Extracorporeal membrane oxygenation (ECMO) is a technique that uses a pump to drain blood from a body, circulate blood through a membrane lung, and return the oxygenated blood back into the body. Venoarterial (VA) ECMO is a simplified version of the heart-lung machine that assists native pulmonary and/or cardiac function. VA ECMO is composed of a drainage cannula in the venous system and a return cannula in the arterial system. Because VA ECMO can increase tissue perfusion by increasing the arterial blood flow, it is used to treat medically refractory cardiogenic shock or cardiac arrest. VA ECMO has a distinct physiology that is referred to as differential flows. It can cause several complications such as left ventricular distension with pulmonary edema, distal limb ischemia, bleeding, and thromboembolism. Physicians who are using this technology should be knowledgeable on the prevention and management of these complications. We review the basic physiology of VA ECMO, the mechanism of complications, and the simple management of VA ECMO.
Catheters ; Drainage ; Extracorporeal Membrane Oxygenation ; Extremities ; Heart Arrest ; Heart-Lung Machine ; Hemorrhage ; Ischemia ; Lung ; Membranes ; Oxygen ; Perfusion ; Physiology ; Postoperative Complications ; Pulmonary Edema ; Shock ; Shock, Cardiogenic ; Thromboembolism

Extracorporeal membrane oxygenation (ECMO) was originated from heart-lung machine for cardiac surgery. This technique that receive the blood from venous system, oxygenate it and support to selected patients with severe respiratory or cardiac failure as flow and oxygen. ECMO can provide partial or total support, is temporary, and requires systemic anticoagulation. ECMO controls gas exchange and perfusion, stabilizes the patient physiologically, decreases the risk of ongoing iatrogenic injury, and allows enough time for decision, diagnosis, treatment, and recovery from the primary injury or disease. The two major ECMO modalities are venoarterial and venovenous. Until 1980s, ECMO usually used to pediatric respiratory failure. However after H1N1 influenza epidemic in the world, venovenous ECMO support for adult has been increased rapidly. Venoarterial ECMO support for cardiac failure and resuscitation also abruptly has been increased. As a support modality, cannula position and possibility of complication is different. Survival rate of ECMO has a range from 30% in extracorporeal cardiopulmonary resuscitation to 70% for acute myocarditis and acute respiratory distress syndrome in adult, and better in neonate and pediatrics. Advancing ECMO technology and increasing experience with ECMO techniques have improved patient outcomes, reduced complications and expanded the potential applications of ECMO. Awareness of the indications and implications of ECMO among physicians managing patients with severe but potentially reversible respiratory or cardiac failure may help facilitate better communication between health care teams and improve patient recovery.
Adult ; Cardiopulmonary Resuscitation ; Catheters ; Diagnosis ; Extracorporeal Membrane Oxygenation* ; Heart Failure ; Heart-Lung Machine ; Humans ; Infant, Newborn ; Influenza, Human ; Myocarditis ; Oxygen ; Patient Care Team ; Pediatrics ; Perfusion ; Respiratory Distress Syndrome, Adult ; Respiratory Insufficiency ; Resuscitation ; Survival Rate ; Thoracic Surgery

OBJECTIVES: Predicting the length of stay (LOS) of patients in a hospital is important in providing them with better services and higher satisfaction, as well as helping the hospital management plan and managing hospital resources as meticulously as possible. We propose applying data mining techniques to extract useful knowledge and draw an accurate model to predict the LOS of heart patients. METHODS: Data were collected from patients with coronary artery disease (CAD). The patient records of 4,948 patients who had suffered CAD were included in the analysis. The techniques used are classification with three algorithms, namely, decision tree, support vector machines (SVM), and artificial neural network (ANN). LOS is the target variable, and 36 input variables are used for prediction. A confusion matrix was obtained to calculate sensitivity, specificity, and accuracy. RESULTS: The overall accuracy of SVM was 96.4% in the training set. Most single patients (64.3%) had an LOS < or =5 days, whereas 41.2% of married patients had an LOS >10 days. Moreover, the study showed that comorbidity states, such as lung disorders and hemorrhage with drug consumption have an impact on long LOS. The presence of comorbidities, an ejection fraction <2, being a current smoker, and having social security type insurance in coronary artery patients led to longer LOS than other subjects. CONCLUSIONS: All three algorithms are able to predict LOS with various degrees of accuracy. The findings demonstrated that the SVM was the best fit. There was a significant tendency for LOS to be longer in patients with lung or respiratory disorders and high blood pressure.
Comorbidity ; Coronary Artery Disease ; Coronary Vessels ; Data Mining ; Decision Trees ; Heart ; Hemorrhage ; Humans ; Hypertension ; Insurance ; Length of Stay ; Lung ; Sensitivity and Specificity ; Social Security ; Support Vector Machine

OBJECTIVES: Clinical Practice Guidelines (CPGs) are an effective tool for minimizing the gap between a physician's clinical decision and medical evidence and for modeling the systematic and standardized pathway used to provide better medical treatment to patients. METHODS: In this study, sentences within the clinical guidelines are categorized according to a classification system. We used three clinical guidelines that incorporated knowledge from medical experts in the field of family medicine. These were the seventh report of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure from the National Heart, Lung, and Blood Institute; the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults from the same institution; and the Standards of Medical Care in Diabetes 2010 report from the American Diabetes Association. Three annotators each tagged 346 sentences hand-chosen from these three clinical guidelines. The three annotators then carried out cross-validations of the tagged corpus. We also used various machine learning-based classifiers for sentence classification. RESULTS: We conducted experiments using real-valued features and token units, as well as a Boolean feature. The results showed that the combination of maximum entropy-based learning and information gain-based feature extraction gave the best classification performance (over 98% f-measure) in four sentence categories. CONCLUSIONS: This result confirmed the contribution of the feature reduction algorithm and optimal technique for very sparse feature spaces, such as the sentence classification problem in the clinical guideline document.
Adult ; Cholesterol ; Data Mining ; Heart ; Humans ; Hypertension ; Information Storage and Retrieval ; Joints ; Knowledge Bases ; Learning ; Lung ; Machine Learning

Hemolysis in blood pumps has been measured by various in vitro tests, in which normalized index of hemolysis (NIH) was established. As NIH is complicated and difficult to calculate, erythrocyte fragment count (EFC) is proposed in the present study to predict hemolysis in roller pumps. Five paired in vitro tests were conducted using the POLYSTAN pediatric pump (group A) and COBE pump (group B). Ten whole blood samples (400ml) were circled in the roller pump for 16 hours. Erythrocyte fragments count and plasma-free hemoglobin (FHb) were measured before pumping and every 2 hours through circulation after 4 hours pumping. The morphological changes of erythrocyte were observed by scanning electron microscope. Simple linear regression analysis showed the two groups' EFC and FHb levels increased linearly during a long period of pumping, and the coefficient of determination (R2) was 0.64. These data suggested that Erythrocyte fragments count could be used as an index in evaluating the in vitro hemolytic properties of blood pumps.
Erythrocyte Deformability ; Erythrocytes ; ultrastructure ; Heart-Lung Machine ; adverse effects ; Hemoglobins ; analysis ; Hemolysis ; physiology ; Humans ; Microscopy, Electron, Scanning ; Osmotic Fragility ; Time Factors

BACKGROUND: Pulsatile pumps for extracorporeal circulation have been known to be better for tissue perfusion than non-pulsatile pumps but be detrimental to blood corpuscles. This study is intended to examine the risks and benefits of T-PLS(TM) through the comparison of clinical effects of T-PLS(TM) (pulsatile pump) and Bio-pump(TM) (non-pulsatile pump) used for coronary bypass surgery. MATERIAL AND METHOD: The comparison was made on 40 patients who had coronary bypass using T-PLS(TM) and Bio-pump(TM) (20 patients for each) from April 2003 to June 2005. All of the surgeries were operated on pump beating coronary artery bypass graft using cardiopulmonary extra-corporeal circulation. Risk factors before surgery and the condition during surgery and the results were compared. RESULT: There was no significant difference in age, gender ratio, and risk factors before surgery such as history of diabetes, hypertension, smoking, obstructive pulmonary disease, coronary infarction, and renal failure between the two groups. Surgery duration, hours of heart-lung machine operation, used shunt and grafted coronary branch were little different between the two groups. The two groups had a similar level of systolic arterial pressure, diastolic arterial pressure and mean arterial pressure, but pulse pressure was measured higher in the group with T-PLS(TM) (46+/-15 mmHg in T-PLS(TM) vs 35+/-13 mmHg in Bio-pump(TM), p<0.05). The T-PLS(TM)-operated patients tended to produce more urine volume during surgery, but the difference was not statistically significant (9.7+/-3.9 cc/min in T-PLS(TM) vs 8.9+/-3.6 cc/min in Bio-pump(TM), p=0.20). There was no significant difference in mean duration of respirator usage and 24-hour blood loss after surgery between the two groups. Plasma free Hb was measured lower in the group with T-PLS(TM) (24.5+/-21.7 mg/dL in T-PLS(TM) versus 46.8+/-23.0 mg/dL in Bio-pump(TM), p<0.05). There was no significant difference in coronary infarction, arrhythmia, renal failure and morbidity rate of cerebrovascular disease. There was a case of death after surgery (death rate of 5%) in the group tested with T-PLS(TM), but the death rate was not statistically significant. CONCLUSION: Coronary bypass was operated with T-PLS(TM) (Pulsatile flow pump) using a heart-lung machine. There was no unexpected event caused by mechanical error during surgery, and the clinical process of the surgery was the same as the surgery for which Bio-pump(TM) was used. In addition, T-PLS(TM) used surgery was found to be less detrimental to blood corpuscles than the pulsatile flow has been known to be. Authors of this study could confirm the safety of T-PLS(TM).
Arrhythmias, Cardiac ; Arterial Pressure ; Blood Cells ; Blood Pressure ; Cardiopulmonary Bypass ; Coronary Artery Bypass ; Extracorporeal Circulation ; Heart-Lung Machine ; Humans ; Hypertension ; Infarction ; Lung Diseases, Obstructive ; Mortality ; Perfusion* ; Plasma ; Pulsatile Flow ; Renal Insufficiency ; Risk Assessment ; Risk Factors ; Smoke ; Smoking ; Transplants ; Ventilators, Mechanical

To observe the erythrocyte fragility and morphological changes of erythrocytes caused by roller pump. Ten tests were divided into two groups, Polystan pediatric pump group A (n = 5) and COBE pump group B (n = 5). Ten whole blood samples (each 400 ml) were circulated in the roller pump for 16 h. Erythrocyte fragility and free hemoglobin were measured before pumping and at every 2 hours during pumping. The possible morphological changes of erythrocytes caused by roller pump were observed by scanning electron microscope. The electron microscopic observation was made before pumping and at every 4 hours throughout pumping. Results showed that the erythrocyte fragility of two groups was not increased during a long period of pumping. The number of acanthocytes of two groups was 1.77/1.81% in the samples before pumping and 6.12/7.13, 9.18/8.73, 13.21/12.89, 16.53/17.21% at 4 h, 8 h, 12 h, and 16 h respectively. The free hemoglobin level of two groups was increased linearly during a long duration of pumping and the index of hemolysis of two groups was 0.296 mg/L/h and 0.3993 mg/L/h respectively. The result shows: 1. the erythrocyte fragility was not increased during a long period of pumping; 2. the erythrocyte membrane was injured or broken by roller pump directly; 3. the morphological changes of erythrocytes would be the basis of post operative hemolysis.
Erythrocyte Deformability ; Heart-Lung Machine ; adverse effects ; Hemoglobins ; analysis ; Hemolysis ; Humans ; In Vitro Techniques ; Osmotic Fragility ; Time Factors

BACKGROUND: Post-CPB bleeding diathesis remains one of main causes of morbidity in open heart operation since it requires significant amount of homologous transfusion. Many approaches have been studied to reduce the amount of postoperative blood loss and blood use. Aprotinin is known to reduce postoperative bleeding. Therefore, hemostatic effects of aprotinin have been searched in open heart surgery. METHODS: Adult patients for open heart opeartion were randomly allocated to two groups, control group and study group. All anesthetic, surgical and bypass techniques were standardized. After induction, 10,000 KIU given for testing and then 2,000,000 KIU of aprotinin was infused for 20~30 minutes before sternotomy, and followed by at rate of 500,000 KIU/hr. Additional 2,000,000 KIU of aprotinin was mixed to pump prime of heart-lung machine. Aprotinin infusion was ended by the time of skin closure. Amount of postoperative bleeding as well as homologous blood requirement were measured. Urine output and serum creatinine were also documented during postoperative period. RESULTS: Postoperative-36hr summation of blood loss differed significantly(1858.4 1182.9 ml vs. 1256.7 688.4 ml, p<0.1). Postoperative homologous blood requirements were also reduced in the requirement of packed RBCs use(3.0 2.5 units vs. 1.0 0.8 units, p<0.01) and of fresh frozen plasma use(6.6 4.4 units vs. 3.9 2.6 units, p<0.05). Postoperative measurement of urine output and serum creatinine showed insignificant difference between groups while remained within normal range. CONCLUSIONS: High-dose aprotinin seems to have beneficial effect in reducing postoperative blood loss and blood use without renal complication.
Adult* ; Aprotinin* ; Blood Platelets ; Cardiopulmonary Bypass ; Control Groups ; Creatinine ; Disease Susceptibility ; Heart ; Heart-Lung Machine ; Hemorrhage ; Humans ; Pharmacology ; Plasma ; Postoperative Hemorrhage ; Postoperative Period ; Reference Values ; Skin ; Sternotomy ; Thoracic Surgery*

BACKGROUND: High-dose aprotinin appears to enhance the anticoagulant effects of heparin, as documented by increases in the activated clotting times (ACTs) during cardiopulmonary bypass. This increase of the ACT in the presence of aprotinin and heparin is due to the use of celite as surface activator. We compared celite and kaolin as surface activators for the measurement of the ACT in cardiac surgical patients treated with high dose aprotinin. METHODS: This study included 25 patients who were scheduled for coronary bypass graft surgery and reoperation of cardiac valvular surgery. The 2 million units of aprotinin were added to the pump prime of heart-lung machine. The dosage of heparin and protamine was 3 mg/kg respectively. Whole blood was sampled 10 minutes after induction, heparin administration, cardiopulmonary bypass(CPB), 10 minutes before the termination of CPB and 10 minutes after protamine administration. The ACT was measured with Hemochron 801 blood coagulation timer with 12 mg of either celite (C-ACT) or kaolin (K-ACT) used as surface activator. RESULTS: At 10 minutes after induction and heparin administration, celite and kaolin ACTs were l20+/-28, 541+/-247 seconds and 126+/-23, 559+/-267 seconds rcspectively. But 10 minutes after initiation of CPB and before the termination of CPB, celite ACTs were 941+/-238 and 787+/-277 seconds; kaolin ACTs were 605+/-182 and 499+65 seconds, which were consistently less than celite ACTs(p<0.01). At 10 minutes after protamine administration, celite ACT was 118+/-12 seconds and kaolin ACT was 142 56 seconds which was consistently more than celite ACT(p<0.05). CONCLUSIONS: We recommend the K-ACT rather than C-ACT when monitoring of heparin-induced anticoagulation in patients treated with high-dose aprotinin. It is also highly recommended that patients being added with aprotinin should receive the usual doses of heparin and that the ACT should be measured with kaolin as the activator.
Aprotinin* ; Blood Coagulation ; Cardiopulmonary Bypass ; Diatomaceous Earth* ; Heart-Lung Machine ; Heparin ; Humans ; Kaolin* ; Reoperation ; Thoracic Surgery* ; Transplants

BACKGROUND: High-dose aprotinin appears to enhance the anticoagulant effects of heparin, as documented by increases in the activated clotting times (ACTs) during cardiopulmonary bypass. This increase of the ACT in the presence of aprotinin and heparin is due to the use of celite as surface activator. We compared celite and kaolin as surface activators for the measurement of the ACT in cardiac surgical patients treated with high dose aprotinin. METHODS: This study included 25 patients who were scheduled for coronary bypass graft surgery and reoperation of cardiac valvular surgery. The 2 million units of aprotinin were added to the pump prime of heart-lung machine. The dosage of heparin and protamine was 3 mg/kg respectively. Whole blood was sampled 10 minutes after induction, heparin administration, cardiopulmonary bypass(CPB), 10 minutes before the termination of CPB and 10 minutes after protamine administration. The ACT was measured with Hemochron 801 blood coagulation timer with 12 mg of either celite (C-ACT) or kaolin (K-ACT) used as surface activator. RESULTS: At 10 minutes after induction and heparin administration, celite and kaolin ACTs were l20+/-28, 541+/-247 seconds and 126+/-23, 559+/-267 seconds rcspectively. But 10 minutes after initiation of CPB and before the termination of CPB, celite ACTs were 941+/-238 and 787+/-277 seconds; kaolin ACTs were 605+/-182 and 499+65 seconds, which were consistently less than celite ACTs(p<0.01). At 10 minutes after protamine administration, celite ACT was 118+/-12 seconds and kaolin ACT was 142 56 seconds which was consistently more than celite ACT(p<0.05). CONCLUSIONS: We recommend the K-ACT rather than C-ACT when monitoring of heparin-induced anticoagulation in patients treated with high-dose aprotinin. It is also highly recommended that patients being added with aprotinin should receive the usual doses of heparin and that the ACT should be measured with kaolin as the activator.
Aprotinin* ; Blood Coagulation ; Cardiopulmonary Bypass ; Diatomaceous Earth* ; Heart-Lung Machine ; Heparin ; Humans ; Kaolin* ; Reoperation ; Thoracic Surgery* ; Transplants