Professional Documents
Culture Documents
Claus Bartels, Anja Gerdes, Jrg Babin-Ebell, Friedhelm Beyersdorf, Udo Boeken,
Torsten Doenst, Peter Feindt, Michael Heiermann, Christian Schlensak and Hans-Hinrich
Sievers
J Thorac Cardiovasc Surg 2002;124:20-27
The online version of this article, along with updated information and services, is located
on the World Wide Web at:
http://jtcs.ctsnetjournals.org/cgi/content/full/124/1/20
The Journal of Thoracic and Cardiovascular Surgery is the official publication of the American
Association for Thoracic Surgery and the Western Thoracic Surgical Association. Copyright 2002
American Association for Thoracic Surgery
Cardiopulmonary
Support and
Physiology
Dr Bartels
12/1/121506
doi:10.1067/mtc.2002.121506
20
Methods
We performed a systematic search of the Medline database for
Medical Subject Headings referring to the various principles of
CPB in the past 20 years. The appropriate selection, combination,
and use of the Medical Subject Headings were cross-checked by
two other members of our working group to ensure as complete a
search as possible.
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Bartels et al
Bartels et al
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Subject
Technical equipment
1. Centrifugal vs roller pump
2. Pulsatile vs nonpulsatile perfusion
3. Heparin-coated surfaces
4. Toxicity of PVC
5. Closed vs open cardiotomy reservoirs
6. Arterial filter systems
7. Autotransfusion vs cell separation
Preparation of CPB
8. Volume substitution before CPB
9. Priming in adults
10. Priming in infants and neonates
11. Application of aprotinin
12. Additive drugs in priming solution
13. Temperature of priming solution
14. Perfusion volume
15. CO2 rinsing of arterial filters
16. Protection of tubes by connectors
Performance and supervision of CPB
17. How should ACT be measured?
18. Other coagulation parameters besides ACT
during CPB
19. Level of ACT during CPB
20. Level of ACT for hemodilution during CPB
21. Level of ACT with aprotinin during CPB
22. Level of ACT with aprotinin in DHCA
23. Heparin administration
24. Heparin resistance
25. Antithrombin III deficiency
26. Protamine application
27. Effects of priming solution on platelet function
28. Effects of oxygenator type on platelet function
29. Effects of pump type on platelet function
30. Platelet-rich plasmapheresis and transfusion
requirements
31. Desmopressin acetate and transfusion
requirements
32. Indicators for platelet transfusion
33. Patient selection for tranexamic acid or
aminocaproic acid treatment
34. Dosage of tranexamic acid or aminocaproic
acid
35. Effects of tranexamic acid or aminocaproic
acid on bleeding
a) in elective patients
b) in patients with increased risk of bleeding
36. pH strategy during DHCA in pediatric cardiac
surgery
37. pH strategy during moderate hypothermia in
pediatric cardiac surgery
38. pH strategy during DHCA in adult cardiac
surgery
39. pH strategy during moderate hypothermia in
adult cardiac surgery
40. Myocardial protection
II
III
IV
Class*
0
0
0
4
5
5
1
7
3
0
0
0
0
0
0
0
0
1
0
1
2
2
6
1
0
1
0
1
0
0
0
3
0
na
na
na
na
4
10
0
1
4
na
na
na
na
0
1
3
2
0
na
na
na
na
0
0
2
0
2
na
na
na
na
0
0
2
5
0
7
3
0
sp
sp, trans
IIa
III
0
0
1
0
0
0
0
0
0
0
0
0
3
1
1
1
1
0
0
2
2
1
2
3
2
1
0
3
0
3
3
2
0
4
1
0
0
2
1
0
0
0
0
0
0
0
0
0
sp,
sp,
sp,
sp,
sp,
sp
sp,
sp,
sp,
sp,
sp
sp,
trans
IIb
III
III
III
III
IIb
IIa
IIb
III
III
III
III
sp, trans
IIb
0
0
1
5
3
3
0
0
sp, trans
sp, mi, cvi, pe, dvt, trans
III
IIb
IIb
IIb
IIb
IIb
sp,
sp,
sp,
sp,
sp,
III
IIb
IIb
IIa
III
III
III
III
III
trans
trans
trans
re, trans, mi, mort, all, byp
cvi, vent
trans
trans
byp
trans, rf
trans
trans
trans
trans
trans
III
III
III
IIb
IIb
IIb
IIa
na
na
na
na
III
na
na
na
na
III
IIa
III
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Bartels et al
TABLE 1. Contd
Scientific level of literature
I
II
III
IV
Class*
0
0
0
10
0
2
1
0
4
0
2
0
III
III
III
0
0
0
0
5
5
1
1
III
III
0
0
0
0
0
0
5
3
6
6
11
0
na
na
na
III
III
III
For complete abbreviation list, see Table 2. na, No scientific publication available.
* Classification of the scientific evidence of the examined principle.
Step 2
Step 3
According to the methodological rigor, the selected articles were
classified according to their scientific level:
Level I: Investigations yielding clear evidence that a given
procedure or treatment is useful and effective (large randomized prospective trials with low false-positive [] and low
false-negative [] errors and high-quality meta-analysis)
Level II: Investigations that do not provide clear scientific
evidence about the usefulness, efficacy, or both of a proce-
trans
mort
morb
mi
neur
byp
rf
cvi
pe
dvt
con
arr
lco
re
vent
icu
hosp
all
sp
qual
DHCA
ACT
23
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Subject
Bartels et al
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pH
pH management
pH management
pH management
pH management
pH management
pH management
pH management
pH management
pH management
pH management
pH management
pH-stat
pH-stat
pH-stat
pH-stat
pH-stat
pH-stat
pH-stat
Alpha-stat
Alpha-stat
Alpha-stat
Alpha-stat
Alpha-stat
Alpha-stat
Alpha-stat
Key word 2
Articles
identified
0
0
Cardiopulmonary bypass
Extracorporeal circulation
Heart-lung machine
Cerebral blood flow
Temperature
Hypothermia
Hypothermic cardiac arrest
Hypothermic circulatory arrest
Cardiac surgery
Heart surgery
0
Cardiac surgery
Heart surgery
Extracorporeal circulation
Cardiopulmonary bypass
Heart-lung machine
Circulatory arrest
0
Cardiac surgery
Heart surgery
Extracorporeal circulation
Cardiopulmonary bypass
Heart-lung machine
Circulatory arrest
226,167
1,481
80
95
0
57
146
97
1
14
26
59
483
15
29
53
58
1
15
139
24
56
100
104
1
22
Results
A total of 33,000 articles identified were retrieved. Of these,
1500 articles fulfilled the criteria for the first step of the
selection procedure. The 225 articles with the best scientific
evidence available were classified according to the level of
their scientific evidence on the basis of their methodological
rigor. Table 1 depicts the scientific level of the evaluated
literature.
Many studies showed methodological problems (eg, imprecise study design or inappropriate statistical methods).
As a result, most of the classified articles showed divergent
results regarding individual principles of CPB performance.
Thus, the scientific evidence regarding CPB principles
could not be conclusive in these cases.
Discussion
Since its first successful clinical application in 1953, the
CPB technique has revolutionized cardiac surgery. Today,
CPB is routinely used for various cardiac and noncardiac
operations with good clinical results. Thus far no systematic
review of the available literature has been undertaken to
determine the amount and quality of scientific information.
On the basis of our scientific evaluation of the current
literature on 48 principles of CPB, not a single condition
was of sufficient scientific merit to conclude that we were
dealing with a principle for which there is clear evidence,
scientific agreement, or both, that a given procedure or
treatment is useful and effective.
Ideally, for each procedure or intervention, there should
be direct and clear evidence from one or more studies that
relate the application of this procedure (compared with
specified alternatives) to the health outcomes of interest of
a specific patient. However, rapid changes in medical practice, ethical considerations, and practical reasons make this
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Bartels et al
We thank Dr Dagmar Luehmann, Department of Epidemiology, Medical University of Luebeck, for expert review of our
article.
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Appendix
The list of articles classified according to their scientific level can
be found in the Internet at our Web site: www.herzchir.muluebeck.de.
Contributing Investigators
J. Babin-Ebell, MD, Klinik und Poliklinik fu r Herz- und Thoraxchirurgie der Universita t Wu rzburg, Wu rzburg
C. Bartels, MD, Klinik fu r Herzchirurgie, Uniklinikum Lu beck,
Lu beck
M. Bechtel, MD, Klinik fu r Herzchirurgie, Uniklinikum Lu beck, Lu beck
C. Benk, Herz- und Kreislaufzentrum der Albert-LudwigsUniversita t, Kardiotechnik, Freiburg
U. Boeken, MD, Klinik und Poliklinik fu r Thorax- und Kardiovaskula re Chirurgie, Heinrich-Heine-Universita t, Du sseldorf
S. Christiansen, MD, Klinik fu r Thorax-, Herz- und Gefa chirurgie, Westfa lische Wilhelms-Universita t, Mu nster
J. Cleuziou, Klinik fu r Herz- und Thoraxchirurgie, Klinikum
Wuppertal GmbH, Wuppertal
T. Doenst, MD, Herz- und Kreislaufzentrum der Albert-Ludwigs-Universita t, Freiburg
H. Doerge, MD, Klinik fu r Thorax-, Herz- und Gefa chirurgie,
Universita tsklinik Aachen, Aachen
A. Erasmi, MD, Klinik fu r Herzchirurgie, Uniklinikum Lu beck,
Lu beck
P. Feindt, MD, Klinik und Poliklinik fu r Thorax- und Kardiovaskula re Chirurgie, Heinrich-Heine-Universita t, Du sseldorf
A. Gerdes, MD, Klinik fu r Herzchirurgie, Uniklinikum Lu beck,
Lu beck
T. Hanke, Klinik fu r Herzchirurgie, Uniklinikum Lu beck, Lu beck
M. Heiermann, MD, Herzzentrum Wuppertal, Herz- und Thoraxchirurgie, Klinikum, Wuppertal GmbH, Wuppertal
S. Johannsson, MD, Herz- und Kreislaufzentrum der AlbertLudwigs-Universita t, Freiburg
E. Joubert-Hu bner, Klinik fu r Herzchirurgie, Kardiotechnik,
Uniklinikum Lu beck, Lu beck
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