Performing modified ultrafiltration on pediatric patients

AORN Journal,  August, 2002  by Lauren Quattro,  Marla Bowser,  Adriana Schwendt

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While rewarming the patient, the perfusionist recirculated the blood in the modified ultrafiltration circuit to obtain normothermic temperatures. Immediately before the patient came off the CPB pump, the perfusionist flushed the modified ultrafiltration line into a small sterile bucket with pump blood until the blood was warm. All blood volume from the flush was returned to the pump via the pump suction. After the modified ultrafiltration line was flushed properly, the surgeon ceased CPB and clamped the venous line (Figure 1). She then removed the IVC cannula. Clamps were placed on either side of the luer-lok connector. The modified ultrafiltration line was attached to the luer port on the connector while blood was dripped through the modified ultrafiltration line to prevent air from entering the venous line. The surgeon removed the distal clamp and again flushed the line to the pump's venous reservoir to remove any remaining air. The surgeon placed the distal clamp on the line and removed the proximal clamp. The modified ultrafiltration procedure then commenced.

[FIGURE 1 OMITTED]

The perfusionist pumped blood at a rate of 10 mL per kg per minute to 20 mL per kg per minute retrograde from the aortic cannula into the hemofilter and back to the patient through the SVC cannula. The flow must be kept low to prevent blood from being delivered from the cranial vessels, which prevents neurological deficit. The surgeon identified the amount of time the modified ultrafiltration pump should be used (eg, 10 minutes). After turning on the modified ultrafiltration pump, the perfusionist started the arterial pump at approximately the same flow rate. If the patient becomes hypovolemic, the perfusionist accelerates the arterial pump, and if the patient becomes hypervolemic, the perfusionist decelerates the arterial pump. The surgeon ensured that the arterial line pressure was not negative, which would result in antegrade flow through the arterial cannula. Factors that may cause negative pressure include kinks, clamped lines, or the aortic cannula resting against the aortic wall.

After the reservoir was reduced, up to 300 mL of crystalloid were instilled. The modified ultrafiltration then was complete, and the remaining cannulas were removed. The anesthesia care provider administered protamine to enhance blood coagulation at the conclusion of modified ultrafiltration.

After surgery, Jill was transferred to the pediatric intensive care unit (PICU) for recovery. Upon arrival, responsibility for monitoring Jill's IV lines was transferred to care providers in the PICU. The perioperative nurse provided a full report to the PICU nurse via telephone. The anesthesia care provider also gave the PICU nurse a more detailed report. Transferring time was approximately one hour. After Jill was stabilized, her family members were allowed to visit her in the PICU for a brief time.

BENEFITS OF USING MODIFIED ULTRAFILTRATION

Research has demonstrated the positive effects of using the modified ultra filtration technique. One study conducted at the Hospital for Sick Children in London found that the modified ultrafiltration technique had a positive effect on pediatric patients undergoing open-heart surgery involving CPB, resulting in a significant decrease in total body water, less blood loss, and fewer blood transfusions. (1) Further research confirmed these results and have shown modified ultrafiltration to be effective in decreasing the adverse effects of CPB. (2)