The Maximal Pore Size of Hydrophobic Microporous Membranes Does Not Fully Characterize the Resistance to Plasma Breakthrough of Membrane Devices for Extracorporeal Blood Oxygenation

Extracorporeal membrane oxygenation (ECMO) in blood-outside devices equipped with hydrophobic membranes has become routine treatment of respiratory or cardiac failure. In spite of membrane hydrophobicity, significant amounts of plasma water may form in the gas compartment during treatment, an event termed plasma water breakthrough. When this occurs, plasma water occludes some gas pathways and ultimately cripples the oxygenator gas exchange capacity requiring its substitution. This causes patient hemodilution and increases the activation of the patient's immune system. On these grounds, the resistance to plasma water breakthrough is regarded as an important feature of ECMO devices. Many possible events may explain the occurrence of plasma breakthrough. In spite of this, the resistance to plasma breakthrough of ECMO devices is commercially characterized only with respect to the membrane maximal pore size, evaluated by the bubble pressure method or by SEM analysis of membrane surfaces. The discrepancy between the complexity of the events causing plasma breakthrough in ECMO devices (hence determining their resistance to plasma breakthrough), and that claimed commercially has caused legal suits on the occasion of the purchase of large stocks of ECMO devices by large hospitals or regional institutions. The main aim of this study was to identify some factors that contribute to determining the resistance to plasma breakthrough of ECMO devices, as a means to minimize litigations triggered by an improper definition of the requirements of a clinically efficient ECMO device. The results obtained show that: membrane resistance to breakthrough should be related to the size of the pores inside the membrane wall rather than at its surface; membranes with similar nominal maximal pore size may exhibit pores with significantly different size distribution; membrane pore size distribution rather than the maximal pore size determines membrane resistance to breakthrough; the presence of surfactants in the patient's blood (e.g., lipids, alcohol, etc.) may significantly modify the intrinsic membrane resistance to breakthrough, more so the higher the surfactant concentration. We conclude that the requirements of ECMO devices in terms of resistance to plasma breakthrough ought to account for all these factors and not rely only on membrane maximal pore size.

Small Pore Size Microporous Membrane Oxygenator Reduces Plasma Leakage during Prolonged Extracorporeal Circulation: A Case Report

Plasma leakage has been regarded as the main technical problem during prolonged extracorporeal circulation (ECC) with microporous membrane oxygenators (MMOs). We report the case of a 15 year old male who underwent long term ECC for ARDS and in whom, by using new MMOs with reduced pore size, we were able to achieve prolonged artificial gas exchange efficiency with minimal plasma leakage. We conclude that reduced pore size MMOs might represent a valuable technical advance in extracorporeal oxygenation therapy.

An in Vitro Physiologic Model for Cardiopulmonary Simulation: A System for ECMO Training

Extracorporeal life support (ELS) systems may be run by certified perfusionists, specially trained nurses or respiratory therapy staff. Guidelines for the training, certification and retraining of ELS operators have been established by the Extracorporeal Life Support Organization. Recommendations include “… a well defined program for staff training, certification, and retraining”. Some clinicians have suggested that ELS operators be certified and recertified in an animal laboratory. But such practice involves veterinary expenses, animal use issues and considerable clean-up and disposal. We describe an alternative method of training, using an in vitro physiologic model designed to simulate various pathophysiologic states. In addition, the in vitro physiologic model may be used to evaluate membrane lung characteristics. This model's ease of construction, maintenance and use for training compared with live animal techniques are discussed. Research capabilities may be more flexible than with the use of the live animal technique. The in vitro physiologic model can be a useful and convenient asset to an extracorporeal membrane oxygenation/extracorporeal carbon dioxide removal (ECMO/ECCO2R) program.

A nonthrombogenic gas-permeable membrane composed of a phospholipid polymer skin film adhered to a polyethylene porous membrane

Polymer membranes are widely used in biomedical applications such as hemodialysis, membrane oxygenator, etc. When the membranes come in contact with blood or body fluids, protein adsorption and cell adhesion occur rapidly. Nonspecific protein adsorption and cell adhesion on the membranes induce not only various bio-rejections but also a decrease in their performance. We hypothesized that a blood compatible gas-permeable membrane could be prepared from polyethylene (PE) porous membranes modified with phospholipid polymers. In this study, poly[(2-methacryloyloxyethyl phosphorylcholine) (MPC)-co-dodecyl methacrylate] (PMD) skin film adhered to a PE porous membrane (PMD/PE porous membrane) was prepared. Elution of PMD was not detected meaning that the PMD film did not detach from the PE porous membrane even after soaking in water for more than 6 months. The permeation coefficient of oxygen gas through the PE membrane with the adhered PMD containing more than 0.20 mole fraction of the MPC unit, was the same as that of the original PE porous membrane. The PMD surface effectively reduced biofouling. We concluded that the PMD/PE porous membrane is useful as a novel membrane oxygenator due to its excellent gas-permeability and blood compatibility.

Rapid cardiopulmonary support for children with complex congenital heart disease

BACKGROUND

Extracorporeal membrane oxygenation has limitations in children with congenital heart disease (prolonged setup times, increased postoperative blood loss, and difficulty during transport). We developed a miniaturized cardiopulmonary support circuit to address these limitations.

PATIENTS AND METHODS

The cardiopulmonary support system includes a preassembled, completely heparin-coated circuit, a BP-50 Bio-Medicus centrifugal pump, a Minimax plus membrane oxygenator, a Bio-Medicus flow probe, and a Bio-trend hematocrit/oxygen saturation monitor. Short tubing length permits a 250-mL bloodless prime in less than 5 minutes. From 1995 to 1997, 23 children with congenital heart disease were supported with this technique.

RESULTS

Overall survival to discharge was 48% (11 of 23 patients). Survival to discharge was 80% (4 of 5) in the preoperative support group, 20% (1 of 5) in the postoperative failure to wean from cardiopulmonary bypass group, 44% (4 of 9) in the group placed on support postoperatively after transfer to the intensive care unit, and 50% (2 of 4 patients) in the nonoperative group. Neonatal cardiopulmonary support survival to discharge was 46% (6 of 13 patients).

CONCLUSIONS

This pediatric cardiopulmonary support system is safe and effective. Advantages over conventional extracorporeal membrane oxygenation include rapid setup time, decreased postoperative blood loss, and simplified transport.

Heparin coating extends the durability of oxygenators used for cardiopulmonary support

Acomparative study was performed between a noncoated and heparin-coated cardiopulmonary support (CPS) systems with the same design and structure (Terumo Corporation, Capiox-SX series) to evaluate whether or not heparin coating extends oxygenator service life. Fifty patients underwent CPS from January 1993 until December 1997, and 54 oxygenators (Capiox-SX series) were used. There were 35 noncoated oxygenators (Group NC) and 19 heparin-coated ones (Group HC). Significant predictors for the durability of oxygenators were evaluated by a nonparametric survival analysis and a proportional hazards regression analysis. Thirteen of 35 Capiox-SX and only 2 of 19 Capiox SX-HP revealed gas transfer failure and had to be exchanged. The average life span of the Capiox-SX and Capiox-SX-HP were calculated to be 78.6 +/- 16.8 and 168 +/- 15.4 h, respectively. Group HP showed significantly longer durability than Group NC (p = 0.0017), although there were differences of perfusion index and platelet counts between the 2 groups. Heparin coating of the CPS system remained one of the 2 significant predictors (hazards ratio 8. 871, p = 0.0449) to determine the durability of oxygenators by increasing stepwise multivariate proportional hazards regression analysis, along with anemia with less than 8 g/dl hemoglobin (hazards ratio 9.438, p = 0.0173). Heparin coating of the CPS system assures improved durability because heparin-coated oxygenators have a longer service life than noncoated ones.

Air trapping ability of the Spiral Gold membrane oxygenator: an ex vivo study

Despite an overall improvement in cardiopulmonary bypass (CPB) technology and materials, air emboli still occur. The latest generation membrane oxygenator from Bentley Laboratories, the SpiralGold, was tested ex vivo for its air handling ability. The study was conducted on four calves. Bolus amounts of air of 10, 15 and 20 cm3 were each injected three times, upstream of the oxygenator and a bubble detector located directly downstream. The amount of bubbles was measured semiquantitatively on a 10 unit scale (U one semiquantitative unit). The animals were killed 10 days after the CPB. When 10 cm3 of air was injected, no bubbles were detected. With 15 and 20 cm3, respectively, 1 +/- 1.5 and 5 +/- 3.3 U of bubbles were detected. Despite a total of 135 cm3 of air injected as large bolus amounts, all the animals survived without any obvious neurological deficit secondary to air bubble manipulation. In conclusion, the SpiralGold oxygenator per se can reliably trap an air bolus of up to 10 cm3. This feature should be taken into account when choosing an oxygenator, as it offers an additional barrier to air bubbles in the CPB circuit.

Effects of ultrathin silicone coating of porous membrane on gas transfer and hemolytic performance

To assess the effect of an ultrathin (0.2 microm) silicone-coated microporous membrane oxygenator on gas transfer and hemolytic performance, a silicone-coated capillary membrane oxygenator (Mera HP Excelung-prime, HPO-20H-C, Senko Medical Instrument Mfg. Co., Ltd., Tokyo, Japan) was compared with a noncoated polypropylene microporous membrane oxygenator of the same model and manufacturer using an in vitro test circuit. The 2 oxygenators showed little difference in the oxygen (O2) transfer rate over a wide range of blood flow rates (1 L/min to 8 L/min). The carbon dioxide (CO2) transfer rate was almost the same in both devices at low blood flow rates, but the silicone-coated oxygenator showed a decrease of more than 20% in the CO2 transfer rate at higher blood flow rates. This loss in performance could be partly attenuated by increasing the gas/blood flow ratio from 0.5 or 1.0 to 2.0. In the hemolysis study, the silicone-coated membrane oxygenator showed a smaller increase in plasma free hemoglobin than the noncoated oxygenator. The pressure drop across both oxygenators was the same. These results suggest that the ultrathin silicone-coated porous membrane oxygenator may be a useful tool for long-term extracorporeal lung support while maintaining a sufficient gas transfer rate and causing less blood component damage.

A clinical study for the durability of oxygenators on cardiopulmonary support

Cardiopulmonary support (CPS) requires durability of the oxygenator. The life span of the oxygenator is affected by various clinical factors, including patient condition, perfusion condition, and equipment usage. Predictors for the durability of oxygenators were evaluated clinically in this study. Thirty-two patients, who had undergone CPS during the last 3 years in our institute were assigned to this study. Fifty oxygenators had been used (Capiox SX in 19, CB Maxima in 23, and AL-6000 in 8). Significant predictors for the durability of oxygenators were evaluated by nonparametric survival analysis and proportional hazards regression analysis. Univariate regression analysis revealed 6 significant predictors for the life span of oxygenators. These were the oxygenator type, type of centrifugal pump, acidosis with blood pH less than 7.35, base excess less than -5, blood glutamic-oxaloacetic transaminase (GOT) levels greater than 1,000 IU, and blood lactate dehydrogenase (LDH) levels greater than 3,000 IU. After multivariate analysis, there remained only 2 significant predictors. An oxygenator used with a noncoated CPS system (Capiox SX with Capiox EBS) proved to have a significantly shorter life span than one used with a heparin-coated system (CB Maxima or AL-6000 with CB BP-80) (hazards ratio, 3.588, p = 0.0065). Patient conditions, which revealed acidosis with less than -5 of base excess, significantly shortened the life of the oxygenator (hazards ratio, 3.595, p = 0.0188).

Silicone-coated polypropylene hollow-fiber oxygenator: experimental evaluation and preliminary clinical use

BACKGROUND

A membrane oxygenator consisting of a microporous polypropylene hollow fiber with a 0.2-microm ultrathin silicone layer (cyclosiloxane) was developed. Animal experimental and preliminary clinical studies evaluated its reliability in bypass procedures.

METHODS

Five 24-hour venoarterial bypass periods were conducted on dogs using the oxygenator (group A). In 5 controls, bypass periods were conducted using the same oxygenator without silicone coating (group B). As a preliminary clinical study, 14 patients underwent cardiopulmonary bypass with the silicone-coated oxygenator.

RESULTS

Eight to 16 hours (mean, 12.2 hours) after initiation of bypass, plasma leakage occurred in all group B animals, but none in group A. The O2 and CO2 transfer rates after 24 hours in group A were significantly higher than at termination of bypass in group B (p < 0.005 and p < 0.03, respectively). Scanning electron microscopy of silicone-coated fibers after 24 hours of bypass revealed no damage to the silicone coating of the polypropylene hollow fibers. In the clinical study, the oxygenator showed good gas transfer, acceptable pressure loss, low hemolysis, and good durability.

CONCLUSIONS

This oxygenator is more durable and offers greater gas transfer capabilities than the previous generation of oxygenators.

Air handling characteristics of five membrane oxygenators

This project looked at the potential of five different membrane oxygenators to allow passage of catastrophic quantities of air in a clinically simulated environment. All the oxygenators were set up in an identical circuit using heparinized human blood as the perfusate. The study was carried out at flow rates ranging from 1.0 to 6.0 l/min. The clinical situation of obstructed venous drainage was simulated by clamping the venous return line at each respective flow rate, while the initial level of blood in the open system hard shell venous reservoir was maintained at 600 ml. The time interval between the application of the clamp on the venous line and the first appearance of macroscopic air in the arterial line was recorded at each level of flow rate. A graph of time versus flow rate was plotted for each oxygenator type. At a flow rate of 6 l/min, the Safe II oxygenator took 20 seconds to allow passage of air after the venous line was clamped, while it took the Bentley Univox Oxygenator only 10 seconds. The Dideco oxygenator, which has a valve incorporated in its reservoir, did not, however, allow any air to be pumped forward at all. At low rates, some of the oxygenators offered protection against passage of air into the arterial line. Thus the Cobe oxygenator offered protection at flow rates of less than 2 l/min, the Safe II oxygenator at flow rates of up to 2.5 l/min and the Bard oxygenator at flow rates up to 3 l/min.(ABSTRACT TRUNCATED AT 250 WORDS)