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Introduction: Heater-cooler units (HCUs) are frequently incorporated into extracorporeal membrane oxygenation (ECMO) circuits to help maintain patient normothermia. However, these devices may be associated with increased cost and infection risk. This study describes our institution's experience managing adult ECMO patients without the routine use of in-circuit HCUs., Methods: We performed a retrospective analysis of adult patients treated with veno-venous (VV) or veno-arterial (VA) ECMO at our institution. The primary outcomes were rates of HCU use and the relative duration of the ECMO treatment course in which patients maintained normothermia (36-37.5°C), with and without HCUs. Secondary outcomes of mortality and ECMO-related complications were planned across HCU and non-HCU groups; exploratory analyses were performed across a 75% "ECMO time in normothermia" threshold., Results: Among a cohort of 71 patients, zero (0%) were managed with in-circuit HCUs. A majority of ECMO patient-hours were spent in the normothermic range. Median and mean percentages of ECMO normothermia time were 75% (IQR 49%-81%) and 62% (SD ± 27%). Twenty-nine patients (40%) met the threshold of 75% ECMO normothermia time, as used to evaluate secondary outcomes. At this threshold, mortality risk was significantly higher among the non-normothermic cohort; other ECMO-related complications did not vary significantly., Conclusions: In the absence of HCU use, the majority of ECMO patient-hours were spent in normothermia. However, only a minority of patients achieved normothermia for at least 75% of their ECMO course. In-circuit HCUs may be required to maintain high percentages of normothermic time in adult EMCO patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Platelet inhibition via glycoprotein (GP) IIb/IIIa receptor antagonists has greatly reduced the need for emergent cardiac surgery. However, this change has come at a cost to both the patient and the cardiac surgical team in terms of increased bleeding risk. Current guidelines for patients requiring coronary artery bypass surgery include: 1) cessation of GP IIb/IIIa inhibitor; 2) delay of surgery for up to 12 h if abciximab, tirofiban, or eptafibitide is used; 3) utilization of ultrafiltration via zero balance technique; 4) maintenance of standard heparin dosing despite elevated bleeding times; and 5) transfusion of platelets as needed, rather than prophylactically. These agents present cardiac surgery teams with increased risk during CABG, although overall risk may be diminished by the substantial benefits to patients with acute coronary syndromes and percutaneous interventions, i.e., reduced infarction rates and improved vessel patency. With judicious planning, urgent coronary artery bypass can be safely performed on patients who have been treated with GP IIb/IIIa receptor inhibitors.

Challenges related to perfusion support of thoracoabdominal aneurysm repair include maintenance of distal aortic perfusion, rapidity of fluid resuscitation, and avoidance of both hypothermia and excessive hemodilution. Using available technology, we have devised a circuit and protocol that addresses these issues. To accomplish such support a bypass circuit consisting of 3/8 inch tubing connected to a centrifugal pump and low-prime heat exchanger was constructed. The circuit was primed via 1/4 inch spiked connectors attached to a 3-liter bag of normal saline. After initial de-airing, the solution was recirculated through this bag. Patients were anticoagulated with 1 mg/kg of heparin prior to initiation of support. Left atrial-descending aorta bypass was used primarily. A cell salvage device was used for autotransfusion. All blood products were delivered via a rapid infusion device. During partial exsanguination, shed blood was not processed, but directed to the rapid infusor for immediate retransfusion. Any packed cells given were washed prior to transfusion. Citrate dextrose solution was used as an anticoagulant for the cell scavenger. This configuration was used successfully in 50 procedures during an 18-month period. Use of this low-prime, custom circuit reduced both hemodilution and cost. A connection off the cell salvage pump offers fast retransfusion of shed blood during partial exsanguination. Minimal heparinization and citrate anticoagulation appears to reduce coagulopathy.