Spallation performance of extracorporeal membrane oxygenation tubing

Impact of mechanical stress on flexible tubing used for biomedical applications: Characterization of the damages and impact on the patient's health

Flexible tubing is a key part of a lot of medical devices used in hospital, but may be subjected to a lot of various mechanical stresses that can led to the failure or to complications for the patients. The nature and causes of these mechanical stresses were listed for peristaltic pump tubing, infusion set tubing and catheters. Their consequences in term of tubing damages and particular contamination were reported. The impact of the chemical nature of the tubing, of its size and also the impact of various parameters of the clinical acts were reviewed. Last the consequences for the patient's health were discussed.

Investigating the static or dynamic flexural and compressive stresses on flexible tubing: Comparison of clamp and peristaltic pump impact on surface damages and particles leaching during infusion acts

This paper deals with the impact of the mechanical stresses on plasticized PVC infusion tubing. Stresses due to clamping were compared to those due to the use of a peristaltic pump. The degradation of the inner surface of plastic tubing due to a dynamic load with repeated flexion and compression was extensively studied in the case of peristaltic pump stress during extracorporeal (EC) acts. Even if clamping results in a less repeated stress, we show it can also lead to damages on the inner lumen of the tubing, especially in static conditions. As these degradations were responsible of particle shedding in the case of EC processes, a first evaluation of particular contamination was performed on the stressed infusion tubes.

Extracorporeal lung support

PURPOSE OF REVIEW

The applications for extracorporeal membrane oxygenation for lung support are constantly evolving. This review highlights fundamental concepts in extracorporeal lung support and describes directions for future research.

RECENT FINDINGS

Since the 1950s, extracorporeal lung support has experienced continuous advancements in circuit design and safety in acute respiratory distress syndrome, chronic obstructive pulmonary disease exacerbations, as a bridge to transplantation, intraoperative cardiopulmonary support, and for transportation to referral centers. Patients on extracorporeal membrane oxygenation are now capable of being awake, extubated, and ambulatory for accelerated recovery or optimization for transplantation.

SUMMARY

Extracorporeal lung support is a safe and an easily implemented intervention for refractory respiratory failure. Recent advances have extended its use beyond acute illnesses and the developments for chronic support will facilitate the development of durable devices and possible artificial lung development.

Particle Spallation in a Microfluidic Blood Processing Device: The Problem of Using Peristaltic Pumps and Silicon-based Microfilters

Peristaltic pumps rely on constant compression of elastomeric tubing from which particles may be shed, a phenomenon known as spallation. We studied spallated particles on microfluidic filtration devices with photolithographically prepared micron-level pore fields. Filtration of ultra-pure water through these pores was analyzed using either the usual peristaltic pump or a reciprocating pair of syringe pumps. Using syringe pumps, transmembrane pressure (TMP) values during filtration at 2.5 cm3/min revealed steady filtration for over 80 minutes at 2.3 mmHg. Using the peristaltic pump, TMP was never stable, increasing to approximately 11 mmHg during the first 10 minutes. Pore plugging was the culprit, evidenced by post-perfusion microphotography.

Spallation of Small Particles From Peristaltic Pump Tube Segments

In most extracorporeal filtration devices such as hemodialysis a peristaltic pump is used to circulate blood. Pump function requires the repeated compression of an elastomeric tube from which particles may be shed into the circulatory system, a process called spallation. Earlier studies are likely to have missed the large number of small particles (<2 µm in diameter) that appear. The present study uses more modern equipment that detects and sizes particles down to 0.6 µm. As polyvinyl chloride (PVC) tubing is commonly used for this process, a series of studies was conducted on three different types to study its spallation characteristics, along with a co-extruded PVC/polyurethane tubing known for its enhanced biocompatibility properties. For all types of PVC tubes, the average size of the spallated particles was 0.83 ± 0.03 µm; for the PVC/polyurethane tubing the average size of the spallated particles was approximately twice that reported for PVC tubing. For PVC tubes with equal inner diameter, those with less plasticizer released fewer particles; for tubes with the same Shore hardness, tubes with larger internal diameters released fewer particles. It was also shown that PVC tubes operating at a slower flow rate does not reduce the total number of particles released per volume pumped. The total number of particles spallated from the PVC/polyurethane tubing was 10 times lower than from the lowest spallating PVC tubing.

Pressure pulsation in roller pumps: a validated lumped parameter model

During open-heart surgery roller pumps are often used to keep the circulation of blood through the patient body. They present numerous key features, but they suffer from several limitations: (a) they normally deliver uncontrolled pulsatile inlet and outlet pressure; (b) blood damage appears to be more than that encountered with centrifugal pumps. A lumped parameter mathematical model of a roller pump (Sarns 7000, Terumo CVS, Ann Arbor, MI, USA) was developed to dynamically simulate pressures at the pump inlet and outlet in order to clarify the uncontrolled pulsation mechanism. Inlet and outlet pressures obtained by the mathematical model have been compared with those measured in various operating conditions: different rollers' rotating speed, different tube occlusion rates, and different clamping degree at the pump inlet and outlet. Model results agree with measured pressure waveforms, whose oscillations are generated by the tube compression/release mechanism during the rollers' engaging and disengaging phases. Average Euclidean Error (AEE) was 20mmHg and 33mmHg for inlet and outlet pressure estimates, respectively. The normalized AEE never exceeded 0.16. The developed model can be exploited for designing roller pumps with improved performances aimed at reducing the undesired pressure pulsation.

Hemolytic characteristics of three commercially available centrifugal blood pumps

OBJECTIVE

As compared with traditional extracorporeal roller-occlusion blood pumps, nonocclusive centrifugal pumps offer the benefits of requiring a smaller circuit surface area and, thus, a smaller prime volume. However, centrifugal blood pumps have been reported to generate unacceptable levels of hemolysis. We hypothesize that the newer generation centrifugal pumps have an incidence of hemolysis similar to the traditional roller head pumps and, thus, could be used for extracorporeal membrane oxygenation circuits.

DESIGN

Randomized, prospective, bench study.

SETTING

University research laboratory.

INTERVENTIONS

Three centrifugal blood pumps (Cobe Revolution, Jostra Rotaflow, and Medtronic BioMedicus) were compared with a roller occlusion blood pump (Cobe Century). Hemolysis generation was examined during 6 hrs of continuous use. Two test runs per group were randomly performed on three consecutive days for a total of six test runs for each of the four pumps (n = 24).

MEASUREMENTS AND MAIN RESULTS

Plasma free hemoglobin values were determined using a Spectra MaxPlus spectrophotometer. A normalized index of hemolysis was calculated to compare the individual trials. The Cobe Revolution and the Jostra Rotaflow compared favorably with the Cobe Century roller occlusion blood pump in the amount of hemolysis produced.

CONCLUSIONS

These data are encouraging for the development of a low-prime, mobile neonatal extracorporeal membrane oxygenation circuit using centrifugal pump technology.

Prebypass filtration of cardiopulmonary bypass circuits: an outdated technique?

Filtration of cardiopulmonary bypass (CPB) priming fluid before connection of the circuit to the patient was first accomplished by arterial line filtration. When dedicated prebypass filters (PBFs) with smaller pore sizes became available, a large number of particles could be found on the filter surface. In recent years, modern manufacturing methods for CPB circuit components were believed to be associated with a reduced number of particles found in components of extracorporeal circuits, making separate filtration of CPB priming solution unnecessary. Microemboli generated during the preparation and priming procedure of the CPB circuit may consist of either solid particles or gaseous emboli and may contribute to patient morbidity. Endotoxins found in infusion solutions and CPB priming solutions may trigger inflammatory responses when administered into the circulatory system. Filtration of crystalloid CPB priming solutions with a PBF consisting of a filter membrane with a pore size of 0.2 microm was found to effectively reduce the number of microemboli. Infusion filters with a filter pore size of 0.2 microm were found to reduce the endotoxin contamination in infusion solutions. Prebypass filtration with filters containing pores of 0.2 pm should be a necessity for contemporary perfusion practice.

Centrifugal versus roller head pumps for cardiopulmonary bypass: effect on early neuropsychologic outcomes after coronary artery surgery

OBJECTIVE

To test the hypothesis that routine use of a centrifugal pump in the cardiopulmonary bypass circuit would result in a lower incidence of early neuropsychologic deficit when compared with conventional roller pumps.

DESIGN

Prospective, randomized, double-blind.

SETTING

University teaching hospital.

PARTICIPANTS

Patients (n = 103) scheduled for elective coronary artery surgery.

INTERVENTIONS

Patients were randomized into group C (centrifugal pump for cardiopulmonary bypass; n = 54) and group R (roller pump for cardiopulmonary bypass; n = 49).

MEASUREMENTS AND MAIN RESULTS

A neuropsychologic test battery of 6 standard tests was administered before surgery and 5 days after surgery. An abnormal test result was defined as deterioration by >1 group SD from an individual's preoperative test performance. There were no significant differences between groups in preoperative or surgical parameters, intensive care unit stay, or hospital stay. There were no significant differences in the incidence of neuropsychologic deficit for patients with a deficit in at least 1 test (group C, 33%; group R, 51%; odds ratio, 0.48; 95% confidence interval, 0.22 to 1.06) or patients with a deficit in >/=2 tests (group C, 6%; group R, 18%; odds ratio, 0.26; 95% confidence interval, 0.07 to 1.03). In group R, there were more individual test deficits per patient than in group C (p = 0.04).

CONCLUSION

There was no significant difference in the incidence of neuropsychologic deficit postoperatively with routine use of centrifugal pumps. The larger number of individual test deficits in the roller pump group suggest that further studies to assess the potential neuropsychologic benefits of the use of centrifugal pumps are warranted.

An in vitro method for comparing biocompatibility of materials for extracorporeal circulation

We measured the response of fresh heparinized human blood to recirculation through circuits made of LVA (Portex Industries, Hythe, Kent, UK), SRT (Rehau UK, Langley, Slough, UK) and Tygon S-65-HL (Norton Performance Plastics, Corby, Northants, UK), as control. Circuit construction: 1/2 in. tubing, heat exchanger (Dideco D-720P), Stockert roller pump, just underoccluded, Cincinnati Sub Zero heater, circuit volume of 500 ml. Flow 3.45 l/min, 37 degrees C.

SAMPLES

at 10 min, 1, 2, 4 and 6 h. n=5 in each group; 2/5 SRT experiments were stopped at 45 and 60 min due to overpressurization.

RESULTS

Baseline activated clotting time (ACT) of 300 s, increasing in all groups as fibrinogen fell to zero with SRT and LVA. Minimum fibrinogen was 1 g/l for Tygon. Absolute thrombocytopenia occurred (SRT and LVA 60 min and Tygon 240 min). International normalized ratio (INR) in both the SRT and LVA circuits increased, but mean increase for Tygon (0.56) was smaller than the other two materials. Plasma free haemoglobin increased in all three materials; the increase was greater in the LVA circuits compared to the control. C5b9 levels increased equally in all groups. Lactoferrin levels rose equally in all groups to a maximum at 150 min. The neutrophil counts fell, mirroring the lactoferrin. The total white cell counts also fell in all groups; in the LVA circuits, the fall was significantly lower than in the control. Rapid disappearance of platelets and fibrinogen from the blood in the SRT and LVA circuits excludes them both from extracorporeal use. Paradoxically, SRT caused the least complement activation of the three materials. This method can be used to compare biocompatibility.