J Extra Corpor Technol 2024 , 56 , 216 – 224 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024026
Available online at : ject . edpsciences . org
TECHNIQUE or APPLICATION
Failure to oxygenate during cardiopulmonary bypass ; treatment options and intervention algorithm
Gregory S . Matte ( CCP , LP , FPP ) * , William L . Regan ( CCP , LP , FPP ), Sarah I . Gadille ( CCP , LP ), Kevin R . Connor ( CCP , LP , FPP ), Sharon L . Boyle ( CCP , LP , FPP ), and Francis E . Fynn-Thompson ( MD )
Department of Cardiac Surgery , Boston Children ’ s Hospital , 300 Longwood Avenue , Boston , MA 02115 , USA Received 28 May 2024 , Accepted 16 September 2024
Abstract – Membrane oxygenator failure remains a concern for perfusion teams . Successful outcomes for this lowfrequency , high-risk intervention are predicated on having written institutional protocols for both the oxygenator change-out procedure as well as how often the procedure is practiced by staff perfusionists . A recent review of peerreviewed journal articles , textbooks and online resources revealed a lack of a unified intervention algorithm for failure to oxygenate during cardiopulmonary bypass ( CPB ). While an oxygenator change-out procedure may still be considered the gold standard for a confirmed device failure , temporizing measures exist that , in select cases , can afford time to the clinical team and even obviate the need for an oxygenator change-out procedure . We now consider the venous piggyback technique sourcing blood from the venous limb of the circuit a first-line intervention to afford enhanced patient safety while the clinical team decides on required interventions when oxygenator failure presents during CPB .
Key words : Cardiopulmonary bypass , Oxygenator failure , Oxygenator change-out , Cardiopulmonary bypass emergency .
“ Failure is not an option .” Attributed to NASA Flight Director Gene Kranz of the Apollo 13 Moon landing mission , April 1970 .
Overview
Membrane oxygenator failure during cardiopulmonary bypass ( CPB ) remains a concern for perfusion teams , even though most perfusionists have never had the occasion to perform an emergent oxygenator change-out [ 1 ]. The reported incidence of oxygenator failure is likely underreported since not all incidents end up in reporting databases and because there is not a standard definition for oxygenator failure [ 1 , 2 ]. Soo et al . reported that there were 50 , 101 , and 133 reported cases of oxygenator failure in the United States in 2009 , 2010 , and 2011 , respectively [ 3 ]. Da Broi et al . reported in 2006 that in the United States alone , one patient per month dies as the result of the oxygenator failure change-out procedure during extracorporeal membrane oxygenator support ( ECMO ) or CPB [ 2 ]. Willcox commented in his 2023 letter-to-the-editor regarding reviewing the literature for oxygenator failures that there were reported “... instances where change-out was considered but not done , sometimes with periods of marked hypoxaemia ” [ 1 ]. These reports highlight how essential it is for perfusion programs to plan for an oxygenator failure emergency . Successful outcomes for this low-frequency , high-risk intervention are predicated on having written institutional protocols for managing primary oxygenator failure as well as how often the procedure is practiced by staff perfusionists [ 3 , 4 ].
It is of principal concern to qualify that failure to oxygenate with the primary membrane oxygenator does not universally require an oxygenator change-out . First , the team must determine if the oxygenator itself is the root cause and not a host of other possibilities [ 3 – 6 ]. Oxygenator change-out procedures have been performed during CPB , with subsequent follow-up revealing an alternate cause for apparent oxygenator device failure [ 3 ]. Table 1 lists primary considerations for assessing the patient and circuit when oxygenator failure is suspected during CPB and is based on team experience and published guidance [ 5 – 7 ]. Basic confirmations of overall sweep flow and FiO 2 are done but also verification that an appropriate ventilation-to-perfusion ( V / Q ) ratio is in use . The consideration of the V / Q ratio is central to avoiding condensation buildup within the microfiber bundles which will consequently result in a wetting-out effect [ 8 – 10 ]. Manufacturer-specific interventions to treat a wetted-out device must be followed . Verification of sweep flow must also ensure that a minimum gas flow , as recommended
* Corresponding author : gregory . matte @ cardio . chboston . org
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