- Email: [email protected]
Perfusion: Part of the Perioperative Blood Transfusion and Blood Conservation Management Team
CORRESPONDENCE
We read with interest the article from Ferraris and associates [1]. We congratulate the authors on the extraordinary achievement of synthesizing an enormous breadth of literature on the topic of blood management in the area of cardiac surgery. This work certainly has and will continue to have an important impact on the management of patients undergoing cardiac surgery. We, members of the International Consortium for Evidence-Based Perfusion (ICEBP), share general support for these guidelines; however, we highlight a concern about their development without the apparent involvement of perfusionists, important members of the multidisciplinary clinical team delivering care to this patient population. The ICEBP (www.icebp.org) is a joint venture of 13 international perfusion societies and is structured as an ad hoc committee of the American Society of Extracorporeal Technology. Our mission is to continuously improve the delivery of care and outcomes for our surgical patients. One of the mechanisms to achieve this is through the development and publication of evidence-based guidelines for extracorporeal circulation. Several perfusionist members of the ICEBP have been involved with evidence-based guideline writing related to cardiac surgery [2]. We believe that the incorporation of our group into the evolution of guidelines provides valuable insight into our technology. Perfusionists play an important role in patient care during the perioperative period and make valuable contributions not only to the day-to-day practice of perfusion but, importantly, also to the development and the interpretation of the knowledge base that already exists. There are recommendations in this article that will be readdressed by the perfusion community. This will be an important and valuable process, allowing additional evaluation and interpretation to understand where gaps exist in our knowledge, research, and education. For example, the recommendation regarding routine ultrafiltration reads “Routine use of ultrafiltration during or immediately after CPB is not helpful for blood conservation in adult cardiac operations. (Level B, Class III).” Such recommendations are reserved for those clinical practices where the risk of performing this action exceeds the benefit and, as such, the procedure should not be performed. The subsequent discussion of this recommendation does not appear to support a class III recommendation. In the field of perfusion, a broader application of ultrafiltration as an alternative to cell processing and direct reinfusion of pump blood is often considered and is an important alternative intervention for perfusionists. Additional perfusion involvement may have afforded contextualization of the evidence in the clinical setting and perhaps the recommendation would have been developed and classified differently. In conclusion, we congratulate the authors on their review and synthesis of this literature. We believe that perfusionists play an important role in perioperative blood management/conservation and that the contribution of the perfusion community in guideline development may enhance this process, especially in generating recommendations that relate specifically to the conduct of cardiopulmonary bypass (CPB) and CPB equipment. The perfusion community will continue to be active in working with peer societies in developing recommendations around topics related to perfusion in the future. © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Robert A. Baker, PhD CCP (Aust) Chair, Guideline Writing Subcommittee, ICEBP Cardiac and Thoracic Surgical Unit Flinders Medical Centre and Flinders University Bedford Park, Adelaide, South Australia, Australia e-mail: [email protected]. Timothy A. Dickinson, MS Executive Committee, ICEBP Hospital Clinical Services Group Nashville, TN Kenneth G. Shann, CCP Executive Committee, ICEBP Department of Cardiothoracic Surgery Montefiore-Einstein Heart Center Bronx, NY Donald S. Likosky, PhD Chair, ICEBP Departments of Surgery, and Community & Family Medicine Dartmouth Medical School Hanover, NH Allison Bednarski Spiwak, MS Member, ICEBP Division of Circulation Technology The Ohio State University Columbus, OH
References 1. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP, et al; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, Spiess BD, Shore-Lesserson L, StaffordSmith M, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007;83(5 suppl):S27– 86. 2. Shann KG, Likosky DS, Murkin JM, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: a focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg 2006;132:283–90.
Reply To the Editor: There are parts of the letter from Baker and colleagues [1] with which I strongly agree and others with which I strongly disagree. First, the agreeable part: I could not be more convinced that perfusionists are a key and essential part of the cardiovascular surgical team. I know that the coauthors of the blood conservation guidelines feel the same. I strongly disagree with the implication that perfusionists were not involved in the guideline creation process. I personally presented preliminary findings of the guidelines to two national perfusion organizations—American Society of Extra-Corporeal Technology and the American Academy of Cardiovascular PerAnn Thorac Surg 2008;85:359 – 63 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.018
MISCELLANEOUS
Perfusion: Part of the Perioperative Blood Transfusion and Blood Conservation Management Team To the Editor:
We read with interest the article from Ferraris and associates [1]. We congratulate the authors on the extraordinary achievement of synthesizing an enormous breadth of literature on the topic of blood management in the area of cardiac surgery. This work certainly has and will continue to have an important impact on the management of patients undergoing cardiac surgery. We, members of the International Consortium for Evidence-Based Perfusion (ICEBP), share general support for these guidelines; however, we highlight a concern about their development without the apparent involvement of perfusionists, important members of the multidisciplinary clinical team delivering care to this patient population. The ICEBP (www.icebp.org) is a joint venture of 13 international perfusion societies and is structured as an ad hoc committee of the American Society of Extracorporeal Technology. Our mission is to continuously improve the delivery of care and outcomes for our surgical patients. One of the mechanisms to achieve this is through the development and publication of evidence-based guidelines for extracorporeal circulation. Several perfusionist members of the ICEBP have been involved with evidence-based guideline writing related to cardiac surgery [2]. We believe that the incorporation of our group into the evolution of guidelines provides valuable insight into our technology. Perfusionists play an important role in patient care during the perioperative period and make valuable contributions not only to the day-to-day practice of perfusion but, importantly, also to the development and the interpretation of the knowledge base that already exists. There are recommendations in this article that will be readdressed by the perfusion community. This will be an important and valuable process, allowing additional evaluation and interpretation to understand where gaps exist in our knowledge, research, and education. For example, the recommendation regarding routine ultrafiltration reads “Routine use of ultrafiltration during or immediately after CPB is not helpful for blood conservation in adult cardiac operations. (Level B, Class III).” Such recommendations are reserved for those clinical practices where the risk of performing this action exceeds the benefit and, as such, the procedure should not be performed. The subsequent discussion of this recommendation does not appear to support a class III recommendation. In the field of perfusion, a broader application of ultrafiltration as an alternative to cell processing and direct reinfusion of pump blood is often considered and is an important alternative intervention for perfusionists. Additional perfusion involvement may have afforded contextualization of the evidence in the clinical setting and perhaps the recommendation would have been developed and classified differently. In conclusion, we congratulate the authors on their review and synthesis of this literature. We believe that perfusionists play an important role in perioperative blood management/conservation and that the contribution of the perfusion community in guideline development may enhance this process, especially in generating recommendations that relate specifically to the conduct of cardiopulmonary bypass (CPB) and CPB equipment. The perfusion community will continue to be active in working with peer societies in developing recommendations around topics related to perfusion in the future. © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Robert A. Baker, PhD CCP (Aust) Chair, Guideline Writing Subcommittee, ICEBP Cardiac and Thoracic Surgical Unit Flinders Medical Centre and Flinders University Bedford Park, Adelaide, South Australia, Australia e-mail: [email protected]. Timothy A. Dickinson, MS Executive Committee, ICEBP Hospital Clinical Services Group Nashville, TN Kenneth G. Shann, CCP Executive Committee, ICEBP Department of Cardiothoracic Surgery Montefiore-Einstein Heart Center Bronx, NY Donald S. Likosky, PhD Chair, ICEBP Departments of Surgery, and Community & Family Medicine Dartmouth Medical School Hanover, NH Allison Bednarski Spiwak, MS Member, ICEBP Division of Circulation Technology The Ohio State University Columbus, OH
References 1. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP, et al; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, Spiess BD, Shore-Lesserson L, StaffordSmith M, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007;83(5 suppl):S27– 86. 2. Shann KG, Likosky DS, Murkin JM, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: a focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg 2006;132:283–90.
Reply To the Editor: There are parts of the letter from Baker and colleagues [1] with which I strongly agree and others with which I strongly disagree. First, the agreeable part: I could not be more convinced that perfusionists are a key and essential part of the cardiovascular surgical team. I know that the coauthors of the blood conservation guidelines feel the same. I strongly disagree with the implication that perfusionists were not involved in the guideline creation process. I personally presented preliminary findings of the guidelines to two national perfusion organizations—American Society of Extra-Corporeal Technology and the American Academy of Cardiovascular PerAnn Thorac Surg 2008;85:359 – 63 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.10.018
MISCELLANEOUS
Perfusion: Part of the Perioperative Blood Transfusion and Blood Conservation Management Team To the Editor: