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Biomedical subjects

E R Bulder

Publications and source records attributed to E R Bulder.

11 recordsLinked to original sources
PubMed2002

Low-prime perfusion circuit and autologous priming in CABG surgery on a Jehovah's Witness: a case report.

Cardiac surgery on Jehovah's Witnesses is a great challenge for the cardiothoracic surgery team and especially for the perfusionist. To reduce the risk of surgery in these patients, a very small extracorporeal circuit was designed to decrease the amount of priming volume and thereby the degree of hemodilution. A small bypass system was built, consisting of a 3/8-in. arterial line and a 3/8-in. venous line, a venous collapsible reservoir, a centrifugal pump, a hollow fiber oxygenator and a cell saver reservoir. The circuit priming volume was 650 ml. By using antegrade and retrograde autologous priming, the total amount of priming was reduced to +/-50 ml. Bypass time was 63 min with an average blood flow of 5300+/-114 ml/min and postmembrane pressures of 180+/-45 mmHg. Venous line pressure was monitored and kept between -8 and -20 mmHg with a mean arterial pressure (MAP) of 55+/-12.3 mmHg. The hematocrit before extracorporeal circulation (ECC) was 36%, per-ECC 35% and post-ECC 35%. On the fifth postoperative day, the hematocrit was 40%. The patient was discharged 7 days after surgery. A low-prime circuit, in combination with autologous priming, seems to be safe and effective in avoiding the use of banked blood.

Adult↗
PubMed1999

The visceral perfusion system and distal bypass during thoracoabdominal aneurysm surgery: an alternative for physiological blood flow?

There are potential benefits to addition of visceral organ perfusion, by means of a 9-Fr. catheter system (octopus), to distal aortic perfusion during thoracoabdominal aneurysm surgery. However, in the literature there are reports of adverse effects. The authors therefore compared two groups of patients who underwent thoracoabdominal aneurysm surgery with and without visceral organ perfusion. In the group in which the visceral perfusion was applied, the use of platelets (26 versus 11 units; P < 0.05), fresh frozen plasma (3.4 versus 1.5 units; P < 0.05) and packed cells (20 versus 8 units, P < 0.05) was significantly increased. An equal number of patients in both groups developed renal failure postoperatively. An explanation for this adverse effect can be found in the high shear rates in the catheters used, mainly as a result of the small diameter. High shear rates cause haemolysis. Also, the flow through the catheters is insufficient to maintain adequate perfusion of the visceral organs. A higher flow in these catheters would result in an even higher shear rate. It is therefore concluded that coagulopathy and insufficient bloodflow is caused by the small internal diameter of the catheters, which renders the device insufficient.

Acute Kidney Injury↗
PubMed1997

Impedance cardiography in cardiac surgery patients: abnormal body weight gives unreliable cardiac output measurements.

BACKGROUND: To study the accuracy of cardiac output measurement by means of Electrical Impedance Cardiography (EIC) in post-cardiac surgery patients. METHODS: In a prospective study, we compared cardiac output measurements by means of thermodilution (COTD) with impedance cardiographic-derived values (COEIC) in 37 mechanically ventilated patients after cardiac surgery. Both methods were used simultaneously. RESULTS: COEIC values were weakly correlated with COTD in the total group when the equation of Sramek-Bernstein was employed to calculate COEIC (r = 0.60, P < 0.001, mean difference and standard deviation: -0.06 +/- 1.25 l.min-1). After exclusion of the 12 patients whose body weight differed > 15% from their ideal body weight, no significant difference was found between the mean values (5.40 +/- 1.80 l.min-1 (COEIC) vs 5.31 +/- 1.69 l.min-1, n = 25) while the correlation coefficient increased substantially (r = 0.85, P < 0.001, mean difference and standard deviation: 0.09 +/- 0.96 l.min-1). CONCLUSIONS: The results of this study indicate that weight is a very important factor in unreliable measurement of CO by impedance cardiography in cardiac surgery patients. The calculation equation as proposed by Sramek and Bernstein is not accurate enough in patients with more than 15% of weight deviation. Therefore, the use of impedance cardiography in these patients is of limited value until an accurate correction factor has been developed.

Adult↗
PubMed1996

Cardiopulmonary bypass with modified fluid gelatin and heparin-coated circuits.

We have assessed the efficacy of cardiopulmonary bypass (CPB) using normal colloid oncotic pressure (COP) in a randomized, controlled study of 20 patients undergoing elective coronary artery surgery using heparin-coated circuits. For CPB, we used either crystalloid priming 1650 ml (n = 10) or colloid priming 1650 ml (2.4% modified fluid gelatin, n = 10). While COP did not change during bypass in the colloid group, a decline was observed in the crystalloid group (P = 0.005). By the end of bypass, the decrease in COP compared with baseline (delta COP) was 8.5 (S.D. 1.1) mm Hg in the crystalloid group compared with 1.5 (2.1) mm Hg in the colloid group (P = 0.0001). delta COP correlated positively with fluid balance during bypass (r2 = 0.41, P = 0.002). Similar increments in complement factors C3b/c and C4b/c, tumour necrosis factor-alpha and neutrophil elastase, but not endotoxins, were found in both groups as indicators of a systemic inflammatory response. A clinical performance score composed of fluid balance, postoperative duration of intubation and the difference between rectal temperature and skin temperature was more favourable in patients treated with colloid priming (P = 0.03). Median postoperative hospital stay was 7 (range 5-16) days in the crystalloid group compared with 5 (4-8) days in the colloid group (P = 0.016). Regression analysis indicated that CPB time, fluid balance during operation and postoperative PO2/FlO2 ratio were independent factors that predicted postoperative hospital stay. From these preliminary results we conclude that in the absence of endotoxaemia, use of a normal COP during CPB with modified fluid gelatin in heparin-coated circuits resulted in an improved postoperative course an a reduction in hospital stay.

Aged↗
PubMed1996

Impedance cardiography. Importance of the equation and the electrode configuration.

OBJECTIVE: Electrical impedance cardiography (EIC) has been suggested as a non-invasive method to measure cardiac output. In several studies it proved to be a reliable method, although there were some restrictions. In 1966 Kubicek et al. developed an impedance cardiac output system based upon electrodes and a specific stroke volume formula. In 1983 Sramek et al. developed a new electrode configuration, and a new equation to calculate stroke volume, an equation that was adjusted by Bernstein in 1986. Since then these two methods have been used in clinical medicine. The purpose of the present study was to compare both electrode configurations and both stroke volume calculation equations with each other. The cardiac output (CO) values obtained by means of EIC are compared with CO values obtained by means of thermodilution. DESIGN: Prospective study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: 20 mechanically ventilated patients after cardiac surgery. MEASUREMENTS AND RESULTS: Simultaneous measurement of CO by means of electrical impedance cardiography (COEIC) and thermodilution (COTD) was performed. COEIC was obtained using the lateral spot electrode configuration (LS) and an adjusted circular electrode configuration (SC). The formulas of Sramek (S), Sramek-Bernstein (SB), Kubicek (K) and an adjusted Kubicek formula (aK) were employed. Using the LS electrode configuration, significant differences were found between COEIC and COTD with the S formula (p < 0.005), the K formula (p < 0.001), and the aK formula (p < 0.05). Using the SC electrode configuration, significant differences between COEIC and COTD were found with the K formula (p < 0.005), the S formula (p < 0.01), and the SB formula (p < 0.05). No significant differences was found between EIC and TD using the LS electrode configuration together with the SB formula or using the SC electrode configuration with the aK formula. In both cases a good correlation was found between COEIC and COTD (r = 0.86, p < 0.001 and r = 0.79, p < 0.001, respectively). The mean difference between EIC and TD was 0.15 +/- 0.96 1/min and 0.19 +/- 1.19 1/min, respectively.

Aged↗
PubMed1995

Reduction in prime volume attenuates the hyperdynamic response after cardiopulmonary bypass.

BACKGROUND: A hyperdynamic response to cardiopulmonary bypass is characteristically observed in the post-operative course. To determine the effect of prime volume on the hemodynamic response, a database study was performed on patients who underwent elective coronary artery bypass grafting with an extracorporeal circuit with either a large prime volume (2,350-mL prime, n = 20) or a small prime volume (1,400-mL prime, n = 20). METHODS: Measurements were carried out at fixed time points before and after cardiopulmonary bypass (until 18 hours postoperatively) and include hematocrit, colloid oncotic pressure, fluid balance, and hemodynamic profile (mean of three measurements). RESULTS: The lower colloid oncotic pressure in the large prime group (16.2 +/- 0.6 mm Hg versus 19.1 +/- 1.1 mm Hg, p = 0.0002) was associated with a highly positive fluid balance (5.5 +/- 0.9 L versus 2.8 +/- 0.7 L, p = 0.0001). With the on-bypass hematocrit aimed at 22% to 23%, autologous blood was predonated by 16 patients in the small prime group but by none in the large prime group. Reinfusion of autologous blood resulted in a reduction in blood bank requirements (p = 0.03). Mean arterial pressure was 83 +/- 4 mm Hg for small prime versus 76 +/- 4 mm Hg for large prime (p = 0.01). Cardiac index was 2.9 +/- 0.2 L.min-1.m-2 for small prime versus 3.8 +/- 0.3 L.min-1.m-2 for large prime (p = 0.0001). Pulmonary vascular resistance index was 281 +/- 40 dyne.s.cm5.m-2 for small prime versus 188 +/- 22 dyne.s.cm5.m-2 for large prime (p = 0.0009). Oxygen delivery was 42 +/- 5 mL.min-1.m-2 for small prime versus 51 +/- 3 mL.min-1.m-2 for large prime (p = 0.004). Vasoactive medication was not different among groups. CONCLUSIONS: Reduction in prime volume attenuates the hyperdynamic response after cardiopulmonary bypass. Furthermore, an important reduction in blood bank products can be obtained with small prime volumes.

Aged↗
PubMed1995

Reduced complement activation and improved postoperative performance after cardiopulmonary bypass with heparin-coated circuits.

A randomized controlled trial that involved 30 patients undergoing elective coronary artery bypass grafting was done to determine the effect of heparin-coated circuits and full heparinization on complement activation, neutrophil-mediated inflammatory response, and postoperative clinical recovery. Peak concentrations of terminal complement complex were 38% lower (p = 0.004) in 15 patients treated with heparin-coated circuits (median 775 micrograms/L, interquartile range 600 to 996) compared with those in 15 patients treated with uncoated circuits (median 1249 micrograms/L, interquartile range 988 to 1443). Although no significant intergroup differences in concentrations of polymorphonuclear neutrophil elastase were found, a positive correlation (rs = 0.74, p < 0.0007) was calculated between peak concentrations of terminal complement complex and polymorphonuclear neutrophil elastase. Differences in patient recovery were analyzed with use of a score composed of fluid balance, postoperative intubation time, and the difference between rectal temperature and skin temperature. The score was significantly lower in patients treated with heparin-coated circuits (p = 0.03), whereas its components showed no intergroup significance. We conclude that the use of heparin-coated circuits with full systemic heparinization results in improved biocompatibility, as assessed by complement activation, and leads to an improved postoperative recovery of the patient.

Body Temperature↗
PubMed1994

Perfusion-related factors of endotoxin release during cardiopulmonary bypass.

To investigate whether the release of endotoxin during cardiopulmonary bypass (CPB) is determined by perfusion-related factors, endotoxin concentrations were determined before, during, and after CPB in 21 male patients (age range 45-75 years) undergoing elective coronary artery bypass grafting. Hemodynamic parameters and oncotic pressure were also measured. Significant increases in endotoxin concentrations were observed after the start of CPB (P < 0.005), before aortic cross-clamp release (P < 0.05), and after aortic cross-clamp release (P < 0.05). The median endotoxin concentration after cessation of CPB was 0.264 EU/ml (range < 0.036-0.480 EU/ml). Endotoxin concentrations derived from the prime solutions were not contributory. Positive correlations were found between arterial pressure after the start of CPB and the endotoxin concentration 10 min after (r = 0.58, P < 0.01) and between the duration of aortic cross-clamping and the endotoxin concentration after the cessation of CPB (r = 0.64, P < 0.005). Arterial pressure after the start of CPB, the duration of aortic cross-clamping, and decrease in oncotic pressure appeared to be independent variables in a forward variable selection model that predicted endotoxin concentrations after CPB. We conclude that in patients undergoing elective coronary artery bypass grafting, an early phase of endotoxin release during CPB could be demonstrated, and that this is due to vasoconstriction. The endotoxin concentrations after the cessation of CPB were determined by early vasoconstriction, duration of aortic cross-clamping, and hypo-oncotic hemodilution.

Aged↗
PubMed1988

Alizapride in prevention of postoperative nausea and vomiting.

A series of 90 ASA class 1 or 2 young adult female out-patients, randomly assigned to four groups, were treated with placebo (saline solution), alizapride 50 mg, alizapride 100 mg or alizapride 200 mg. The incidence of postoperative nausea and vomiting has been estimated. The incidence of nausea and vomiting was lower with the alizapride-treated patients, while, contrary to the experience with other antiemetics, prolonged recovery was not observed. The incidence of vomiting in the placebo-group was twice as high as in the alizapride-groups. Of the placebo-treated patients, 20 percent requested further antiemetic medication within four hours while none of the alizapride-treated patients needed this. Alizapride 100 to 200 mg intravenously is efficacious in the prevention of postoperative nausea and vomiting.

Anesthesia, General↗