 All right, well, thank you very much for the invitation to participate in this symposium. Texas Heart is very close to my heart, is where I first did my training in the United States. So I have very fond memories. Today we're going to talk about profusion in low and middle income countries staying out of trouble, not an easy task. The format I am going to take you through a few scenarios of things that actually happen to us when we travel to our profusionists and we can go over the different episodes and how to prevent them and how to be prepared for them. So the first one is what I call the Too Many Cooks Syndrome. And in some countries when we go and they have their own profusionists and their own heart surgery team that perform surgery when we're not there, this could happen if you don't set it up right. As an example, we went to a country that performs pediatric heart surgery on their own and we were there to help them set up the first or do the first hypoplastic left heart syndrome. There were three profusionists. One of our staff profusionist is a very senior, very qualified individual and two very experienced local profusionists. Everything is going well. The temperature in the patient is 28 degrees. We're cooling down in preparation for deep hypothermia, circulatory arrest. Heart rate is almost nothing due to the temperature. The matter is about 28, 30 and suddenly we hear big bang. And the big bang was followed by a spray of blood everywhere. And the screaming by one of the profusionists saying that the oxygenator and the reservoir had exploded. Clamps were applied to the lines. We give cardioplasia. We continue to do the procedure while the profusionist changed the whole setup and tried to clean up a little bit of the mess. In doing the investigation the day after quality analysis, we realized that one of the vents for air had not been the cap and one of them had not been removed. Therefore, air was building up pressure up to the point in which it cracked the whole system and sprayed blood everywhere. So the two take home lessons for this event was that there weren't too many cooks. All of them were doing everything and because they're all qualified and this happens in every circumstance, every scenario in which all the people involved are very qualified. Everybody counts like on everybody else to do the right thing and you stop paying attention as if you were the only person there. And that brings it to where I always bring out in those countries is not the same to be responsible than to be accountable. We had three very responsible individuals. Nobody was accountable for who was the profusionist for the case. So interestingly enough, accountable is not a word that is easy to use or translate rather to any other languages or to many languages. The other concept that especially is important for young profusionists, there's a phenomenon called the cognitive tunnel vision. It happens to surgeons. You're so concentrated in doing your task that you are not paying attention to the rest and it's very important to have situational awareness, to know what you're doing but at the same time to know and understand what everybody else is doing. So from that trip on, at least when I travel, even if there are more than two or three profusionists all eager to learn, we decide the head of the profusion who's going to be responsible and accountable for setting up the system and who's going to be answering one to one with a surgeon regarding any problems that may occur during the profusion. That's extremely, extremely important. On the second example, let's talk a little bit about cardioplegia. As you know, the history of congenital heart surgery, particularly neonatal cardiac surgery changed dramatically after the introduction of the delnoid of cardioplegia. I don't need to go over the formula with you, you're all familiar, you probably all use it but you do know that this based on a solution of plasma light. And plasma light is extremely, extremely expensive in any country, well, it's not even available in most countries, but when it is available, it is about $300 or so at the back. So you will not have this unless you smuggle in your luggage bags of plasma light. And I have done it and it's pretty heavy, but you're going to be offered two solutions to replace plasma light in order to make the needle cardioplegia. One is lactated ringer and the other one is sodium chloride. My preference and the preference of many people I work with, me and profusionist, is to use sodium chloride. In this table, I don't think it's very complicated, but you can see the different components of each one of the solutions and a normal saline is just sodium and water. Lactate has two different types of sodium chloride and lactate, it has potassium and it has calcium. Meanwhile, plasma light has three different kinds of sodium, sodium chloride, sodium gluconate and sodium acetate. It has some potassium, but most importantly, it has absolutely no calcium. And that is one of the number one advantage of using normal saline. Calcium, and if you talk to a senior profusionist, I have seen it myself 30 years ago when cardioplegias were handmade and somebody had put calcium or too much calcium in it. And you have the stone heart. Just ask people around you what stone heart is and what it looks like and how awful of a complication that is. And believe me, you don't want calcium anywhere closer to your cardioplegia. The second difference is plasma light already has magnesium which has to be added to saline or to the lactate, if you were to use lactate ringer. The other advantage of the saline is that the pH is closer to normal as it is the one for plasma light. And the same happens with the osmolarity which is closer to normal as it happens with plasma light. So we have been using, so this is the formula that we use to reconstitute the cardioplegia del nido when we use saline. You all have it somewhere. So we don't need to spend time there. We switch to do all our patients with del nido cardioplegia in June, 2016. So in reviewing the 100 patients before, using del nido, we were using St. Thomas. In reviewing the 100 patients before and the first 100 patients, these are all 208 consecutive patients comparing St. Thomas to del nido with saline. We were able to see a few things, nothing significant, which is a good thing. The mortality is about the same, slightly higher with St. Thomas with non-statistical significance. Although I have to make the observation that in the group of the nido patients, there were nine neonates while there was no neonate in the St. Thomas. So I suspect that if these groups were bigger than 104 each, we would begin to see a tendency and you can see it there, eight compared to 5%. The extubation and we call early extubation any extubation that happens in less than six hours upon arrival in the ICU or extubations in the operating room. We're about the same with the median of one and a half hours and compared to four and a half. Now again, this patients with median of four and a half that may look like longer had neonates in them. And the endotropic support was practically identical. So non-statistically significance on any of these variables. What is really important is to observe what happens after 45 minutes of cross-clamp because to do an interceptal defect or ventricular septal defect with cross-clamps of 10, 15, 20, 30 minutes is irrelevant what you use. But when the cross-clamp goes above 45 minutes it's more important to have good protection of the heart. And I will make two observations here and none of them with statistical relevance but showing a trend, the mortality was higher for patients on the Sainte-Thomas group than patients with the needle. Again, small numbers, no significant but significant enough empirically 21% compared to seven and a half percent. These are only 37 patients on one group, 53 and the other group. The second difference is on the inotropic support. Maybe something there, 24 hours later, almost 60% of the Sainte-Thomas patients were still receiving inotrops. Only 43% of the normal saline del nido were on inotropic support. The rest of the variables were practically identical, the same cardiopulmonary bypass time, very close and cross-clamp time, early extubation and median ventilation. So in conclusion, we decided that at least using del nido based on normal saline is not inferior to using what we used to use which is a Sainte-Thomas solution. And since then, we have instituted using del nido in all our cases. This is another thing that you have to be very aware of as a profusionist, you manage these two drugs every day, the main drugs that you will be using. And we have had many issues of bleeding in some countries. Particularly when we don't use drugs manufacturer in Western countries. And the reason is the quality control and the fractioning of the drug, despite of what is printed may not turn out to be exactly what it says it is. So you have to be very aware. This brings me back to 2013, one of my first trips to North Macedonia, actually my first trip in which we were doing cases not neonates, the trilogy of a lot, five or six years of age and another child with some other two ventricular repair that normally should be inconsequential. It has severe, severe bleeding, so much that we ended up using factor seven twice in a week in two different patients, which I had never done before in 25 years. So we began to investigate what was the problem in this patients. And we realized that we had used heparin and protamine, not only they were not made in Western countries, we had mixed heparin made in China for instance with protamine made in India. So that compounded the effect of inaccuracies of labeling and fractioning of the drug. So the solution, because the ACT, as you can see on the table on the right, the ACT is in approximation of your correlation status is a very unspecific measure of where you are. And unless you can do text, the value of the ACT after the first hour is completely irrelevant really. So in that particular country, they had the means to be able to buy a HEPCON correlation system and they consistently measure after each bypass the amount of heparin still circulating and gave the corresponding dose of protamine from whichever origin until there was no more circulating heparin. But if you do it empirically, you have to remember that excessive protamine, you can keep giving protamine, but excessive protamine also produces bleeding. So that's something to be aware. And I would strongly suggest that when you travel to other countries and you have to use these drugs, any drug, but particularly these drugs, which are your responsibilities of profusionist, you should try to use USA, European, Canadian, UK or Australian manufactured drugs. But if you can't and you have to use what you have in those countries available, try to use drugs manufactured in the same country. If you're going to use Chinese heparin, see if you can find Chinese protamine. If you're going to use Indian manufactured heparin, use Indian manufactured protamine. Probably the relationship is more equal than mixing from different countries. Something that affects you very fairly is the fact that in many countries, as it was here in America before 1989, the only product available is whole blood, taken from family members the morning or the day before the surgery. And sometimes you don't have, and this is very important postoperatively, you don't have all the different components, individual components of blood available for either priming of the pump, to do FFP on rewarming, especially when you're doing a neonate and the most important of all, the use of platelets and postoperative bleeding when you know that platelet is what is needed for the patient. I have personally and many of us have the same experience of being in a country in which they were not platelets when you asked for it. And you say, well, call another hospital and they tell you, well, no, there's no platelets. I say, well, call the Red Cross. No, there's no platelets in the entire country. So your only resource is to use whole blood, which as you can imagine, if you're using blood, you have to transfuse a lot to be able to achieve the number of platelets. And when you're doing this to a neonate, your hematography is going to end up being 70% if you're not careful. Regardless of what you have or you don't have, my strong recommendation would be that whether you use whole blood for blood pliaming or if you use pax cells, you always, always check the potassium concentration. We need to tell you, this is fresh blood from yesterday because it's always higher than you expect to be. A little bit about the alarms, the alarms of cardiopulmonary bypass systems and the four top complaints that perfusionists have about the alarms. One of the complaints is that all the alarms sound the same and make the same noise. And you can distinguish whether it's a low level alarm, high pressure or air in their tail line. The second complaint that low level alarm will not stop the pump. The third complaint that not every monitor parameter has an alarm. And the fourth one is that the operating room is too loud and you can't hear the alarm. Well, that's great and dandy, especially here in America, but when you are in a low and middle income country, we can guarantee that the operating room is going to be too loud. But plan to work without any alarm. Line pressure alarms are a luxury. Sometimes you have air bubble alarms. And occasionally, for the most part you have it, but occasionally you don't have blood level alarms, which brings me to another anecdote from my last trip to Ecuador Hospital that never had a heart surgery, not pediatric, not adult. First time ever doing the first ever case on that hospital, an ASD, ADHD or so. And we had put everything together. We brought everything. And as we go and bypass five minutes into it and preparing to put the stitches for the cardioplegia cannula, I see that the blood pressure drops to zero on the heart is empty. And what happens was that the, I was immediately informed by the profusionist that was not expecting it. There was a mild function on the blood level alarm, but not a mild function because the level drop and the alarm stopped, the several mechanisms that stopped the pump. No, the level was fine. It was a misfunctioning, a misreading of the alarm and trigger the complete stop of the pump. So the patient was basically exsanguinating into the pump. So we put the clamp on the venous line, which is what you have to do. We crank by hand, the arterial line until that alarm cable, the whole system was ripped off and fill up the heart again. The patient was normal heart. He was beating normally. It was just empty. The whole thing took 30 seconds. But it's very scary because you can have a serious complication in a very simple surgery that you have zero mortality and zero complications. So it's bad to work with other alarms. It's even worse to work with mild functioning alarms. You have to be aware of that too. You know, on a different topic, this was related to me by one of our senior proficient, staff proficient is very capable of individual. If he had been any junior or not so experienced, this could have ended up in a real disaster. In this particular hospital, all cases were done for that day. The pump was clean as you should. The heater and cooler unit was clean and it was filled with sterile water of what they thought was sterile water. So he comes the next morning. The heater has been filled up overnight. He prepares everything for the first case and it's a small child. So it's a blood prime pump. And he begins to circulate it to make sure everything is working and he detected a reddish color in the tubing going between the oxygenator unit and the heater color, heater cooler. So he stopped throw away the whole system, empty the heater cooler. Everything new, delay the case of course. What happened is that that sterile water was not sterile water, it was sodium bicarbonate and the sodium bicarbonate solution had destroyed the membrane and had allowed the blood to go into the heating cooler tubing. It's one of those oxygenators in which everything is polyurethane. There is no metal. In any case, this, number one, if the priming had been with clear fluid, nobody could have detected that. And this patient would have been perfused with a solution of bicarbonate and probably would have had serious problems with oxygenation and with the alkalosis. So that's number one. This prompted me and others together with an observation that Brian Forsberg who's sitting there on the panel today, observed that in some of his adult patients that were placed on metal in blue and a very old way of keeping blood pressure after you exhausted all the other inotropes that you can think of, this end stage heart failure patients on metal in blue, he observed that there was a contamination of a blue color in the heater cooler. So we proceeded to do some in vitro research in Florida and we realized this is for cold storage of the units for ECMO. We realized that after 13 days of storage, some chemicals like metal in blue, like bicarbonate, may seriously damage the membrane, allowing the passage of substances between the two circuits that should be completely isolated. And that lead us to be able to publish that data and to the intention was to make people aware that there could be other chemicals. I mean, we know for sure there are other chemicals that are used in cleaning the heater cooler that had potential deleterious effect on the membrane per se. So that's a very important, I would recommend that you read this just for reference and to start thinking in a different way. Not everything is safe that you think is safe. We should question whether other chemical compounds currently recommended for cleaning the heater cooler unit may be able to interact with the polyurethane membrane and do damage. And finally, I just, it's more like an empirical thing, but if you haven't experienced it, this would be good for you to know. When operating in low and middle income countries in severely cyanotic patients, we're talking about patients with hematocrites of 65, patients who have saturations that equal their hematocrit. I recently adopted a child from Afghanistan. Her hematography was 68 and her saturations were 68. So upon termination of cardiopulmonary bypasses, as everything is fixed, whether it's a old technology of a lot, completion of the fontan, whatever surgery that your surgeon is doing, you should try to match the post pump to the pre-op hematography. And this will facilitate the postoperative management. And this is something that surgeons sometimes are not aware of and you should not be shy to interact and to make them aware of this. The thing, and this is, there's no proven, we're trying to find a way to measure this, but we know that when you have a cyanosis for a long time, you develop more capillaries due to the low oxygen in all your tissues. And those capillaries are filled with this high hematocrit blood. If you fix the patient, and the patient now can have a normal saturation and you don't bypass, but you give the patient a normal hematocrit, 35, 40, a bunch of those capillaries are going to be empty and there's not enough albumin or vasoconstrictors or saline or anything that you can give that they will fill up that bed the way that high hematocrit does. And it will make a very difficult postoperative management. And if you are with Western trained surgeons, nurses, intensivists and they're not used to thinking in this terms, they may end up with a serious complication because it's something that we here in this country, we don't see the 68% or 70% hematocrites every day. So that's just anecdotal, no papers, no, but that's experience and I would recommend that you look into it. So in closing, thanks again for the opportunity to give you this presentation. I hope that we are alive there to be able to answer any questions. I'm sure you're wondering why my map is upside down. There's an explanation for that and thank you again for the opportunity to talk at this very nice meeting. Thanks.