50061 PRF27510.1177/0267659112450061Wang S et al.

Perfusion

Perfusion

Current ultrafiltration techniques before,

27(5) 438­–446
© The Author(s) 2012
Reprints and permission: sagepub.
during and after pediatric cardiopulmonary co.uk/journalsPermissions.nav
DOI: 10.1177/0267659112450061
bypass procedures prf.sagepub.com

S Wang,1 D Palanzo1,2 and A Ündar1,3

Abstract
Ultrafiltration, which is currently considered as a standard method to remove excess water administered during pediatric
cardiopulmonary bypass (CPB), aims to minimize the adverse effects of hemodilution, such as tissue edema and blood
transfusion. Three ultrafiltration techniques can be used before, during and after CPB procedures, including conventional
ultrafiltration (CUF), modified ultrafiltration (MUF) and zero-balance ultrafiltration (Z-BUF). These methods are widely
different, but they have common benefits on hemoconcentration, less requirement for blood products, and reduction
of the systemic inflammatory responses (SIRS). The present review attempts to restate these ultrafiltration circuitries,
application methods, end-points, and clinical impacts.

Keywords
ultrafiltration; MUF; Z-BUF; cardiopulmonary bypass; pediatrics

Introduction
Ultrafiltration (UF) has been widely used during pediat-
ric cardiopulmonary bypass (CPB). It was originally
adapted from a renal dialysis technique which is used to
provide an artificial replacement for kidney dysfunction
in patients with renal failure by removing waste and
excess water from blood. Ultrafiltration can reverse
hemodilution during CPB by removing plasma water
directly across a semipermeable membrane using hydro-
static forces. Although hemodilution is usually utilized
during CPB and facilitates tissue-perfusion, hemodilu-
tion has been shown to contribute to some adverse
effects, such as a decreased plasma colloidal oncotic pres-
sure, increased total body water and interstitial edema in
vital organs, hypoxia, hypotension, hypocoagulation,
renal dysfunction, myocardial and cerebral ischemia, and
be used at any time during CPB prior to weaning from
CPB. Modified ultrafiltration (MUF) developed by
Naik et al.,2 in contrast, is performed after CPB in
order to concentrate circulating blood by removing
excess water from the patient, and also to salvage blood
from the bypass circuit. The technique of MUF has
become widely adopted for use with hemodilution
1Penn State Hershey Pediatric Cardiovascular Research Center,
Department of Pediatrics, Penn State Milton S. Hershey Medical
Center, Penn State Hershey College of Medicine, Penn State Hershey
Children’s Hospital, Hershey, Pennsylvania, USA
2Perfusion Department, Penn State Heart and Vascular Institute, Penn
State Milton S. Hershey Medical Center, Penn State Hershey College of
Medicine, Hershey, Pennsylvania, USA
3Department of Surgery and Bioengineering, Penn State Milton S.

even increased mortality.1 Therefore, the application of Hershey Medical Center, Penn State Hershey College of Medicine,
ultrafiltration at the end of CPB primarily aims to con- Penn State Hershey Children’s Hospital, Hershey, Pennsylvania, USA
centrate the perfusate and then re-infuse it back to the
Corresponding author:
patient. This method made wide use of hemodilution Akif Ündar
techniques and multidose cardioplegia for myocardial Professor of Pediatrics, Surgery, and Bioengineering
preservation during CPB. Penn State Hershey College of Medicine,
To date, there are three types of ultrafiltration tech- Department of Pediatrics,
H085 500, University Drive
niques used during CPB procedures. Conventional
P.O. Box 850; Hershey
ultrafiltration (CUF) is a common method to maintain PA 17033-0850
moderate hemodilution during CPB and a minimal USA
venous reservoir blood after CPB. This technique can Email: aundar@psu.edu

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Wang S et al.
Figure 1. Arterio-venous ultrafiltration.
A: from the arterial filter to the venous reservoir; B: from the arterial line to the venous line; C: from the recirculation line to the venous reservoir;
D: from the arterial line to the cardioplegia delivery line.
CPB in pediatric populations. In addition, zero-balance
ultrafiltration (Z-BUF), first reported by Journois
et al.,3 has a similar circuit to CUF and is performed
during CPB with ultrafiltrate and replacement fluid
with balanced electrolyte solution in a ratio of 1:1 so
as to keep constant the blood volume during the
Z-BUF procedure. It is usually performed after
rewarming and aims to adjust electrolyte and acid-
base balance and remove inflammatory mediators.
Each one of these methods has its own advantages and
disadvantages. Therefore, the combined application of
different ultrafiltration styles may reach its maximal
effect in the patient undergoing the CPB procedure.
Ultrafiltration circuitries
There are two main circuit connection methods during
ultrafiltration – arterio-venous UF and veno-venous UF.
Arterio-venous ultrafiltration
a. From the purge line of the arterial filter to the
venous reservoir (Figure 1.A) - This is the most
commonly used method of CUF and plays an
essential role in removing gaseous microemboli
from the arterial filter.
b. From the arterial line to the venous line (Figure
1.B) - A classical connection method for MUF.
The blood pump should be used as the power to
control the blood flow rate.
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439
c. From the recirculation line to the venous reser-
voir (Figure 1.C) - An alternative method for
CUF.
d. From the arterial line to the cardioplegia deliver
line (Figure 1.D) - Blood flow can be kept warm
during the MUF procedure, using a heat
exchanger of a cardioplegic system, especially for
neonates and infants.
Veno-venous ultrafiltration
a. From the venous line to the venous reservoir
(Figure 2.A) – The blood pump was inserted into
the circuit.
b. From pump boot (pump loop) after the main
blood pump to the venous reservoir (Figure 2.B).
c. From the vent line to the venous reservoir (Figure
2.C) - This method can be used after the release
of the aortic cross-clamp and after cessation of
CPB.
d. Other alternative methods - An ultrafilter was
inserted between the femoral vein and contralat-
eral femoral vein,4 or the venous reservoir and the
cardiotomy reservoir.5 A dual-lumen catheter
located in right atrium was used for veno-venous
MUF.6 The blood pump should be used for power.
Type of ultrafilters (Hemoconcentrators)
Several ultrafilters are available for clinic use (see Table 1).
440 Perfusion 27(5)

Figure 2. Veno-venous ultrafiltration.

A: from the venous line to the venous reservoir; B: from the pump boot (after the main blood pump) to the venous reservoir; C: from the vent line
to the venous reservoir.

Table 1. Ultrafilters: different characteristics.

Ultrafilter system Minntech HPH Jostra Dideco Fresenius Terumo

Jr.-Mini-400-700-1000-1400 BC20-60-140 DHF02-06-SH1.4 HF3000-5000 HC05-11
Fiber material Polysulfone Polyarylsulfone Polyethersulfone Polysulfone Polysulfone
Prime volume (ml) 8-14-27-58-70-86 17-65-98 30-60-80 30-72 35-70
Membrane surface area (m2) 0.09-0.07-0.3-0.71-1.06-1.31 0.2-0.7-1.35 0.25-0.68-1.4 0.4-1.2 0.5-1.1
Pore size (Dalton) 65000 / / / /
MTP (mmHg) 500 600 500 600 500
Pressure drop (mmHg) 55-30-61-142-85-78 / 50-150 144-65 /
Fiber internal diameter (μm) 200-620-200-200-200-200 215 200 200 /
Membrane thickness (μm) / 50 30 / /
MTP: maximum transmembrane pressure

Application methods pressure, the ultrafilter outlet tubing can be partly

Currently, there are three methods for the application of
ultrafiltration.
Conventional ultrafiltration
The most commonly used method is placing an ultrafilter
between the arterial filter purge line and the venous reser-
voir. No pump is used. CUF can be performed by opening
the arterial filter purge line of the arterial filter with blood
flow from the high pressure of the arterial line to the low
pressure of the venous reservoir at any time during the
CPB procedure. In order to increase the transmembrane
clamped and the “stolen” blood flow from the purge line
can decrease. A proper negative pressure in the dialysate
compartment can be used to favor further ultrafiltration.
Modified ultrafiltration
The ultrafilter is placed with the inlet connected to the
arterial line and the outlet connected to the venous line.
The blood pump must be used before the ultrafilter. The
ultrafilter should be primed for de-airing before CPB
and kept isolated during CPB by clamping the inlet of
the ultrafilter. After CPB ceases, the venous line between

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Wang S et al.
the venous reservoir and the outlet of the ultrafilter is
clamped. The inlet of the ultrafilter is unclamped. Then
MUF is conducted, with blood flowing from the arterial
line through the ultrafilter and back through the venous
line to patient. At the same time, the arterial pump is
simultaneously activated to deliver the blood in the
venous reservoir to the patient for compensating the vol-
ume of ultrafiltrate.
Zero-balance ultrafiltration
An identical circuit is used with CUF. Z-BUF is usually
performed after the rewarming phase by administering a
replacement fluid equal to the ultrafiltrate volume into the
venous reservoir. The most commonly used replacement
fluid is Plasmalyte, an isotonic electrolyte solution. Other
crystalloid solutions, such as Duosol,7 or PrismaSATE®
BK0/3.58 are also used by clinical perfusionists. A single
pump can be used for ultrafiltrate tubing and substitute
tubing to ensure volume balance. High-volume Z-BUF
allows one to control blood potassium and glucose levels
throughout the conduct of CPB.
UF end-points
Before CPB. Z-BUF can be performed before CPB; aim
to “wash” perfusate (containing packed red blood cells or
fresh plasma) to reach normal electrolyte concentration
and acid base balance. A replacement fluid should be
administered during Z-BUF to maintain a constant
blood level in the venous reservoir and blood gas analysis
for the priming solution is needed to decide the Z-BUF
end-point. CUF may also be used to concentrate the per-
fusate to a proper blood level in the venous reservoir
when more priming solution is added by mistake. The
ultrafilter is left in the CPB circuit, so it can be used for
CUF or MUF.
During CPB
CUF can be performed at any time during the CPB pro-
cedure, especially when more crystalloid solution enters
into the CPB circuit, resulting in a lower hematocrit.
Circulating blood is concentrated by CUF and then the
hematocrit increased when more packed red blood cells
are added into circuit, if need be. The blood reservoir
level can be kept at an acceptably minimal and safe oper-
ating level and the hematocrit reach a maximum before
the termination of CPB. CUF’s effectiveness is limited by
the need to maintain a minimum blood level in the
venous reservoir, especially in pediatric patients. Z-BUF
usually is performed after the rewarming phase. The
blood level in the venous reservoir is maintained con-
stant by administering replacement solution during the
Z-BUF procedure. A time-based criterion or a filtrate-
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441
volume end-point may be adopted, depending on one’s
own clinical guideline.
After CPB
MUF is usually performed for a period of 10 - 20 min-
utes, with 5 - 10 minutes after the cessation of CPB if the
patient is hemodynamically stable. Reducing the amount
of body water accumulation and concentrating circulat-
ing blood elements are its final aims. MUF is completed,
either when the CPB circuit empties, or when the hema-
tocrit reaches a reasonable level. Fresh plasma or packed
red blood cells may be administered to further enhance
the effects of MUF.
During ECMO
An ultrafilter can be placed in-line with an ECMO circuit
from the high pressure arterial line to the low pressure
venous line. Both CUF and Z-BUF can be adopted dur-
ing ECMO. The goal is to remove excess body water and
increase blood osmolarity or normalize fluid-electrolyte
and acid-base balance by administering fluid replace-
ment solutions. Blood gas analysis and the clinical situa-
tion are regarded as essential tools in determining its
end-point.
Clinical impacts
Hemoconcentration. The CPB circuit must be primed
with fluid and all air expunged before connection to the
patient. Transfusion of large volumes of crystalloid solu-
tion during CPB can result in excessive hemodilution.
Normal saline as “maintenance” fluid may cause increas-
ing hemodilution. Most of all, there is a high ratio of
prime volume to patient blood volume during a pediatric
CPB procedure. However, these clear fluids cannot be
totally removed by the kidneys after CPB ceases. Long
duration of bypass, hypothermia and low body weight
increase the risk of the accumulation of water in the
body. Therefore, the primary goal of the introduction of
CUF is the removal of the crystalloid priming fluid, and
MUF can remove more body water from patients than
CUF. This is the most direct and visual effect of ultrafil-
tration. Almost all published articles about ultrafiltra-
tion have demonstrated this effect and significant clinical
benefit. Ultrafiltration can remove water from the circu-
lation and, meanwhile, lead to increases in hematocrit
and hemoglobin levels. Administering fresh plasma,
packed red blood cells and human albumin into the CPB
circuit may further increase the hematocrit (Hct) and
plasma osmolarity. It is well known that blood concen-
tration can increase the oxygen-carrying capacity of the
blood to avoid end-organ ischemia and dysfunction after
CPB procedures.
442
Blood product requirements
Excess water removal and blood salvage from the residual
volume of the CPB circuit by MUF result in higher hema-
tocrit and platelet levels after CPB, and then lead to a
reduction in blood transfusion,9 although some clinical
researches did not show this clinical effect.10,11 A clinical
study reported a significant reduction in blood loss in the
first 48 hours after CUF plus MUF.12 This effect may be
related to the concentration of clotting factors (fibrinogen,
prothrombin and factor VII) and platelets by ultrafiltra-
tion.13 In an animal experiment, lower thrombin anti-
thrombin complex levels after MUF indicated less
thrombin formation and might have been associated with
better preserved coagulation function in neonatal piglets.14
Cardiac function
A clinical study demonstrated that MUF could improve
intrinsic left ventricular systolic function, improves dia-
stolic compliance, increases blood pressure, and decreases
inotropic drug use in the early postoperative period in
infants.15 Chaturvedi et al. showed that MUF improves
global left ventricular systolic function in terms of the slope
of the end-systolic pressure volume (median increase
57.8%, p=0.005) in infants and children following open-
heart surgery.16 Honjo et al.17 demonstrated that MUF
ameliorated the myocardial performance index of the sys-
temic ventricles and may be particularly useful for restor-
ing the global ventricular performance of pediatric patients
undergoing longer CPB. Aggarwal et al.12 also reported sig-
nificant improvements in ejection fraction (EF) and frac-
tional area change (FAC) and a decrease in posterior wall
thickness after CPB with CUF plus MUF. The mechanism
that accounts for the improvement in cardiac function by
MUF may be MUF-induced hemoconcentration and
reduction of myocardial edema. The increases in heart rate
and diastolic blood pressure after MUF may have a benefi-
cial effect on coronary arterial flow in neonates undergoing
the first stage of the Norwood reconstruction.18
Pulmonary function
A clinical study showed that continuous ultrafiltration
(Z-BUF+MUF) reduced the inflammatory response as
well as helped pulmonary function. Pulmonary air
exchange and pulmonary ventilation function were
improved after CPB, which was associated with the con-
centration of blood and the removal of inflammatory
mediators.19 Ultrafiltration could shorten time on
mechanical ventilation and improve the postoperative
alveolar-arterial oxygen gradient.3 Mahmoud et al.20
found a temporary improvement in lung compliance and
gas exchange capacity after MUF in infants. Hiramatsu
et al.4 reported that Z-BUF and MUF suppressed the
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Perfusion 27(5)
increase in plasma endothlin-1 (ET-1) concentration and
maintained lower pulmonary vascular resistance after the
Fontan procedure. In another study, Lou et al.21 found
decreases in plasma procalcitonin level, PaCO2 and
mechanical ventilation time, and an increase in pulmo-
nary compliance. They concluded that improved respira-
tory function might be due to a lower plasma procalcitonin
level in patients with congenital heart disease. An animal
experiment confirmed the clinical finding. Lower pulmo-
nary vascular resistance, lower IL-8 levels in airway lavage
fluid, higher static pulmonary compliance and lower lung
water content were observed after MUF in 2-h bypass
neonatal piglets.14
Intensive care unit (ICU) stay
Kotani retrospectively analyzed clinical data and reported
that MUF could shorten ICU stay, but did not change the
duration of ventilator support in neonates who under-
went the arterial Switch operation.22 Sever et al.9 also
reported a shortened length of ICU stay by MUF. Z-BUF
of the blood prime combined with CUF significantly
reduced inotropic support and shortened the duration
of ventilator support and ICU stay.23
Electrolytes
The semipermeable membrane ultrafilter allows water
and some small molecules to pass through the mem-
brane. Increasing the transmembrane pressure forces
more fluid and solutes to be ‘‘pulled’’ through the mem-
brane. During CPB, hyperkalemia may be caused by the
administration of high-volume, high-potassium cardio-
plegia for myocardial protection, hemolysis, or packed
red blood cells. In this situation, high-volume Z-BUF
with no potassium replacement fluid can maintain the
plasma potassium level in the normal range before the
release of the aortic cross-clamp so as to contribute to
the recovery of normal sinus rhythm. López et al.24
reported that, after separation from CPB, the plasma
potassium level was reduced by 13.7% after 10 minutes of
MUF in pediatric patients; however, the reduction in mag-
nesium at the same period of time was not significant.
Pre-treatment of the priming solution can also minimize
electrolyte and acid-base disturbances after the initiation
of CPB. A clinical prospective study demonstrated that
Z-BUF of pediatric priming blood before CPB could sig-
nificantly increase pH, actual bicarbonate (HCO3), base
excess, sodium and calcium concentrations, decrease glu-
cose, lactate and potassium concentrations and maintain
the electrolyte and acid-base levels within normal ranges
after approximately 1000ml of ultrafiltrate was hemofil-
trated using a bicarbonate-buffered hemofiltration solu-
tion (Duosol, B.Braun, Melsungen, German) as a
replacement solution.25 An animal study showed that the
Wang S et al.
“washing” of priming blood could reduce levels of potas-
sium, serotonin, lactate and IL-8. As a result, pre-treatment
of priming solution could adjust concentrations of elec-
trolytes and metabolites and attenuate inflammatory
mediators.14 A recent study reported that Z-BUF of the
blood prime reduced metabolic load, resulting in low lac-
tate and potassium before and after CPB.23
Systemic inflammatory response syndrome
Exposure of blood to non-physiologic surfaces induces a
systemic inflammatory response syndrome (SIRS), charac-
terized by the systemic release of inflammatory cytokines.
The ultrafiltration technique utilizes a hemoconcentrator
to remove excess body water; at the same time, low–
molecular-weight substances will be removed from plasma,
such as TNF-α, IL-1, IL-6, IL-8, IL-10, and complements
C3a, C5a, and C5b-9. The ultrafiltration efficiency of ultra-
filters depends on the port size of the ultrafiltration mem-
brane, flow across the membrane surface, ultrafiltrate
volume, transmembrane pressure and operating tempera-
ture. So, different ultrafiltration membranes and different
clinical situations may have different ultrafiltration effi-
ciency. Ultrafiltration of priming blood could reduce the
initial attack of inflammatory mediators after the onset of
CPB and prohibit the increase of cytokine following CPB.26
MUF decreased levels of IL-8 during the early postopera-
tive hours in pediatric cardiac surgery, but there was no
significant difference at 24h after CPB when compared
with CUF.9 Berdat et al.27 found that polyamide ultrafilter
was more effective in lowering IL-10 and the terminal sol-
uble C5b-9 complement complex (TCC) plasma levels,
whereas the polyarylethersulfon ultrafilter was more effec-
tive in lowering IL-6, and CUF with the polyarylethersul-
fon ultrafilter could remove more IL-6 than MUF.
Drugs
Children undergoing cardiac surgery usually need the
support of drugs after surgery. Certain drugs could be
removed by ultrafiltration, and those highly protein-
bound drugs were concentrated, dependent on the pore
size of the ultrafiltration membrane used. Sieving coef-
ficients for selected drugs are critical parameters in
decreasing the plasma concentrations of drugs.28
Bivalirudin is a direct thrombin inhibitor for heparin-
induced thrombocytopenia (HIT); there is no known
antidote to it. In a case report,29 the activated clotting
time (ACT) could rapidly fall with the discontinuation
of bivalirudin infusion during MUF after CPB. Because
bivalirudin can be removed by ultrafiltration, MUF
could help to maintain good hemostasis after CPB.
Masuda et al. found that almost one-fourth of the given
dose of Flomoxef (a second generation cephalosporin
antibiotic with a broad spectrum) was removed by MUF
in children undergoing cardiac surgery.30
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443
Ultrafiltration disadvantages
Hypertension. The increase in blood pressure during
MUF may come from the improvement of myocardial
contractility associated with a reduction in myocardial
water content.31 No correlation was detected between the
increases in blood pressure and hematocrit.32 In addi-
tion, one study demonstrated that the removal of prosta-
glandin E2 (PGE2 - a major intrinsic vasodilator) is one
reason for increased blood pressure during MUF in
pediatric patients, with no change in the central venous
pressure and dopamine dosage and with the effect more
marked in low-weight patients.33
Hypokalemia
Since plasma potassium, as a small ion, can pass freely
through the ultrafiltration membrane, plasma potas-
sium levels may decrease after MUF in children under-
going CPB procedures;24 high volume Z-BUF with
potassium-poor replacement fluid may result in abnor-
mally low plasma potassium concentrations. Attention
must be paid in this situation. López and colleagues
suggested that supplementation with potassium in
patients with low plasma potassium levels before MUF
could prevent even lower plasma potassium levels after
MUF.24
Hemolysis
Long periods of ultrafiltration, high transmembrane
pressures, and high flow rates through the ultrafilter can
result in hemolysis. Early perfusate hemoconcentration
during CPB may also induce hemolysis. The ultrafilter
cannot remove free hemoglobin, but concentrates it.
Air delivery
The aortic cannula may entrain air during MUF.11 When
the tip of the aortic cannula touches the back wall of the
aorta during MUF, the arterial tubing may collapse,
resulting in injury to the aorta. During ECMO, if the
outlet of the ultrafilter connects with the inlet side of a
centrifugal pump, clamping the inlet of the ultrafilter
may induce air entrainment from the hollow-fiber mem-
brane pores in the ultrafilter. So, the ultrafiltration cir-
cuit keeps open continuously or both sides of the
ultrafilter are clamped completely and not re-used.
Patient cooling
A long period of ultrafiltration without a heat exchanger
may induce cooling of the patients and affect the coagula-
tion system and the hemodynamic response to drug ther-
apy, especially in neonates and infants. The application
444
of heat exchangers during MUF will prevent patient
cooling.
Hemodynamic instability
Ultrafiltration may result in hemodynamic instability or
may impair aortic pulmonary shunt flow.11 There are
various reasons for this, including rapid decrease in
blood volume, more aortic shunt by MUF, low body
temperature, or cardiac dysfunction. In this situation,
the best advice is to delay or stop MUF.
Cerebral ischemia
Medlin et al.34 reported the trends in cerebral tissue oxy-
genation changes during MUF. Cerebral oxygen satura-
tion (rSO2) has positive correlations with pCO2 and
mean arterial pressure, and negative correlation with
ultrafiltration pump flow rate. Rodriguez et al.35 found
decreases in middle cerebral artery blood flow velocities
and cerebral mixed venous oxygen saturations during
MUF, despite mild increases in systemic blood pressures
and hematocrit, especially when high blood flow rates
through the MUF circuit were used. This is possibly a
result of “stolen” blood flow from the carotid circulation
during MUF in small infants. Much attention should be
given to performing any ultrafiltration during or after
CPB in neonates or infants to prevent hypoperfusion,
because of shunting flow through the ultrafiltration
line. Controlling proper ultrafiltration speed is very
important.
Others
There is an extra cost to the use of ultrafiltration.
Exposure of blood to the non-endothelial surfaces of the
ultrafilter may induce more immunologic reactivity.
MUF extends the duration of cardiac surgery and delays
protamine administration.
Penn State Hershey Children’s Hospital
Approach
There is a concerted effort by most pediatric cardiac sur-
gery centers to reduce the amount of hemodilution on
CPB. That has been accomplished by reducing the length
of the circuit, reducing the diameter of the tubing,
assisted venous return, etc. Reducing the exposure of the
patient to blood transfusions is important, but anything
to excess can be detrimental. Reducing the size and
length of the CPB circuit can increase the pressure of the
circuit, which has been demonstrated to be detrimental,
not to mention the increased risk of gaseous microem-
boli (GME). Our philosophy at Penn State Hershey
Children’s Hospital is to have matched components
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Perfusion 27(5)
(packed red blood cells (PRBC), fresh frozen plasma
(FFP), and platelets) from the same donor, thus, reduc-
ing exposure. Our desired hematocrit on CPB is 26% or
greater, so we usually prime with 250 ml of PRBC on our
smaller patients. This affords us the ability to reach our
goal of the desired Hct level while supplying enough vol-
ume to the MUF at the end of our case. We feel that it is
important to remove 400-600 ml of effluent during MUF
in order to raise the hematocrit to at least 40% and
remove significant levels of circulating pro-inflammatory
mediators. Better postoperative outcomes may be more
than a result of higher hemoglobin levels.
Conclusion
Removal of excess water from the patient’s body is the
main reason for using ultrafiltration during CPB proce-
dures, regardless of CUF, Z-BUF or MUF before, during
and after CPB. Removing larger amounts of water may
lead to more clinical effects, including a reduction in the
need for blood products, an increase in postoperative
hematocrit, improvements of heart and lung function,
and shorter periods of mechanical ventilation time and
ICU stay, especially in neonates and infants. Apart from
these clinical benefits, greater removal of systemic
inflammatory mediators is another targeted purpose,
and has benefits for early postoperative recovery in car-
diac surgery patients. If possible, monitoring the inflam-
matory response in a continuous, real-time fashion will
allow perfusionists to recognize variable trends in the
inflammatory response during CPB, and to reach maxi-
mum effects by ultrafiltration.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of Interest Statement
None declared.
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