Saturday, October 20, 2007

SA Strengthens My Belief that CI-81 was Overpressurized

SA's "Addendum to SA case report for patient CI-81" from SA's News Bulletin Number 12 ( appears in italics, below. My comments appear in bold.

Addendum to SA case report for patient CI-81

1. Heparin.
The precise time and dosage of heparin administered remains undetermined. We will continue to investigate this issue. No blood clots were observed in effluent during washout. The medications protocol that SA uses does include multiple agents that modulate the clotting cascade.

Does the SA medications protocol now include verifying a proper loading dose of heparin has been given, and call for maintenance doses, in response to my criticisms? My guess is, it does. I'm not going to go into a technical discussion of the coagulation cascade, but I stand firm in my opinion that cryonics patients should be adequately heparinized, regardless of the other "multiple agents" SA, (or any other organization), may be administering. Note that, in the SA case report, while the mortician did not SEE any clots, they were unable to "get good steady flow." SA failed to include flow and pressure charts in their report, but taking the time and volume into consideration, and adding the remarks made about pressure, the perfusion flows were extremely low, while pressures were high. This could be an indication of extensive clotting.

2. Washout.
The report contains an inaccuracy in its description of procedures at the mortuary. It describes the mortician finding blood spurting when he made an incision in the femoral vein. This event actually occurred when an incision was made in the femoral artery (see source text below). Since the air transportable perfusion (ATP) unit was not connected to the patient until after blood was drained on the venous side, active chest compressions and residual diastolic pressure may have caused blood to spurt from the arterial side.

I disagree. I don't think anyone can prove this occurred during an incision into the femoral artery, based on the "source text". In fact, I think the "source text" further verifies my suspicions that this patient was overpressurized. See my further comments, below.

3. Mannitol.
A statement attributed to the Consulting MD, regarding prevention of crystallization of mannitol by storing it in small glass containers, is incorrect. The Consulting MD did not state that such crystallization is impossible, only that in his experience it is less likely to occur than if the mannitol is stored in bags.

The "Consulting MD" has publicly printed blatant lies about a former SA employee whom he does not know, and in my opinion, he has also made many questionable comments regarding medical protocols and procedures. I think it's foolish for SA, (or anyone else), to make decisions based on his input. Why not consult with the supplier of the Mannitol in this situation? That would be the logical thing to do, wouldn't it?

Excerpts from Reference Sources
(except for names, case notes are unedited)

From the second team member’s case notes:
The mortician raised the femoral, chest compressions were still being administered, the ATP had been primed by the third team member, the mortician cut the femoral and the pressure in the vessel shot blood out onto his legs, he had no problem with he cannula, the pump was set to very low and blood was drawn back into the cannula and a near perfect bubble-less connection was made by the third team member (ATP) and the second team member (cannula).

Only someone who has little-to-no perfusion knowledge/experience would fail to realize that this, in fact, indicates the vessel being cannulated was on the venous side of the perfusion circuit. There is positive pressure on the arterial side, and negative pressure on the venous side, of the circuit. Blood does NOT get "drawn back into the cannula" on the arterial side of the circuit; it only gets pushed out. However, it definitely DOES get "drawn in" to the venous line, which is open to the reservoir. The statement that the "pump was set to very low and blood was drawn back into the cannula" indicates VERY STRONGLY this was a VENOUS cannulation. While blood can be drawn back into an arterial line when using a centrifugal pump that is not turned on, SA uses an occlusive pump that prevents this from happening, even if the pump is turned off. The perfusionist does not need to clamp the arterial line, (though they do), when turning the pump off while using an occlusive pump...the pump itself acts as a "clamp" and blood does not flow retrograde (in a reverse direction, toward the pump), in the arterial line.

From the third team member’s case notes:
We placed some bags of ice around his had and proceeded in making more bag of ice. I then continued to give chest compressions while the mortician started cutting into the femoral artery I could tell that I was making it harder for him and asked if he wanted me to stop while he cut in. He said it would help if I stop for a bit, I continue compressions whenever I saw an opening where he wasn’t cutting or tying to suture. He stated that the patient had a very big artery and as he sliced into it a large squirt of blood shot out and onto his apron onto his leg and onto his shoe, I wasn’t pumping the chest at that point.

Don't misunderstand these remarks. The compressions were making the cannulation difficult for the mortician, due to the movement of the patient, NOT any amount of vascular pressure being generated. The fact that Ken was continuing compressions "whenever (Ken) saw an opening where he (the mortician) wasn't cutting or tying to suture" indicates there was a good amount of the cannulation process being completed during this time. The normal cannulation sequence is femoral artery, followed by femoral vein. Based on my professional knowledge and vast experience with the cannulation process as a perfusionist, I still believe the mortician completed the cannulation of the femoral artery, (while Ken was providing intermittant chest compressions, and without the "spurting" of any blood), the pump was turned on and pressurizing the patient, and then the mortician cut into the femoral vein which provided "blood spurting onto him (the mortician) under pressure from the cannula that was already attached to the ATP on the arterial side" (a direct quote from the original SA case report). Referring back to the original SA report, the comment about the "large artery" was made well before the spurting of the blood, again confirming my suspicion that the spurt was cased by pressurization from the perfusion circuit during an incision into the femoral vein. Ken's comment that a "large squirt of blood shot out and onto his apron onto his leg and onto his shoe, I wasn’t pumping the chest at that point" again confirms my opinions. This type of spurt was not caused by any residual pressure from manual CPS; it was almost certainly caused by the improper pressurization of the patient. I believe any experienced perfusionist would agree this is the logical interpretation of the information provided not only in SA's original case report, but now verified in this addendum.

From the third team member’s case notes:
I noticed the mortician was pulling on a slide that was pulling blood from the leg; I assumed this devise was provided by SA, the second team member asked if he was done and I went from compressions to the other side of the ATP. I explained to the second team member that I was going to pull the hose apart and plug it into the cannula that he had sewn into the body, and that we need to make sure that little to no air entered as we did this.

This is meaningless, without the full context. I'm not even sure why it has been included. However, it possibly places Ken and Gary in a discussion at the ATP and lengthens the time between the last chest compressions performed by Ken, and the spurt.

Final Comments: While I know certain people who have the best of intentions want to believe the spurt occurred during an arterial incision, due to residual pressure from manual chest compressions that most likely had not been performed for at least a minute, or two, prior to the spurt, this is EXTREMELY unlikely. I admire you and your diligent studies, but with all due respect, none of you are knowledgeable enough about clinical perfusion to interpret your own report as any experienced perfusionist would.

One last comment I would like to make is, two of the three SA staff members who were at the CI-81 case have allowed Charles Platt to write documents for them, in the past. In my opinion, these two people are not knowledgeable enough about the procedures to write their own reports, and neither of them has very good writing skills. I'm going to speculate here, that Charles Platt (who was not present for the case) assisted at least these two members of the SA team to draft their case reports, (either officially, or unofficially), something that would be highly improper. I find it nearly impossible to believe these two people sat down and wrote their own case reports, without first discussing the case with Platt and/or others. This is speculation, based on my past experiences at SA. I will not make any remarks on the third person, as I do not know of that person allowing Platt to write documents for him. I will, however, say that I doubt that person would be able to distinguish a femoral artery from a femoral vein.

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