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control, safety features( bubble detector and arterial occluder), and frame for the different components. The initial setup of the Quantum CPB system used a primed Pixie reservoir( Medtronic, Watford, UK) and CSC 14 cardioplegia device( Sorin Group, Mirandola, Italy), given at a 4:1 cold blood configuration. The water lines were removed from the HILITE 2400 LT ECMO oxygenator( MEDOS, Medizintechnik AG, Stolberg, Germany), and the gas line was redirected to the Quantum Ventilation Module on the Quantum CPB frame. The ECMO oxygenator and CentriMag pump head were then moved simultaneously to the Quantum CPB frame, with the oxygenator remaining higher than the pump head. Water lines and the cardioplegia system were attached to the oxygenator, and the arterial line was placed in the tubing occluder. The circuit pressures and CDI Ò 550( Terumo, Leuven, Belgium) monitoring remained on the ECMO cart.
In preparation for conversion to CPB, the patient was fully heparinized with a loading dose of 300 I. U./ kg. The patient had standard cannulation, ascending aorta with an 8fr DLP™ One- Piece Pediatric Arterial Cannula( Medtronic, Watford, UK) and right atrium with 16fr DLP™ Single Stage Venous Cannulae with right angle( Medtronic, Watford, UK), the cannula remained for CPB. The patient was then converted to CPB in the following sequence: the pump head speed was reduced, the arterial line clamped, and the venous line double clamped in a predefined area( Fig. 1). Using aseptic technique, the venous line between the two clamps was cut and a Pixie venous reservoir inserted. The upper limb was connected to the reservoir inlet, and the lower limb to the reservoir outlet, ensuring an air-free connection. After both connections were made, the venous clamps were removed, the pump flow increased, and the arterial line was unclamped to initiate CPB( Figs. 2 and 3).
Figure 1. Bristol University Hospital for Children ECMO circuit design. CVVH: Continuous Veno-Venous Hemofiltration, DLP: Drainage line pressure. V-A ECMO to CPB conversion using s5 MES
To convert the patient from ECMO to CPB, the s5 heartlung machine( HLM) with the CentriMag ECMO circuit was used simultaneously, with the ECMO New Born A. L. One( Eurosets, Medolla, Italy) oxygenator. However, pump flow was controlled via a roller pump on the s5 HLM. In preparation for conversion to CPB, a primed Pixie reservoir, roller pump tubing, and CSC 14 cardioplegia device( given at a 4:1 cold blood configuration) were set up on the s5 HLM. This also regulated gas flow and safety features( bubble and level sensor). All other components remained on the ECMO cart.
Again, the patient was fully heparinized prior to CPB conversion, with the same cannulation as patient one. The process was similar to the Quantum MES conversion; however, the lower limb of the venous line was attached to the roller pump outlet( Figs. 4 and 5). As of note, the CentriMag console power remained on for the pump head to be magnetically levitated for optimum blood flow pathway.
In both cases, the patients were successfully separated from CPB and recovered in pediatric intensive care.
Comment
Systemic inflammatory response syndrome( SIRS) from CPB has been widely documented, with possible causes being
Figure 2. Quantum MES circuit design. DLP: Drainage line pressure, CVVH: Continuous Veno-Venous Hemofiltration. Figure 3. Quantum MES circuit technique.