Hasenclever P, Konetzka A
Universitätsspital Zürich, Abteilung Herz- und Gefässchirurgie, Kardiotechnik

Der Vortrag gibt eine Übersicht über die geschichtliche Entwicklung von simulierten Situationen, beginnend in der Aviation (1928) bis hin zu den ersten Simulationen im medizinischen Bereich (1958).
Simulation umfasst heute nahezu alle medizinischen Bereiche (z.B. Anästhesie, Endoskopie etc). Anhand von Beispielen aus Critical Incident Reporting (CIRS) werden typische und immer wiederkehrende Zwischenfälle im Bereich des kardiopulmonalen Bypasses beschrieben.
Fehlervermeidung und Sensibilität gegenüber kritischen Situationen können trainiert und im Team erarbeitet werden.
Orpheus ist ein vollumfassender Perfusions-& Teamsimulator, der in den letzten Jahren entwickelt wurde und seit dem in verschiedenen Zentren weltweit im Einsatz ist.
Das Herzstück ist ein hydraulischer Simulator mit dem über eine Kontroll- bzw. Steuereinheit realitätsnahe Szenarien während einer Perfusion  umgesetzt werden können.

Trainingssituationen werden durch ein Briefing und Debriefing aufbereitet und ausgewertet.
Mit Hilfe einer Video & Mikrofonanlage können diese zusätzlich unterstützt werden.

Durch den Einsatz eines Simulators wie den Orpheus, wird die Teamarbeit verbessert, Stressfaktoren sowie Fehler können gemindert und eine höhere Patientensicherheit gewährleistet werden. Neues Equipment kann im Vorfeld getestet sowie diverse Abläufe verbessert werden.
Im Universtätsspital ist in naher Zukunft mit diesem Simulator ein Trainingsprogramm für interne und externe Fortbildungen geplant.

Dreizler T³, Born F¹, Behrens M², Botha CA², Starck C³:
¹ Heinrich Heine Universität Düsseldorf
² Herz- & Neurozentrum Bodensee AG Kreuzlingen/Herzzentrum Bodensee GmbH Konstanz
³ Universitätsspital Zürich

Retrograde Autologous Priming (RAP) in combination with Modified Adult Perfusion System (MAPS) did not offer a higher benefit in saving Packed Red Blood Cells (PRBC). The results of a database analysis

Background
MAPS (Modified Adult Perfusion System) is a hybrid system which consists from components of a Standard Extracorporeal System (CECC) and a Minimised Bypass System (MECC). The benefit on patient's outcome was proven in several studies, published in the last years. The system is used as standard system in more than 2500 cases yet.

Methods
The current work underlies a analysis of more than 1500 cases out of the database from the years 2008 - 2011.
Cases with a calculated priming after RAP more than 0 ml and less than 700ml were excluded from the analysis. We also excluded emergency cases. Furthermore we have no exclusion criteria. Cases with a priming of 0ml were assigned to the 0-RAP Group (n=57) and with a priming more than 700ml forms the non-RAP group (n=307).
We analysed the hemoglobin course (Hb) for 3 days, the PRBC consumption of the whole hospital stay, the priming volume and cardioplegic solution.
Our first point was to find out which influence MAPS has on the consumption of PRBC. The second step was a closer look  on RAP.
The statistics was done with with Student's unpaired T-Test with a significance level of p=0,05.

Results
There was no difference between the groups in Age, Gender, EuroScore (ES) and Body Mass Index (BMI). Also the amount of Cardioplegic Solution wasn't significant. In the postoperative PRBC consumption were no differs between the groups.
Differences were found in the Pre Hb course, in the units of PRBC given to the machine and also in the amount of priming volume. The perfusion time in the non-RAP group was significantly longer.
28,9% of the cases received PRBC. In average they got 2,76 units per case PRBC.
Between the groups 0-RAP and non-RAP were no difference in consumption of PRBC during the whole hospital stay. But the administration of PRBC on-pump were high significantly lower in the 0-RAP group.
Due to lack of a standard group, a comparison was made with international studies. It could be shown that MAPS contributes to a very low average in consumption of PRBC.

Conclusion
There is a strong suspicion that all cases gets the same volume amount in the first 24h after extracorporeal circulation. But the cases of the non-RAP group gets it on-pump and the 0-RAP postoperative, later, on ICU.
RAP in combination with MAPS shows no more benefit for the PRBC consumption of the whole hospital stay. But the advantage is clear. RAP leads to a higher hemoglobin course on-pump and should be used in future further on. A higher on-pump hemoglobin has advantages for the neurological outcome and prevents Acute Renal Failure. PRBC given on-pump underlies a higher shear stress and the survival of erythrocytes decreases by contact to the foreingn surface of the circuit. There are changes in the erythrocyte quality during storage, e.g. a decrease of 2,3-DPG concentration leads to a decrease in the oxygen uptake of tissues in the next 24 - 36 h after transfusion. Clinical data also show a lack of initial improvement of tissue oxygenation due to the transfusion of stored blood in critically ill patients. With the decrease in ATP concentration accompanied a loss of deformability of red blood cells and a possible negative effect on the rheological properties. So a administration of PRBC in the postoperative phase will be better.