title: A systematic approach to the understanding and redesigning of cardiopulmonary bypass.
abstract: Cardiopulmonary bypass (CPB) is a highly complex process. We developed a system to capture and study detailed information during cardiac surgery that serves as a framework for understanding variation that occurs during CPB. The system allows the surgical team to link unwanted variation (ie, hypotension) and unwanted events (ie, the production of microemboli) to the processes of care. A more thorough understanding of embolic activity and hemodynamic aberrations, precursors to both stroke and subtle neurologic injury, that occur during CPB, will allow the surgical team to identify high leverage, modifiable aspects of care and abate these precursors to patient injury. Multimodality simultaneous monitoring and recording of physiologic parameters, emboli in the CPB circuit and in the middle cerebral arteries, and cerebral NIRS during surgery was carried out in patients undergoing open heart surgery with CPB. A system was designed that captures physiologic data from the patient monitors and the heart-lung machine at 20-second intervals and time synchronizes all measures with a video recording of the surgical procedure. Emboli counts count in the CPB circuit and right and left middle cerebral arteries were continuously recorded. Video recordings depicting various surgical and perfusion techniques with associated embolic activity were provided to the surgical team. Wide variation in embolic counts, cerebral blood flow velocity, and physiologic parameters were observed. Periods of embolic activity and cerebral desaturation could be related to surgical and CPB processes of care. We have identified increased emboli counts in the CPB circuit and in the middle cerebral arteries related to the method of venous drainage, manipulation of the aorta, and anastomotic techniques. se of this model provides the surgical team detailed information about these precursors to neurologic injury. This system provides a systematic approach to the understanding and redesigning of CPB.
authors.affiliation: Maine Medical Center, Northern New England Cardiovascular Disease Study Group, Portland, USA. groom@mail.mmc.org
authors.forename: Robert C
authors.initials: RC
authors.lastname: Groom
mesh_terms: D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000379:methods / Q000639:trends*; D002560:Cerebrovascular Circulation / Q000502:physiology; D006801:Humans; D020766:Intracranial Embolism / Q000139:chemically induced / Q000517:prevention & control; D016343:Monitoring, Intraoperative; D009422:Nervous System Diseases / Q000209:etiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000517:prevention & control; D017749:Total Quality Management