance (+2003 +/- 1211 vs. +4194 +/- 1276 mL, p = .001), respectively. Estimated plasma loss from the cell salvage device was 477.6 mL greater in the no-MUF group. In primary adult cardiac procedures, MUF did not change coagulation values as measured by thromboelastography, number of allogeneic unit transfusions, or chest tube output at 24 hours postoperatively. There was a significant difference in autologous cell salvage units processed and end of procedure net fluid balance that benefited MUF subjects.

Early institution of extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation improves outcome.

BACKGROUND: Primary graft dysfunction (PGD) after lung transplantation (LTx) carries a significant mortality and clinical management is controversial. Extracorporeal membrane oxygenation (ECMO) has been used infrequently for recovery from acute lung injury (ALI) in this setting. We reviewed our experience with ECMO after primary LTx. METHODS: The present study is a retrospective analysis of all LTx patients between 1991 and 2004. Twenty-two patients sustained severe PGD with subsequent placement on ECMO. We analyzed indications and 30-day, 1-year and 3-year mortality. Complications and incidence of multiple-organ failure (MOF) were determined. Critical appraisal of the evidence available to date was performed. RESULTS: A total of 297 LTxs were performed during the study period, with 97.5%, 88.6% and 73.8% survival at 30 days, 1 year and 3 years, respectively. Twenty-two patients (7.9%) had severe allograft dysfunction leading to ECMO support. Twelve patients received single-lung (SLTx), 8 double-lung (BLTx), 1 single-lung/kidney (SLKTx) and 1 heart/lung (HLTx) transplantation. Thirty-day, 1-year and 3-year survival of LTx recipients with ECMO support post-operatively were 74.6%, 54% and 36%, respectively. MOF was the predominant cause of death (58.3%) in patients on ECMO support for PGD. CONCLUSIONS: Our data suggest that, in addition to prolonged ventilation and pharmacologic support, ECMO should be considered as a bridge to recovery from PGD in lung transplantation. Early institution of ECMO may lead to diminished mortality in the setting of ALI despite the high incidence of MOF. Late institution of ECMO was associated with 100% mortality in this investigation.