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Sancheti M, Rentschler M, Bolch C, Li W, Necco K, Rath T, Esfandiarei M, Darban N. Designing an experimental method for assessing biocompatibility of circuit coatings using biomarkers for platelet activation during cardiopulmonary bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:37-44. [PMID: 38888546 PMCID: PMC11185148 DOI: 10.1051/ject/2024003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/10/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Cardiopulmonary bypass is an essential component of cardiothoracic surgeries. However, significant complications such as systemic inflammatory response syndrome (SIRS) resulting from cardiopulmonary bypass (CPB) are a common occurrence due to contact between circulating blood and foreign surfaces that leads to platelet activation. It is suggested that different available CPB circuit coatings can potentially reduce platelet activation. However, there have been no published evidence-based reports confirming these claims. In addition, there is no well-established protocol for studying platelet activation biomarkers during CPB in vitro in a laboratory setting. METHODS CPB was simulated in the laboratory using bovine blood in two different types of coated CPB circuits: Trillium® Biosurface by Medtronic, and XcoatingTM Surface by Terumo. Fresh bovine blood samples were collected and circulated through the CPB circuit following the standard protocol used in the operation rooms. Blood samples were then collected at 5 min, 30 min, and 55 min during the circulation. Blood plasmas were separated and subjected to enzyme-linked immunosorbent assay to measure most established platelet activation markers P-selectin, Platelet Factor 4 (PF4), Glycoprotein IIb/IIIa (GPIIb/IIIa), and β-thromboglobulin (β-TG) at different time points. RESULTS The biomarker values at 30 min and 55 min were compared to the base values at 5 min for each type of CPB circuit. The results of the means from all measured biomarkers showed data measurements that indicated no significant variability within each coating. All collected data points fell within ±2 SD of the means, which was considered acceptable variations across technical replicates. Conclusion: In this study, we were able to establish an in vitro protocol in the laboratory setting that is precise and reliable with minimum intra-variability. This established protocol will allow for future studies in which different coated CPB circuits can be compared for their effectiveness in blocking platelet activation during the CPB.
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Affiliation(s)
- Meghal Sancheti
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Arizona College of Osteopathic Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Mitchell Rentschler
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Arizona College of Osteopathic Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Charlotte Bolch
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Office of Research & Sponsored Program, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Weidang Li
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College of Veterinary Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Katelyn Necco
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College of Graduate Studies, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Thomas Rath
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College of Health Sciences, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Mitra Esfandiarei
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College of Graduate Studies, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
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College of Medicine Phoenix, University of Arizona 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Nathaniel Darban
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College of Health Sciences, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
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Michihara A, Hanada M, Nagatsuka Handa Y, Mizoguchi T, Ohchi Y, Sato Y. Change of dexmedetomidine and midazolam concentrations by simultaneous injection in an in vitro extracorporeal circuit. Perfusion 2023:2676591231184715. [PMID: 37325845 DOI: 10.1177/02676591231184715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Patient sedation and analgesia are vital for safety and comfort during extracorporeal membrane oxygenation (ECMO). However, adsorption by the circuit may alter drug pharmaco-kinetics and remains poorly characterized. This study is the first to examine the concentrations of DEX and MDZ in the presence of drug-drug interactions using an in vitro extracorporeal circuit system that incorporates a polymer-coated polyvinyl chloride tube, but not a membrane oxygenator. METHODS AND RESULTS Nine in vitro extracorporeal circuits were prepared using polymer-coated PVC tubing. Once the circuits were primed and running, either a single drug or two drugs were injected as boluses into the circuit with three circuits per drug. Drug samples were drawn following injection at 2, 5, 15, 30, 60, and 120 min and at 4, 12, and 24 h. They were then analyzed using high-performance liquid chromatography with mass spectrometry. When compared with an injection of DEX alone, the combination of DEX and MDZ is highly changed, with DEX and MDZ affecting the availability of free drugs in the circuit. CONCLUSIONS The change of DEX and MDZ concentrations was confirmed by a combination of both drugs as compared with either single-infusion DEX or MDZ in an in vitro extracorporeal circuit. Drug-drug interactions developed between DEX and MDZ through albumin in an extracorporeal circuit; as a result, the unbounded drugs might change in the circuit.
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Affiliation(s)
- Ayana Michihara
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Miyu Hanada
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Yuka Nagatsuka Handa
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Takayuki Mizoguchi
- Department of Clinical Engineering, Oita University Hospital, Yufu-shi, Japan
| | - Yoshifumi Ohchi
- Department of Intensive Care Unit, Oita University Hospital, Yufu-shi, Japan
| | - Yuhki Sato
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
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Hasegawa T, Oshima Y, Yokoyama S, Akimoto A, Misaka Y, Akiyama S. Clinical application of a new ternary polymer, SEC-1 coat™, for pediatric cardiopulmonary bypass circuits: a prospective randomized pilot study. Perfusion 2020; 35:826-832. [PMID: 32308128 DOI: 10.1177/0267659120915387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The use of biocompatible materials to reduce the systemic activation of inflammation and coagulation pathways is expanding rapidly. However, there have been few clinical studies of biocompatible circuits for pediatric cardiopulmonary bypass. This pilot study aimed to preliminarily evaluate the biocompatibility of SEC-1 coat™ (SEC) for cardiopulmonary bypass circuits in pediatric cardiac surgery. METHODS Twenty infants undergoing cardiac surgery for isolated ventricular septal defects at Kobe Children's Hospital were assigned randomly to an SEC-coated (SEC group, n = 10) or heparin-coated (control group, n = 10) circuit. Perioperative data and the following markers were prospectively analyzed: platelet counts and interleukin-6, interleukin-8, C3a, β-thromboglobulin, and thrombin-antithrombin complex levels. RESULTS Neither patient characteristics nor postoperative clinical outcomes differed significantly between the SEC and control groups. Platelet counts markedly decreased during cardiopulmonary bypass in both groups, but were significantly better preserved in the SEC group. Fewer patients needed postoperative platelet transfusions in the SEC group. After cardiopulmonary bypass termination, serum levels of β-thromboglobulin and thrombin-antithrombin complex were significantly lower in the SEC than in the control group. Although the differences were not statistically significant, serum levels of interleukin-6, interleukin-8, and C3a had a tendency toward being lower in the SEC group, with good preservation of leukocyte counts, fibrinogen, and antithrombin III. CONCLUSION SEC-1 coat™ for cardiopulmonary bypass circuits have good biocompatibility with regard to platelet preservation and in terms of attenuating inflammatory reaction or coagulation activation during pediatric cardiac surgery. It can be beneficial in pediatric as well as adult cardiac surgery.
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Affiliation(s)
- Tomomi Hasegawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.,Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yoshihiro Oshima
- Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Shinji Yokoyama
- Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Asuka Akimoto
- Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yusuke Misaka
- Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Shota Akiyama
- Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
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Tagaya M, Okano S, Murataka T, Handa H, Ichikawa S, Takahashi S. Biocompatibility of a polymer-coated membrane possessing a hydrophilic blood-contacting layer: Adsorption-related assessment. Int J Artif Organs 2019; 43:405-410. [PMID: 31875413 DOI: 10.1177/0391398819895525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Currently, the foreign surfaces of extracorporeal circulation devices are coated with an acrylate-based copolymer that creates a hydrophilic blood-contacting layer to enhance biocompatibility. Several reports of acrylate-based copolymer with respect to biocompatibility have been published; however, the adsorption of peptide compounds on acrylate-based copolymer-coated membranes still requires clarity. In this study, we aimed to understand the adsorption of several peptide compounds of various molecular weights, including albumin, lysozyme, and vancomycin, on acrylate-based copolymer-coated membranes using in vitro studies. METHODS Six experimental circuits consisting of acrylate-based copolymer-coated tubes and membranes, and six comprising acrylate-based copolymer-coated tubes and non-coated membranes were prepared for comparison. An experimental solution, composed of albumin, lysozyme, vancomycin, and saline, was continuously stirred in a reservoir, recirculated in each experimental circuit, and then filtered. Concentrations of albumin, lysozyme, and vancomycin were measured after 0, 15, 30, 45, 60, 90, and 120 min of recirculation. Similar experiments were performed in all the prepared circuits. RESULTS The ratio of measured values at each time point to those at 0 min was not significantly different between acrylate-based copolymer-coated and non-coated membranes for albumin and lysozyme, but differed significantly for vancomycin; the ratios were higher in acrylate-based copolymer-coated than in non-coated membranes. CONCLUSION This study suggests that albumin is not adsorbed on either acrylate-based copolymer-coated or non-coated membranes, that lysozyme is not adsorbed on either membrane or is adsorbed at a similar rate on both membranes, and that vancomycin is less adsorbed on acrylate-based copolymer-coated membranes. Thus, acrylate-based copolymer coating could inhibit the adsorption of various peptide compounds.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Shunsuke Ichikawa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
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Tagaya M, Hara K, Takahashi S, Nagoshi S, Handa H, Okano S, Murataka T. Antithrombotic properties of hemofilter coated with polymer having a hydrophilic blood-contacting layer. Int J Artif Organs 2018; 42:88-94. [PMID: 30486706 PMCID: PMC6343425 DOI: 10.1177/0391398818815480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE: Extracorporeal circulation devices are coated with a biocompatible polymer coating agent (BPCA) that has a hydrophilic blood-contacting layer, but hemofilters are not. We aimed to investigate the antithrombotic properties of a BPCA-coated hemofilter. METHODS: Four experiments using BPCA-coated circuits and non-coated hemofilters and four experiments using BPCA-coated circuits and BPCA-coated hemofilters were performed with whole human blood and compared by measuring the circuit pressure every 5 min, antithrombin activity every 40 min, and thrombin-antithrombin complex every 40 min, for a total of 240 min of recirculation. RESULTS: The mean time required for the pressure at the inlet of the hemofilter to increase sharply was longer in BPCA-coated than in non-coated hemofilters (66 ± 11 min vs 25 ± 9 min, p < 0.01). The mean antithrombin activity value at 200 and 240 min of recirculation was significantly higher in the experiments with BPCA-coated versus non-coated hemofilters (43.3 ± 2.87 vs 33.3 ± 5.74, p = 0.04; 42.8 ± 3.59 vs 31.0 ± 5.35, p = 0.01, respectively); the antithrombin activity values at the other time points were not significantly different. Furthermore, all thrombin-antithrombin complex values in experiments with the BPCA-coated hemofilters achieved overrange at 80 min of recirculation, whereas those with the non-coated hemofilter achieved overrange at 40 min. CONCLUSION: This study suggests that BPCA-coated hemofilters can inhibit antithrombin consumption, contributing to antithrombotic effects in extracorporeal circulation circuits.
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Affiliation(s)
- Masashi Tagaya
- 1 Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Kazunobu Hara
- 1 Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- 2 Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Saki Nagoshi
- 3 Department of Clinical Laboratory, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- 1 Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- 1 Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- 1 Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Hemodialysis membrane coated with a polymer having a hydrophilic blood-contacting layer can enhance diffusional performance. Int J Artif Organs 2017; 40:665-669. [PMID: 28777393 PMCID: PMC6159844 DOI: 10.5301/ijao.5000631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2017] [Indexed: 12/02/2022]
Abstract
Purpose Currently, the foreign surfaces of various extracorporeal circulation devices are coated with a biocompatible polymer coating agent (BPA), which creates a hydrophilic blood-contacting layer to reduce thrombogenicity, while the membranes in hemodialyzers are not. We aimed to clarify other side effects of BPA-coated membranes by examining the diffusion performance in in vitro experiments. Methods We used a polyethersulfone membrane (sieving coefficient of albumin is ≤0.01) coated with BPA product, SEC-1™ (Toyobo), in a hemodialyzer. To estimate the diffusion rates of a wide range of molecules, 2 L of saline containing vancomycin, lysozyme, and albumin were recirculated in the circuit configured with a hemodialyzer, and dialyzed continuously using water. The concentrations of sodium, vancomycin, lysozyme, and albumin were measured every 5 minutes for 30 minutes and compared in experiments with BPA-coated (n = 4) and BPA-noncoated (n = 4) membranes. Results The removal rates of sodium and vancomycin after 5 minutes of dialysis (n = 24) were significantly higher in BPA-coated than noncoated membranes, while those of lysozyme and albumin were not significantly different. The removal rates of sodium and vancomycin after 30 minutes of dialysis (n = 4) were significantly higher, and those of lysozyme were significantly lower in BPA-coated than noncoated membranes, while those of albumin were not significantly different. Conclusions The preliminary study suggests that BPA-coated membranes enhanced the diffusion rate of molecules with low and middle molecular weight without affecting the sieving coefficient of albumin. Thus, BPA coating can enhance the dialysis performance of membranes.
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Suehiro S, Shimizu K, Imai K, Niii A, Akeho K, Nakata H, Yamaguchi A, Matsumoto KI, Oda T. Polymer-coated cardiopulmonary bypass circuit attenuates upregulation of both proteases/protease inhibitors and platelet degranulation in pigs. Perfusion 2017; 32:645-655. [DOI: 10.1177/0267659117715506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Interaction of blood with a cardiopulmonary bypass (CPB) circuit activates the coagulation-fibrinolysis, complement and kinin-kallikrein systems that are mainly supported by proteases and their inhibitors. Methods: Biocompatibility of a new polymer-coated (SEC-coated) CPB circuit was globally evaluated and compared with that of a non-coated CPB circuit by quantitative proteomics, using isobaric tags for relative and absolute quantification labeling tandem mass spectrometry. Plasma samples were taken three times (5 min after initiation of CPB, just before declamping and just before termination of CPB) in 12 pigs undergoing 120 min of CPB with the SEC-coated CPB circuit or a non-coated CPB circuit (n = 6, respectively). Results: Identified were 224 proteins having high protein confidence (>99%) and false discovery rate (FDR) <5%. Among these proteins, there were 25 significantly upregulated proteins in the non-coated CPB group compared to those in the SEC-coated CPB group. Dominant protein functions were platelet degranulation, serine-type (cysteine-type) endopeptidase inhibitor activity and serine-type endopeptidase activity in the 25 proteins. Bioinformatics analysis similarly revealed upregulation of proteins belonging to platelet degranulation and negative regulation of endopeptidase activity in the non-coated CPB group; these upregulations were effectively attenuated in the SEC-coated CPB group. Conclusion: The new polymer (SEC)-coated CPB circuit effectively attenuated upregulation of proteins compared to the non-coated CPB circuit. These proteins were associated with both proteases/protease inhibitors and platelet degranulation.
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Affiliation(s)
- Shoichi Suehiro
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Kouji Shimizu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Kensuke Imai
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Atsushi Niii
- Department of Medical Engineering, Shimane University Hospital, Izumo, Japan
| | - Kazuhiro Akeho
- Department of Medical Engineering, Shimane University Hospital, Izumo, Japan
| | - Hayato Nakata
- Department of Medical Engineering, Shimane University Hospital, Izumo, Japan
| | - Akane Yamaguchi
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Ken-ichi Matsumoto
- Department of Biosignaling and Radioisotope Experiment, Interdisciplinary Center for Science Research, Organization for Research, Shimane University, Izumo, Japan
| | - Teiji Oda
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Japan
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Abstract
Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.
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Affiliation(s)
- Sarvesh Pal Singh
- Department of CTVS, Cardiac Surgical Intensive Care Unit, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Tagaya M, Matsuda M, Ryugo M, Takasaki T, Kurita S, Handa H, Hara K. Is using an open-reservoir cardiopulmonary bypass circuit after 6 days on standby safe? Interact Cardiovasc Thorac Surg 2015; 22:155-60. [PMID: 26573764 DOI: 10.1093/icvts/ivv302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/21/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To investigate the sterility and biocompatibility of a stored open-reservoir cardiopulmonary bypass circuit maintained on standby. METHODS A total of four cardiopulmonary bypass circuits were assembled, primed and left to recirculate. One unit was placed in a positive-pressure operating room and the other three were placed in the intensive care unit. The primed solutions, which employed Ringer's acetate, hydroxyethylated starch and hydrate steroid, were sampled after 0, 24, 48, 72, 96, 120 and 144 h in all cardiopulmonary bypass circuits to measure the bacteria count, endotoxin count and chemical substances within the primed solution. Chemical substances were detected by assessing the following: the total organic carbon by the combustion oxidation infrared spectrometry, and molecular weight spread by gel permeation chromatography. The environments were left unattended and were uncovered during the storage period to mimic the clinical scenario. RESULTS There were no bacteria in any of the primed solutions, and only very minute concentrations of endotoxins were detected, both in the operating room and in the intensive care unit. The total organic carbon concentration was slightly more concentrated in the 144-h samples when compared with that in the 0-h samples. However, the molecular weight spread of the 0-h sample was identical to that in the 144-h sample. DISCUSSION With regard to the presence of bacteria and endotoxins, we noted that the hardshell reservoirs in the cardiopulmonary bypass circuit were effectively sealed and not invaded by bacteria. With regard to the presence of chemical substances, we noted that an increase in total organic carbon concentration was caused by bedewing, and that there was no release of chemical substances such as a polymer-coating agent, or other molecular materials in the primed solution. CONCLUSIONS There was no contamination or release of chemical substances in 6-day old cardiopulmonary bypass circuits maintained on standby, confirming that they are safe to use in terms of sterility and biocompatibility.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Morihiro Matsuda
- Department of Internal Medicine, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Masahiro Ryugo
- Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Taiichi Takasaki
- Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Shigeaki Kurita
- Department of Anesthesiology, Critical Care and Pain Medicine, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - Kazunobu Hara
- Department of Medical Engineering, National Hospital Organization Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
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