Letters To ‘Surfers: From China: Pediatric Priming Solutions ?

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Editor’s Note:

I got this question regarding pediatric priming protocols from a perfusionist in China.

My pediatric experience is limited to ECMO- so I defer to the more experienced pediatric perfusionists out there to help formulate an informed response 🙂

Leave your answers or suggestions in the “Comments” section plz?

Frank

To Circuit Surfers :

Happy Day!

How are you? I hope everything is well!

I am working on a protocol for our institution. Since the hospital is still on a taking off phase so we are focusing more on standardizing the procedures.

Working with it along the way, I want to ask your professional advice..

Anyway, last Wednesday we did a TOF Correction of a 7 years old kid, 22 kgs and visibly cyanotic. Pre- bypass hematocrit was 54%. Oxygenator – Dideco 902; A-V circuit = 1/4 – 3/8 and pump boot = 3/8. Since we take turns in doing cases, another perfusionist  did the pump run.

Apparently, coming from different orientation and obviously with the age gap , we sometimes differ on the management of the patient. Of course, it is understandable that since she is in the profession for how many years, she feels uncomfortable whenever I give suggestions.

More often we we have different opinions on depriming more and reducing the circuit because she is used to the old practice of priming more/blood prime and would depend on the idea that- “anyway, during post-bypass, MUF is done for every pediatric patient”.

So I have the difficulty in adjusting with her on this kind of perspective until last week, even our new anesthesiologist from London observed that she primed 400 ml of FFP + 900 ml of Crystalloid giving her reason that she wants to lower down the hematocrit and in order to increase the COP.

I am concerned with this and our anesthesiologist asked me, if I were to do the case, how would I manage the perfusion? I told him that I could slowly withdraw blood from the venous up to 200 ml before bypass, my priming volume would be 200 ml FFP plus 300 ml of crystalloid and based on my computation, pump hematocrit would go down to 28% and COP is 18mmHg whereas when I computed the COP of the other perfusionist’s management, it is just 14mmHg.

The patient went well actually but the anesthesiologist lead us to a post case discussion saying that better perfusion management should have done. Based on your experiences Frank and being updated with modern perfusion protocol, what would be the best management for this kind of case?

Second thing, since I am reconciling our standard practice now particularly in Pediatric Perfusion protocol, I have actually adapted some circuit and priming protocol from New York Presbyterian hospital, will it be okay Frank if I can also get an idea from the perfusion protocol you have in your hospital? That would be of great help for us here so that I could really show them the International way of Perfusion management.

Thank you for your response:)

Thank you for taking the time to ask this question

Anybody out there want to tackle this?

Frank