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CVPR 326 Pediatric Perfusion > Ultrafiltration / Test 3/3 > Flashcards

Ultrafiltration / Test 3/3 Flashcards

1
Q

3 benefits of Hemodilution ?

A

↓ Strain on Blood Banks
↓ Exposure to blood-born
pathogens.
Improved microcirculatory blood flow.

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2
Q

Enormous variation in degree of hemodilution accepted:
Loma Linda ?
Bostoon ?

A

Loma Linda 5%

Bostoon 30%

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3
Q

Hemodilution relies on the relationship of:

A

Oxygen delivery to

Metabolic needs of

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4
Q

the study of deformation and flow of materials

A

Rheology

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5
Q

Name 3 Newtonian Fluids?

A

water, saline, plasma

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6
Q

Viscosity does not vary with shear rate in what fluids?

A

Newtonian Fluid

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7
Q

New-Newtonian Fluid ?

A

Blood

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8
Q

Viscosity decreases with increasing shear rate with what fluids?

A

New-Newtonian Fluid

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9
Q

If were not supplying enough oxygen what is the c\body producing ?

A

Lactic Acid

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10
Q

Velocity Gradient AKA ?

A

Shear Rate

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11
Q

For a given fluid, the velocity gradient varies with ?

A

the amount of force applied (shear stress)

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12
Q

Viscosity =

A

shear stress/shear rate

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13
Q

During Physiological Effects of Hemodilution, what must be considered ?

A

Viscocity

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14
Q

Flow (C.O.) =

A

Perfusion Pressure
______________________
Total peripheral resistance

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15
Q

Flow =

A

Perfusion Pressure
____________________
Resistance x Viscosity

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16
Q

When you ↓ temp you ↑ Viscosity.

What should you do?

A

↑ Hemodilution

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17
Q

Decreased O2 in the microcirculatory system is offset by what?

A

↑ Flow in the capillaries from ↓ viscosity.

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18
Q

Hemodilution Rationale for CPB

A

Reduce donor exposure

Optimize Cerebral perfusion

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19
Q

Advantages of Hemodilution

A

↓ viscosity
↓ exposure to homologous blood
↑ Regional Flow
↑ O2 delivery

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20
Q

Adverse effects of hemodilution

A
  • Reduced concentration of vital substances
  • Extracellular/interstitial fluid accumulation
  • Redistribution of coronary blood flow
  • Intra-pulmonary shunting
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21
Q

What population is more susceptible to fluid overload and capillary leak ?

A

Neonates

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22
Q

Natural ultrafilter

(glomerular basement membrane) statistics?

A

5 x 10^6 hollow capillaries
8 x 10^-4 cm
parallel & interconnecting configuration

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23
Q 
Artificial ultrafilter (hemofilter)
statistics ?
A

4000-12,000 hollow fibers
.02 cm
parallel configuration

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24
Q

Natural and Artificial ultrafilters both produce an ?

A

Albumin Free filtrate containing electrolytes and metabolic wastes

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25
Q

Size of Albumin ?

A

68,000 daltons

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26
Q

The Ideal Ultrafiltration Material Should have the following 3 characteristics:

A

Good biocompatibility
No passage of Albumin
High Plasma water flux

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27
Q

Membrane Materials are formulated from a

wide range of thermoplastics, name 6?

A 
Polysulfone
Polyestersulfone
Polyacrylonitrile (PAN)
Polyamide
Polymethyl methacylate
Cellulose triacetate
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28
Q

During Fiber Manufacturing Thermoplastic Polymer is dissolved in a solvent, then
Precipitation of the polymer is accomplished by exposure with a non-solvent. This describes what phase ?

A

Phase Inversion

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29
Q

During Fiber Manufacturing the PRECIPITATION step Determines the membrane structure and permeation properties, describe this ?

A

solvent/polymer ratio
resin/non-solvent ratio
casting temperature

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30
Q

In regards to the Anatomy of a Hollow Fiber, the inner diameter is ?

A

200 um

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31
Q

In regards to the Anatomy of a Hollow Fiber, the wall thickness is ?

A

75 - 150 um

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32
Q

The Anatomy of a Hollow Fiber is Divided into two domains, what are they?

A

Skin AKA Active layer (inner)

Substrate Layer ( body)

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33
Q

Within a hollow fiber, what controls all transport related activities?

A

Skin Layer because it contains the pores.

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34
Q

Large porous (micron sized) structure that gives mechanical support & strength to the hollow fiber?

A

Substrate Layer

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35
Q

Polyamide Hollow Fiber wall thickness?

A

50 um

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36
Q

Membrane surface area can be altered by changing:

A

of fiber in a bundle
Length of fibers
Fiber diameter

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37
Q

What ultrafilter would I use for cytokine removal ?

A

Polyacrylonitrile (PAN)

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38
Q

Molecular Weight Cut Off can vary from material to material and within each polymer depending on formulation
Typical range in CPB application:

A

55,000 - 65,000 daltons

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39
Q

standard unit that is used for indicating mass on an atomic or molecular scale

A

Dalton

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40
Q

Minntech Polysulfone
&
Jostra Polyamide

Daltons ?

A

55,000 Daltons

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41
Q

Bentley Polysulfone

Daltons ?

A

60,000 Daltons

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42
Q

COBE PAN

Daltons ?

A

65,000 Daltons

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43
Q

5 Factors affecting Filtration

A 
Pore size
Surface charge
Hydrostatic pressures
protein adsorption
protein interactions
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44
Q

Sieving coefficient =

A

[conc] ultrafiltrate
______________
[conc] filter inlet

conc = concentration of whatever where looking at.

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45
Q

K+
Aprotitnin
Mg++

Sieving coefficients ?

A

1.0

Freely crosses

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46
Q

Ca++

Sieving coefficients ?

A

.55

Protein bound

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47
Q

Heparin Sieving coefficients?

A

.20

Protein bound

48
Q

Fentanyl Sieving coefficients?

A

.28

Protein bound

49
Q

Midazolam Sieving coefficients?

A

.06

Protein bound

50
Q

For drugs that are highly protein bound, what was the primary factor limiting drug sieving?

A

protein binding

51
Q

Sieving properties of what membranes tend to be different from the other materials?

A

PAN

52
Q

Early 1990’s: Gomez/Grootendorst/Lee suggested what?

A

filtering blood of septic animals may remove several mediators simultaneously.

53
Q

When examining the data dealing with mediator removal several things must be consisdered:

A
  • Complement & cytokines are “middle molecules” 10 - 20 kD
  • Behavior of these molecules in-situ
  • Type of membrane used
54
Q

PreBypass Ultrafiltration ?

A

Pre-BUF

55
Q

During CPB Ultrafiltration:

A

CUF
DUF
Z-BUF

56
Q

CUF

A

Conventional Ultrafiltration

57
Q

DUF

A

Dilutional Ultrafiltration

58
Q

Z-BUF

A

Zero-Balance Ultrafiltration

59
Q

After CPB Ultrafiltration:

A

Modified Ultrafiltration:

MUF

60
Q

Modified Ultrafiltration breaks down into two other categories?

A

AV MUF

VV MUF

61
Q

Conventional ultrafiltration ?

A

Removal of volume

62
Q

PRE-BUF results in a more ?

A

Physiologic Prime

↓ potassium levels
↓ glucose levels
↓ lactate levels
↓ bradykinin levels
↓ ammonia levels
↑ pH levels
63
Q

PRE-BUF Rationale:
The substrate load of the pump priming fluid has a major influence on the metabolic response of children during cardiac surgery and may be ?

A

neurologically detrimental

64
Q

PRE-BUF - Rationale:

The addition of banked blood to pump prime elevates what?

A 
↑ primed potassium 
↑ Glucose 
↑Bradykinin 
↑ Citrate 
↑ Lactate levels
65
Q 
PRE-BUF - Rationale:
What determines the level of any one of these substances.
     potassium levels
 glucose levels
 lactate levels
 bradykinin levels
 ammonia levels
 pH levels
A

The AGE of banked blood

66
Q

BLOOD STORAGE LESION : As the RBC metabolize glucose during storage, what happens ?

A

↑ [ H+]

↓ pH over time

67
Q

BLOOD STORAGE LESION: As the pH decreases during storage, what happens

A

↓ in 2,3 DPG

= Release of O2 to tissues will decrease

68
Q

Within 3-8 hours after transfusion previously stored RBC will regenerate ___ of normal 2,3 DPG levels

A

50%

69
Q

BLOOD STORAGE LESION: As the blood sits in storage, red cells lyse over time causing what?

A

↑ K+ in the unit

70
Q

BLOOD STORAGE LESION: What does not function in the cold temperatures which will result in K not being pumped into the RBC ?

A

Na/K+ pump

71
Q

BLOOD STORAGE LESION: What gradually decreases as RBC use it for glycolysis?

A

ATP

72
Q

What do you use to “Wash” the blood prime of the circuit at Duke ?

A

1 liter of Normosol R +
500 units of heparin
25 mEq. NaHCO3

73
Q

Manage intraoperative volume and Increase hematocrit during an intraoperative procedure using what ?

A

Conventional Ultrafiltration

74
Q

4 Technical considerations for the use of conventional ultrafiltration ?

A
  • Adequate volume
  • Arterial line shunt may reduce blood flow to pt.
  • Level Detector
  • Aggressive CUF = inadequate volume for weaning from CPB.
75
Q

Rationale for High-Volume Hemofiltration during CPB?

A 
↓ edema
↑ Hemodynamics
↑  Hct
- Remove certain  
  inflammatory mediators
- Improvement in lung 
  compliance
- Reduction in postoperative blood loss
76
Q

High volume hemofiltration improves RVEF and cardiac performance by ?

A

Removal of vasoactive mediators responsible for myocardial depression.

77
Q

Which are the kissing cousins and are very similar in a lot of ways?

A

Zero-Balance
&
Dilutional Ultrafiltration

78
Q

Z-BUF Composition of Replacement Solution?

A 
To 1 Liter Normosol-R, add;
25 mEq NaHCO3
500 units heparin
2 ml  50% glucose
2.8 ml CaCl2 (warming)
79
Q

Use High-Volume, Zero-Balanced Hemofiltration to ?

A

Reduce Delayed Inflammatory Response to Cardiopulmonary Bypass in Children

80
Q

Significant removal of TNF, IL-10, C3a and myeloperoxidase observed at end of bypass and Markedly lower levels (TNF, IL-1B, IL-6) at 24 hr describes what method of ultrafiltration ?

A

Z-BUF

81
Q

Dilutional and Modified Ultrafiltration Reduces Pulmonary Hypertension After Operations for ?

A

Congenital Heart Disease

82
Q

High-Volume, Continuous Hemofiltration braches out into 2 other groups, name them?

A

(Z-BUF, DUF)

83
Q

Combination of HVHF and MUF shows to be more effective in ?

Although beneficial effects may be more pronounced in high-risk patient groups.

A
  • Reducing capillary leak

- May reduce delayed inflammatory response

84
Q

Z-BUF Technique?

A

2 tubings inserted in single, dual roller pump:
- 1 from ultrafiltrator port
to collection waste
reservoir.
- 1 from replacement solution to cardiotomy reservoir.

Blood flowrate: 200ml/min/m2

Ultrafiltration rate: 3000-6000 ml/m2

85
Q

CURT definition ?

A

Continuous Ultrafiltration Replacement Therapy.

86
Q

What type of ultrafiltration is popular with the pediatric population ?

A

MUF

87
Q

Babies are more susceptible to what ?

A

Capillary leak

88
Q

What are 4 great characteristics of MUF?

A

↓ TBW/Edema
↑ hemodynamics
↓ need for blood products
↓ circulating cytokines

89
Q

Modified Ultrafiltration Attenuates what in Pediatric Open Heart Operations?

A

Dilutional Coagulopathy

90
Q

attenuate definition

A

reduce the force, effect, or value of:

91
Q

Only 42% of Pediatric centers are using ?

A

MUF

92
Q

3 Published Modes of MUF ?

A

1) AV MUF “Classical /
dominate method”
2) VV MUF
3) VA MUF

93
Q

With which modes of MUF must we avoid retrograde flow in the arterial line?

A

VV MUF

VA MUF

94
Q

Re-circulation line around oxygenator

> Pump > Right Atrium describes what method of MUF ?

A

AV - MUF

95
Q

Benifits of using the blood cardioplegia system (BCPS) to MUF ?

A 
- Has a heat exchanger 
  to prevent cooling
- Acts as a bubble trap
- Allows for convenient 
  pressure monitoring
- Pressure relief shunt
96
Q

What if you don’t use blood cardioplegia?

A
  • Consider VV-MUF
  • Select a pump to act
    as a “MUF Pump”
  • Take steps to prevent patient cooling
97
Q

When using the blood cardioplegia system, where should you position the hemoconcentrator ?

A

between the roller pump and heat exchanger

98
Q

Non-BCPS users should invert hemoconcentrator prior to MUF to ?

A

optimize bubble trapping.

99
Q

Transitioning from CPB to MUF, Before termination of CPB:

A 
- Completely de-air 
  MUF circuit 
*BCPS users*
- warm heater-cooler
- clamp out crystalloid 
  portion
- chase out residual BCSP
- Ready servo-regulation and/or safety devices
100
Q

Transitioning from CPB to MUF, Termination of CPB in usual manner then: 5 steps

A
  • Surgeon attaches MUF infusion line to right atrial access and indicates “You can MUF”.
  • Clamp out arterial line (filter if applicable).
  • Communicate with MD’s on desired filling pressures.
  • Begin MUF pump flow
  • Open ultrafiltrate line
101
Q

MUF Flow Rates For neonates and infants ?

A

Index Flow Rates to Weight.

15 - 30 cc/kg/min

102
Q

As volume is being removed, it will become necessary to titrate in circuit volume to maintain the desired filling pressures. In general, it is best to set MUF pump at ?

A

Constant

103
Q

Increase or decrease the arterial pump to adjust filling pressures up or down. The arterial pump should ?

A

not exceed the flow rate of the MUF pump.

104
Q

A good practice is to begin MUF conservatively, with little or no vacuum applied to the hemoconcentrator.
After MUF flows are established and stable, vacuum can be increased slowly to ?

A

180 mmHg.

105
Q

The number one problem that can happen is when a negative arterial line pressure occurs and cavitates air out of solution or pulls air across the membrane oxygenator. (AV-MUF)
What should you monitor?

A

Monitor arterial line pressures like a hawk!!!

If possible, Servo-regulate the MUF pump to stop if a negative arterial line pressure develops.

106
Q

Monitor MUF circuit pressures for ?

A

over-pressurization

107
Q

What gives you actual data regarding direction and rate of flow in arterial line. Allows fine tuning during MUF.

A

Flowmeter attached to the arterial line

108
Q

When do you stop MUFing?

For “end-point” use a combination of:

A

-Duration 15-20 minutes
-Complete salvage of
circuit contents
- Increased HCT
- Surgeon’s patience

109
Q

When would you consider the need to add a one way check valve in the circuit to prevent exsanguination during MUFing ?

A

VV-MUF

with a Non-occlusive arterial pump (Centrifugal Pump)

110
Q

Venous line > MUF pump > hemoconcentrator > SVC describes what method ?

A

VV-MUF

111
Q

Advantages of VV MUF?

A 
- no retrograde flow 
  down arterial line
- no aortic “steal”
- Easy to re-initate CPB
- Safer?
112
Q

Disadvantage of VV MUF?

A

oxygenated blood not delivered to pulmonary vasculature

113
Q

How can I prevent complications?

A
  • Preparation
  • Servoregulation
  • Communication
  • Congregation
  • Information
114
Q

What if I need to go back on pump during AV-MUF?

A

Have aortic line visually checked for air

115
Q

What if I need to go back on pump during BCPS-MUF?

A

hemoconcentrated blood will have to be chase out.

116
Q

What if I need to go back on pump during MUF?

A
  • Terminate MUF (Clamp ultrafiltrate line)

- Reposition clamps

117
Q

3 benefits of Hemodilution ?

A

↓ Strain on Blood Banks
↓ Exposure to blood-born
pathogens: Hepatitis, HIV
Improved microcirculatory blood flow.

CVPR 326 Pediatric Perfusion (23 decks)

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