Current Published Guidelines - Shann

Reference

This is an evidence-based review for conducting safe, patient-centered, and effective CPB-practice. The authors have graded the level of evidence and classified the findings by using the criteria from the AHA/ACC Task Force on Practice Guidelines. The development of the findings evolved from a structured MEDLINE search coupled with critical review of the peer-review literature and debates stemming from presentations at regional and national conferences.

The group of authors has the mission to promote literature-supported and evidence-based perfusion practice to improve patient care and enhance clinical outcomes.

In this document, the focus was set on neurologic protection, euglycemia, hemodilution, and the inflammatory response. There are eight recommendations, each mentioned with class and level of evidence.

Neuroprotection

pH management:

The clinical team should manage adult patients undergoing moderate hypothermic CPB with alpha-stat pH management. (Class I, level A)

Hyperthermia:

Limiting arterial line temperature to 37˚C might be useful for avoiding cerebral hyperthermia. (Class IIa, Level B)

"Coupled temperature" ports for all oxygenators should be checked for accuracy and calibrated

Pericardial Suction Blood

Direct reinfusion to the CPB circuit of unprocessed blood exposed to pericardial and mediastinal surfaces should be avoided (Class I, Level B)

Blood cell processing and secondary filtration can be considered to decrease the deletirious effects of reinfused shed blood (Class IIb, Level B)

Aortic Assessment

In patients undergoing CPB at increased risk of adverse neurologic events, strong consideration should be given to intraoperative TEE or epiaortic ultrasonographic scanning of the aorta: (1) to detect nonpalpable plaque (Class I, Level B) and (2) for reduction of cerebral emboli (Class IIa, Level B)

Arterial Line Filtration

Arterial line filters should be incorporated in the CPB circuit to minimize the embolic load delivered to the patient (Class I, Level A)

Maintenance of Euglycemia

The clinical team should maintain perioperative blood glucose concentration within an institution's normal clinical range in all patients, including non-diabetic subjects (Class I, Level B)

Hemodilution

Efforts should be made to reduce hemodilution, including reduction of prime volume, to avoidsubsequent allogeneic blood transfusion (Class I, Level A)

Inflammatory Response

Reduction of the circuit surface area and the use of biocompatible surface-modified circuits might be useful-effective at attenuating the systemic inflammatory response to CPB and improving outcomes (Class IIA, Level B)