K . Kohlsaat et al .: J Extra Corpor Technol 2023 , 55 , 175 – 184 183
Another limitation of our retrospective study is that while we found no statistically significant difference between groups in terms of overall ultrafiltration volumes , we could not control for perfusionist practice variation . We do know that on our large team , there is variability in how much conventional and zero balance ultrafiltration ( ZBUF ) one performs . The final lab values may have been similar between groups overall because of individual practice to perform ZBUF , and how much , particularly when additional blood was required during surgery .
This single-center study is also limited by the generalizability of our study findings to centers with a similar case mix and perfusion practice . This study shows that PBUF allows electrolyte values to correct to physiologic ranges more quickly , as opposed to waiting for the body to do this on its own . However , the statistically significant data that appear in final prime values does not automatically indicate that the change is clinically significant . Validation of these findings in a larger , preferably multicenter prospective cohort is warranted .
Implications / next steps
The results suggest that PBUF is a useful and beneficial practice that can attenuate the perioperative stressors during infant cardiac surgery cases requiring CPB and a blood prime . Taking the load of correcting these electrolyte values off of the patient and putting it onto the perfusionist was a primary consideration when we started utilizing PBUF . It would be interesting to measure other elements of homeostasis during the perioperative period to determine where else PBUF may be beneficial . For example , avoidance of hypernatremia , starting with normalization of the sodium content of the prime components , may be particularly important in the protection of the neonatal brain . Rapid acute fluctuations in sodium levels and water movement may have detrimental sequelae such as cerebral edema , osmotic demyelination , and even intraventricular hemorrhage [ 24 – 26 ]. This is not well studied in neonatal and infant CPB cases but is certainly worthy of consideration when modifying priming procedures .
Furthermore , while the study indicates that the use of PBUF in a single surgical instance does not have any significant impact on immediate clinical outcomes , many single ventricle patients , for example , as well as congenital patients who require unplanned reoperations , must undergo CPB more than once . Looking at the cumulative effects of PBUF throughout these consecutive surgeries on patients and their long-term outcomes may demonstrate that PBUF is not only safe and effective but mayalsobebeneficial in the long term . With one of the original concerns with PBUF being the possibility for negative neurologic implications as patients ages , a long-term review of patients who underwent PBUF would provide the clearest picture of its impact .
Conclusion
The use of PBUF allows for more physiologic values for electrolytes , glucose , and lactate before the initiation of bypass without a negative impact on clinical outcomes or an increase in postoperative adverse events . PBUF creates predictable and consistent prime values when using bank blood products . We believe that PBUF is a safe and effective means to adjust blood prime values for neonates and infants undergoing surgery with CPB circuits requiring a blood prime .
Glossary of abbreviations
AABB CCT CICU CNS CPB CUF ECMO FNHTRs Gy IU LOS PBUF PRBC RBC SP STAT TA-GVHD TPS TRALI VAD WBCs ZBUF
Conflict of interest
American Association of Blood Banks Cross-Clamp Time Cardiac Intensive Care Unit Central Nervous System Cardiopulmonary Bypass Conventional Ultrafiltration Extracorporeal Membrane Oxygenation Febrile Non-Hemolytic Transfusion Reactions Gray Units International Units Length of Stay Pre-Bypass Ultrafiltration Packed Red Blood Cells Red Blood Cells Standard Prime Society of Thoracic Surgeons-European Association
for Cardio-Thoracic Surgery Transfusion-Associated Graft Versus Host Disease
Technical Performance Score Transfusion-Related Acute Lung Injury Ventricular Assist Device White Blood Cells Zero Balance Ultrafiltration
The authors declare no conflict of interest .
Funding This project was funded with departmental funds .
Data availability All available data are incorporated into the article .
Institutional Review Board Approval IRB-P00038496 ; Date of Exemption : 4 / 13 / 21 .
Informed consent
PatientwaiverofconsentwasapprovedbyBostonChildren ’ s Hospital IRB .
Author contributions
Katherine Kohlsaat : data curation , project administration , writing ; Kimberlee Gauvreau : data analysis and validation ;