What Is New to Stop In OR

Chun Soo Park Pediatric Cardiac Surgery Asan Medical Center Disclosure

• None

Hemostasis Cardiopulmonary Bypass

• A whole body inflammatory response • Dilutional coagulopathy • A profound thrombotic reaction • Continuously generated • Consumption of factors • Platelet • Decreased amount and function

Children • ↑Vulnerability to post-CPB bleeding • The immature hemostatic system • ↑hemodilution and coagulopathy due to a relatively large CPB circuit prime • Liver dysfunction and decreased factor synthesis in children with CHD (esp. cyanotic CHD) Children • ↑Vulnerability to post-CPB bleeding HEMOSTATIS IN OR Surgical vs. Coagulopathic - Surgical Bleeding - • Prevented with • Timely discontinuation of anticoagulant before surgery • Asanguenous opening and careful dissection before heparin infusion • Meticulous hemostatic sutures Surgical vs. Coagulopathic - Surgical Bleeding - • Traditionally controlled with • Adequate hemostatic sutures with surrounding tissue • Hemostatic compression Surgical vs. Coagulopathic - Coagulopathic Bleeding - • Transfusion of products • Platelets • Fresh frozen plasma (FFP) • Cryoprecipitate • Packed-RBC • Fresh whole blood Surgical vs. Coagulopathic - Coagulopathic Bleeding - • Recombinant and plasma-derived products (off-label) • Recombinant factor VIIa • Prothrombin complex concentrate • concentrate • Factor XIII concentrate Coagulopathic Bleeding - Recombinant Factor VIIa -

Anesth Analg 2012;115:364-378 Coagulopathic Bleeding - Prothrombin Complex Concenrate -

Ann Thorac Surg 2017;104:1423-1431 Coagulopathic Bleeding - Prothrombin Complex Concenrate - Coagulopathic Bleeding - Prothrombin Complex Concenrate - Topical Hemostatic Agents Category Class Sub-class Brand (manufacturer)

Helistat® (Integra, Plainsborough, NJ) Bovine collagen-based sponge Actifoam® (MedChem Products, Woburn, MA)

Colgel™ (Laboratoire Interpharm, Aubervilliers, Microfibrillar bovine collagen powder Mechanical HAs France) Surgicel® (Ethicon, Somerville, NJ) Non-active Surgicel® Nu-Knit (Ethicon, Somerville, NJ) HAs Polysaccharide spheres Arista® (Medafor, Minneapolis, MN) Porcine gelatin Gelfoam® (Pfizer, Kalamazoo, MI) Bovine serum albumin with glutaraldehyde BioGlue® (CryoLife Inc. Kennesaw, GA) Synthetic sealants Polyethylene glycol CoSeal® (Baxter, Hayward, CA) Cyanoacrylate OMNEX™ (Ethicon™ Somerville, NJ) Bovine-derived thrombin Thrombin-JMI® (Pfizer, New York, NY) Evithrom® (Ethicon, Somerville, NJ) Human plasma-derived thrombin with porcine gelatin sponge Active HAs Gelfoam® Plus (Baxter, Hayward, CA)

Recombinant thrombin Recothrom® (ZymoGenetics, Seattle, WA)

® Thombin plus Bovine-derived gelatin matrix and human thrombin FloSeal Matrix* (Baxter, Hayward, CA) Porcine-derived gelatin and thrombin Surgiflo® (Ethicon, Somerville, NJ) mechanical HAs CoStasis® (Cohesion Technologies, Palo Alto, (flowable HAs) Bovine microfibrillar collagen with bovine thrombin CA)

HAs with both Autologous Vivostat® (Vivolution A/S, Birkeroed, Denmark) non-active and Bolheal® (Chemo-Sero Therapeutic Institute, active Kumamoto, Japan) characteristics Beriplast® P (CSL Behring, Marburg, Germany) Fibrin sealants Human plasma-derived TISSEEL® VH and TISSEEL® VH S/D (Baxter, Westlake Village, CA) Tissucol® (Baxter, Utrecht, Netherlands) Human pooled plasma and equine collagen patch TachoSil® (Baxter, Westlake Village, CA) Topical Hemostatic Agents - Evidence-Based Recommendation -

Ann Thorac Surg 2017;104:353-360 Topical Hemostatic Agents - Evidence-Based Recommendation - Bypass Circuit - Low Priming - Bypass Circuit - Low Priming -

Priming Tubing Reservoir Hct Bwt Author volume pump oxygenator AF UF (kg) (ml) A V V (ml) D Preop Lowest

3.2 SIII Mast Mounted Pump Safe Micro Merkle 190 3/16 3/16 30 V+G Y Y NA 17 ~5.9 (Stoeckert) (Polystan) 160 TONOKURA compo III 3/16 3/16 Safe Micro Ando 4.3 30 K Y Y NA 15.2 (130) (Tonokura Medical) (5/32) (5/32) (Polystan) 4 125 3/16 Capiox RX 05 Durandy NA 3/16 NA NA N N NA 24 (9.1) (155) (1/4) (Terumo) TONOKURA compo III Capiox RX 05 Miyaji 5.4 140 5/32 5/32 15 NA Y Y NA 22.2 (Tonokura Medical) (Terumo) 1.7 Mast Mounted Pump KIDS D100 33.3 19.2 Koster 110 3/16 3/16 NA NA Y NA ~4.1 (Stoeckert) (Sorin) ~48 ~44.4 Jostra HL 30 Capiox RX 05 Kim 3.72 140 3/16 3/16 20 V N Y 29.9 21.7 (Jostra) (Terumo) Bypass Circuit - Autologous Cord Blood - Bypass Circuit - Autologous Cord Blood -

Semin Thorac Cardiovasc Surg. 2017;29(1):70-76 Bypass Circuit - Autologous Cord Blood -

Korean Circ J 2016;46:714-718 Washed RBC Washed RBC

Pediatr Crit Care Med 2012; 13:290–299 Modified Ultrafiltration

Ann Thorac Surg 1997;64:1787–9 Modified Ultrafiltration

Surg Today 2002;32:203–206 Modified Ultrafiltration

Perfusion 2017;32:97-109 Modified Ultrafiltration

Perfusion 2017;32:97-109

Reversing hemodilution (modified ultrafiltration) Preventing hemodilution (circuit miniaturization) Others

• Controlled hypotension • agents • • Withdrawn from the market (May 2008) • Re-licensed 2012 • Epsilon • Conclusion

• Traditional methods are still a major part of after pediatric cardiac surgery • New hemostatic methods might provide additional support to the traditional hemostatic methods

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