Objective:
In conducting international cardiac surgery, an unanticipated intraoperative perfusion complication encouraged us to review procedure and equipment checks for perfusion management when standards of excellence are not available. We describe the index case, contrast it to a similar case in a mature program and detail our response: pediatric perfusion protocols, specific for developing programs.
Methods:
Case 1 occurred in an advanced cardiac center: blood-air foam penetrated the oxygenator's air/oxygen inflow line. During hypothermic arrest, oxygenator substitution permitted continuation of the surgical procedure without adverse outcome. An oxygenator design moulding fault was confirmed.
Case 2, occurred during an international start up program, using donated equipment that included a single air circuit alarm. Suddenly, massive air entered the oxygenator. Despite retrograde cerebral perfusion and satisfactory heart procedure, brain damage and death occurred. The oxygenator was faultless; a malfunctioning oxygen tank regulator valve was confirmed.
Results:
These experiences with divergent outcomes in contrasting settings motivated us to develop a modified algorithm for pediatric perfusion management which specifically addresses: numerical unit value differences, sterility, un-contaminated blood availability, room temperature and humidity, atmospheric pressure differences in various geographical locations, quality checks on donated equipment, safety protocols, documenting non-availability of equipment, and counter measures to prevent air/oxygen inflow disasters using modified circuitry to ensure controlled delivery when tank gas air/oxygen is used.
Conclusion:
Protocols assist compliance with international standards in developing programs. They also reduce ethical concerns about operating or withholding surgery, team dynamics, unfamiliar settings, language barriers and when procedural missteps are possible.