Cardiac Perfusionists Research Articles

Hospital Administration Considerations for Implementation of Normothermic Regional Perfusion DCD Heart Transplant Program

<h3>Purpose</h3> The successful use of abdominal organs from donation after circulatory death (DCD) donors has highlighted potential opportunities for thoracic programs to establish methods for utilization of DCD donor hearts. DCD heart transplant implications on cost, staffing needs, and volume changes were unknown. We report our experience from a hospital administration perspective on starting a normothermic regional perfusion (NRP) DCD heart transplant program. <h3>Methods</h3> We chronologically describe the start of our NRP DCD heart transplant program and report the current volumes, staffing models and financial impact. <h3>Results</h3> Hospital administration gave early institutional support for the use of DCD hearts via participation in the U.S. TransMedics Organ Care System DCD trial. Successful DCD heart transplants during this trial highlighted the potential opportunity of expanding the heart donor pool from DCD donors. The NRP protocol for DCD heart procurement was studied and presented to hospital ethics committee and the institutional review board who approved its use. Early evaluation of financial projections did not seem to be cost prohibitive. A mobile medical team capable of instituting cardiopulmonary bypass (CPB) at remote hospitals were assembled and trained. The team consisted of 2 transplant recovery specialists, 1 cardiac perfusionist and 2 cardiac surgeons. An existing CPB machine used for mobile ECMO was utilized for NRP. The concept of remote NRP was first demonstrated by this team with the recovery and transplant of a DCD donor heart from our local OPO at a remote hospital in May 2021. Refinements in the process and logistics has allowed fly-out procurements by this team at remote sites as far as 1000 nautical miles. To date our program has transplanted 20 hearts (28.2% of heart transplants YTD) from DCD donors using the NRP protocol. Eight fly-outs did not yield a heart transplant: 6 DCD donors did not expire within 90 minutes, 1 organ declined for quality after NRP successfully started the heart, and 1 heart declined due to prolonged ischemia from logistical complications. Financial review of the 20 NRP protocol heart transplants demonstrated positive contribution margins. <h3>Conclusion</h3> Utilizing existing staff and equipment, remote NRP DCD heart procurement is feasible at acceptable cost and can expand the heart donor pool by up to 28%.

Understanding medicine prescription and administration practices during cardiopulmonary bypass

There is variation between institutions in the administration practices by cardiac perfusionists of drugs to patients while on cardiopulmonary bypass. Our interest was in the extent of variation in practice, and reasons for it.

Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions With the Cardiopulmonary Bypass Pump.

This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB) pump during real-life cardiac surgery. Estimations of operators' cognitive workload states in naturalistic settings have been derived using noninvasive psychophysiological measures. Effective CPB pump operation by perfusionists is critical in maintaining the patient's homeostasis during open-heart surgery. Investigation into dynamic cognitive workload fluctuations, and their relationship with performance, is lacking in the literature. HRV and self-reported cognitive workload were collected from three Board-certified cardiac perfusionists (N = 23 cases). Five HRV components were analyzed in consecutive nonoverlapping 1-min windows from skin incision through sternal closure. Cases were annotated according to predetermined phases: prebypass, three phases during bypass, and postbypass. Values from all 1min time windows within each phase were averaged. Cognitive workload was at its highest during the time between initiating bypass and clamping the aorta (preclamp phase during bypass), and decreased over the course of the bypass period. We identified dynamic, temporal fluctuations in HRV among perfusionists during cardiac surgery corresponding to subjective reports of cognitive workload. Not only does cognitive workload differ for perfusionists during bypass compared with pre- and postbypass phases, but differences in HRV were also detected within the three bypass phases. These preliminary findings suggest the preclamp phase of CPB pump interaction corresponds to higher cognitive workload, which may point to an area warranting further exploration using passive measurement.

Preoperative investigations of open heart surgical patients: Our current institutional protocol (1)

Background: Open heart surgery is one of the complex procedures physicians undertake in modern medicine. It requires high tech equipment, special infrastructure and highly skilled manpower, especially in the areas of cardiology, cardiac surgery, anaesthesiology and cardiac perfusion. Preoperative diagnosis must be accurate and patients’ safety determined in order that appropriate informed consent is given. In open heart surgery, our institution developed preoperative assessment protocol. They are clinical evaluation and preoperative investigations.The objective of this study is to highlight our institutional preoperative investigative protocol and compare same with what is available in the literature.Materials and Method: In our institution, the first open heart surgery was done in 1974. We performed a retrospective review of the preoperative investigation protocols from 1974 to 2016, spanning a period of 42 years noting the changes and outcome of the changes. The 42 years of cardiac surgery activity occurred in 3 phases: 1. from 1974 – 2000; 2. 2003; 3. 2013 – 2016. Data were obtained from our hospital Record Department. The types of the preoperative investigative protocol and outcome of the changes were analyzed using Microsoft excel and results expressed in arithmetic percentages and presented in tables and bar chart.Results: These investigations are broadly divided into diagnostic and patient’s fitness assessment investigations. The diagnostic investigations aid proper clinical evaluations and are used in evaluating congenital heart defects and acquired heart diseases. In addition, fitness assessment tests have two functions and they are 1. determining the risks of postoperative morbidity and mortality from patients’ co-morbidities and the systemic effects of the cardiac disease(s). 2. Predicting the postoperative support that may be required in order to maximize the chances of uneventful surgery. The diagnostic and fitness investigations guide the quartet (cardiologist, cardiac surgeon, cardiac anaesthetist and cardiac perfusionist) in making appropriate management decisions especially with regard to complex congenital heart defects and complex cardiac cases in the elderly, discussed in the setting of cardiac team meetings.Conclusion: Preoperative investigations form part of an intrinsic preoperative checklist to ensure where possible uneventful surgery. When they are holistically done and accurate diagnosis is made including patients properly worked up via-a-vis the results of the investigations, the outcome is bound to be favourable.Keywords: complex, congenital, diagnostic, preoperative, investigation

Survey of the Clinical Assessment and Utility of Near-Infrared Cerebral Oximetry in Cardiac Surgery

Near-infrared cerebral oximetry increasingly is used for monitoring during cardiac surgery. Nonetheless, the scientific basis for incorporating this technology into clinical practice, the indications for when to do so, and standard diagnostic and treatment algorithms for defining abnormal values are yet to be rigorously defined. The authors hypothesized that there would be (1) variation in clinical use and practices for near-infrared spectroscopy (NIRS), and (2) variation in management of patients when clinicians are provided with NIRS information. In order to test this hypothesis, they sought to assess the nature and strength of response heterogeneity among anesthesiologists and cardiac perfusionists when provided with cardiac surgery patient scenarios and cerebral oximetry data. A prospectively collected survey. A hospital-based, multi-institutional, multinational study. By e-mail, the authors surveyed the membership of the Society of Cardiovascular Anesthesiologists and the online Cardiovascular Perfusion Forum. This survey was focused on ascertaining what actions clinicians would take in each scenario, given case information and cerebral oximetry tracings. Questions were based on 11 patient scenarios selected to represent small, large, symmetric, or asymmetric decreases in measured regional cerebral oxygen saturation (rScO2) encountered during cardiac surgery. Information on the respondents' (n = 796; 73% anesthesiologists) clinical practice, demography, and cerebral oximetry utilization was collected. An index of dispersion was used to assess response heterogeneity overall and within demographic subgroups. The majority of respondents indicated that cerebral oximetry monitoring was either useful or an essential monitor, especially perfusionists and clinicians who used cerebral oximetry most frequently. There were marked differences in responses between perfusionists and anesthesiologists for 4 of the 6 scenarios (p<0.005 for each of these 4 scenarios) occurring during cardiopulmonary bypass. Scenarios having greatest rScO2 reduction or asymmetry in rScO2 were associated with the highest dispersion, indicating least agreement in management. Scenarios with mild or moderate rScO2 reduction were associated with the lowest dispersion, indicating greater agreement in management. Although experimental data gradually are accumulating to support the role for cerebral oximetry monitoring during cardiac surgery, the results of the present survey support the view that its role remains poorly defined, and consensus for its appropriate use is lacking. Importantly, the authors observed marked variation in the use, perceived utility, and management of patients for 4 of the 6 CPB scenarios between perfusionists and anesthesiologists who share the management of CPB. These findings support the need for well-designed, adequately-powered clinical trials examining the value of this technology.

A Multidisciplinary Approach with Reducing Cardiac Surgical Site Infections

BACKGROUND/OBJECTIVES: Despite adherence to evidenced-based practice recommendations, SSIs can still occur. The Cardiac Surgical Team, Infection Control & Prevention Department, and the Performance Improvement Department collaborated to implement best practices for reducing SSI morbidity and mortality in cardiac surgical patients. We proceeded to compare the Centers for Disease Control & Prevention (CDC) and the Surgical Care Improvement Project's (SCIP) best practices to our current practice. Additionally, process of care opportunities were identified from intense analyses involving cardiac surgical patients. Time was spent observing patient care in the Operating Room and Cardiac Surgical Intensive Care Unit. Opportunities to improve the correct timing, dosing, and documentation of antibiotics during the preoperative & intraoperative periods were found. METHODS: Buy-in from the Department of Anesthesia and Surgery Chiefs was obtained. A summary of hospital preoperative antibiotic timing data compared to best practices was presented to the members of the Departments of Anesthesia and Surgery. The practice of giving antibiotics “on-call” was discontinued; instead, the medication was administered in the Operating Room Holding Area. The Anesthesia Record was revised to highlight the preoperative antibiotic. Questioning if the preoperative antibiotic has been administered became part of the surgical time out process. The Cardiac Perfusionist assisted with antibiotic documentation on the Perfusion Record. Timers were placed in every operating room suite as a reminder to ensure the re-bolusing of selected antibiotics. Cefazolin 2 Grams was given preoperatively to all patients who weigh ≥200 pounds. Preoperative antibiotic timing and postoperative antibiotic discontinuation continued to be reviewed monthly for every case. Cardiac surgical infection surveillance continued for all open heart procedures. RESULTS: Pre-op antibiotic administration compliance within one hour before surgery was at 28.6% during December 2003 and has now been sustained at or near 100%. Use of appropriate antibiotics has been consistently 100% since October 2003. Surgical Site Infection Rates for Risk 1 CABG procedures, previously slightly greater than the 50th decile during 2002, is now below the 10th decile when compared to NNIS data. CONCLUSIONS: The Cardiac Surgical Team's acceptance/buy-in of the numerous recommendations came willingly. Operational issues at times were challenging. However, our multidisciplinary team was able to improve and sustain a high rate of performance to significantly reduce infection in the cardiac surgical patient. BACKGROUND/OBJECTIVES: Despite adherence to evidenced-based practice recommendations, SSIs can still occur. The Cardiac Surgical Team, Infection Control & Prevention Department, and the Performance Improvement Department collaborated to implement best practices for reducing SSI morbidity and mortality in cardiac surgical patients. We proceeded to compare the Centers for Disease Control & Prevention (CDC) and the Surgical Care Improvement Project's (SCIP) best practices to our current practice. Additionally, process of care opportunities were identified from intense analyses involving cardiac surgical patients. Time was spent observing patient care in the Operating Room and Cardiac Surgical Intensive Care Unit. Opportunities to improve the correct timing, dosing, and documentation of antibiotics during the preoperative & intraoperative periods were found. METHODS: Buy-in from the Department of Anesthesia and Surgery Chiefs was obtained. A summary of hospital preoperative antibiotic timing data compared to best practices was presented to the members of the Departments of Anesthesia and Surgery. The practice of giving antibiotics “on-call” was discontinued; instead, the medication was administered in the Operating Room Holding Area. The Anesthesia Record was revised to highlight the preoperative antibiotic. Questioning if the preoperative antibiotic has been administered became part of the surgical time out process. The Cardiac Perfusionist assisted with antibiotic documentation on the Perfusion Record. Timers were placed in every operating room suite as a reminder to ensure the re-bolusing of selected antibiotics. Cefazolin 2 Grams was given preoperatively to all patients who weigh ≥200 pounds. Preoperative antibiotic timing and postoperative antibiotic discontinuation continued to be reviewed monthly for every case. Cardiac surgical infection surveillance continued for all open heart procedures. RESULTS: Pre-op antibiotic administration compliance within one hour before surgery was at 28.6% during December 2003 and has now been sustained at or near 100%. Use of appropriate antibiotics has been consistently 100% since October 2003. Surgical Site Infection Rates for Risk 1 CABG procedures, previously slightly greater than the 50th decile during 2002, is now below the 10th decile when compared to NNIS data. CONCLUSIONS: The Cardiac Surgical Team's acceptance/buy-in of the numerous recommendations came willingly. Operational issues at times were challenging. However, our multidisciplinary team was able to improve and sustain a high rate of performance to significantly reduce infection in the cardiac surgical patient.

The managed care revolution: how medical technologists have tolerated the change.

A repeated cross-sectional study on the psychological profiles and interpersonal styles of highly stressed medical technologists (perfusionists) has found remarkable consistency in internal psychological profiles and differences in interpersonal dynamics over a 6-year period. Six years ago a longitudinal study was begun to track the psychological profiles of perfusionists. Surgeons can repair cardiac defects only after a beating heart has been stopped. In order for the brain and other organs to survive cardiac surgery, they must be perfused with well-oxygenated blood. As a result, the life of every cardiac surgery patient literally sits in the hands of the cardiac perfusionist. The stress of placing patients on and off the 'pump' is one that is experienced by cardiovascular perfusionists on a daily basis. This stress has been likened to that of air traffic controllers who continually prepare planes for take off and/or landing. In the 6 years between studies, medical technologists have changed very little psychologically. They remain very well balanced. However, there have been significant changes in their interpersonal behaviours. Instead of the 'well-balanced' interpersonal profiles of 6 years ago, there is a higher degree of assertiveness/aggressiveness being reported. Managed Care has begun to impact interpersonal behaviours but has not yet altered the more resilient platform of internal psychological balance.