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Peer-reviewed evidence (Class IIa, Level B) suggests that arterial blood temperature should be limited to 37°C during cardiopulmonary bypass. We implemented a regional quality improvement initiative to reduce regional variability in our performance around this recommendation at four northern New England medical centers between January 2006 and June 2010. Cardiovascular perfusionists at four medical centers collaborated by conference calls regarding blood temperature management. Evidence from the recommendations were reviewed at each center, and strategies to prevent hyperthermia and to improve performance on this quality measure were discussed. Centers submitted data concerning highest arterial blood temperatures among all isolated coronary artery bypass grafting procedures between 2006 through June 2010. Scope and focus of local practice changes were at the discretion of each center. The timing of each center’s quality improvement initiatives was recorded, and adherence to thresholds of 37°C and 37.5°C were analyzed. Data were collected prospectively through our regional per-fusion registry. Data were available for 4909 procedures (1645 before interventions, 3264 after interventions). Prior to the quality improvement interventions, 90% of procedures had elevated arterial line temperatures (37°C or more), and afterwards it was 69% (p< .001) for an absolute difference of 21%. Prior to the intervention, 53% of procedures had temperatures beyond a threshold of 37.5°C versus 19% subsequent to interventions, for an absolute difference of 34% (p< .001). This regional effort to reduce patient exposure to elevated arterial line temperatures resulted in a significant sustained reduction in high arterial outflow temperatures at three of the four centers. A regional registry provides a means for assessing performance against evidence-based recommendations, and evaluating short and long-term success of quality improvement initiatives.

Using a regional cardiopulmonary bypass (CPB) registry, we compared the practice of CPB at eight northern New England institutions to recently published recommendations. We examined CPB practice among 3597 adult patients undergoing isolated coronary artery bypass grafting surgery from January 2004 to June 2005. Registry variables were used to compare regional CPB practice to recommendations on topics of neurologic protection (pH management, avoidance of hyperthermia, minimizing return of pericardial suction blood, aortic assessment, arterial line filtration), maintenance of euglycemia, reduction of hemodilution, and attenuation of the inflammatory response. We report overall regional practice (regional minimum, maximum). All centers used alpha-stat pH management and arterial line filters. Avoidance of hyperthermia (temperature <37°C) was achieved during 23.4% of procedures (regional minimum, 1.5%; maximum, 83.2%). Minimizing return of pericardial suction blood was achieved in 23.7% of cases (0.7%, 93.6%). Aortic assessment was performed during 45.7% of procedures (1.3%, 98.9%). Maintenance of euglycemia (<200 mg/dL) was accomplished in 82.7% (57.1%, 97.9%) of cases. Hemodilution (hematocrit <23% on CPB) was lower for men 32.4% (20.6%, 52.3%) than women 77.9% (64.7% 88.9%). Men were less likely to receive red blood cell transfusions in the operating room (11.0%; 1.8%, 20.9%) than women (54.6%; 30.1%, 70.6%). In an effort to attenuate the inflammatory response, surface coated circuits were used in 83.3% of procedures (8.8%, 100%). During this time, gaps existed between regional CPB practice and recently published recommendations. We continue to prospectively measure CPB practice relating to these recommendations to monitor and improve the care provided to our patients.

The intraaortic balloon pump is the most common method of left ventricular support in use today. Various types of ventricular assist devices and centrifugal pumps are also used at many institutions for both single and biventricular support. Balloon pump technology can also be used to support the right ventricle, as we were able to recently demonstrate in a successful application of concomitant aortic and pulmonary artery balloon counterpulsation.