ABCP Perfusion Technology FINAL EXAM MATERIALS Solved 100%

Who is the accrediting body for perfusion education? - Answer Accreditation Committee - Perfusion Education (AC-PE) In the consensus curriculum, what does "emergency preparedness" refer to? - Answer In the event of an emergency, such as a natural disaster, perfusionists should be prepared to provide services to assist in triage of patients. What are the two national organizations related to perfusion? - Answer American Society of Extracorporeal Technology (AmSECT) and the American Academy of Cardiovascular Perfusion (AACP). What concepts and elements are found in the consensus curriculum as established by the AC-PE? (Long one--just review it) - Answer Anatomy, pathology, surgical repair, physiology, pharmacology, physics, chemistry, mathematics, immunology, circuit components, bypass techniques, adequacy of perfusion, myocardial preservation, systemic hypothermia, blood conservation, special considerations, catastrophe management, adjunctive techniques, patient monitoring, organ transplantation, extracorporeal life support techniques, intra-aortic balloon pumping, ventricular assist devices, laboratory analysis overview, special chemistry, blood chemistry, coagulation, biomedical instrumentation, biophysical transport phenomenon, biomedical electrical safety, medical and diagnostic imaging technology, blood/fluid exposure, patient safety, continuous quality assurance - CQI for the perfusionist, medical ethics, historical development of extracorporeal technology, research methods, business practice regulatory agencies, and emergency preparedness What is the AmSECT Scope of Practice, and what does it cover? (Long one--just review it) - Answer The AmSECT Scope of Practice contains the areas of proficiency required for practicing perfusionists, and in so doing it provides a standard for perfusion education. 1.1.0 Extracorporeal Support 1.1.1. Cardiopulmonary bypass for Adult, Pediatric, and Neonatal Patients. 1.1.2. Cardiopulmonary bypass for congenital and acquired cardiovascular disorders. 1.1.3. Extracorporeal circulatory support for renal, neurological, hepatic and vascular surgery. 1.1.4. Extracorporeal resuscitation. 1.1.5. Extracorporeal circulation for long term support of failing respiratory and/or cardiac function. 1.2. Associated Extracorporeal Support Functions 1.2.1. Myocardial protection. 1.2.2. Hemofiltration/hemodialysis. 1.2.3. Anticoagulation and hemostasis monitoring, analysis, and intervention. 1.2.4. Thermal regulation. 1.2.5. Blood gas and blood chemistry monitoring, analysis, and intervention. 1.2.6. Physiological monitoring, analysis, and intervention. 1.2.7. Administration of blood components, pharmaceuticals, and anesthetic agents 2.1. Heart Failure Therapy and Support 2.1.1. Ventricular Assist Device management 2.1.2. Intra-aortic Balloon Counterpulsation 2.1.3. Temporary Pacemaker management 2.1.4. External counterpulsation 2.1.5. Transportation of Extracorporeal Supported Patients 2.1.6. Hemofiltration (i.e. "Aquapheresis") 2.1.7. Periodic flow augmentation therapy 3.1. Blood Management 3.1.1. Autotransfusion 3.1.2. Platelet Gel Production 3.1.3. Non-Differentiated Progenitor Cell Harvest 3.1.4. Acute Normovolemic Hemodilution 3.1.5. Phlebotomy 3.1.6. Hemostasis monitoring and analysis 4.1. Other Clinical 4.1.1. Isolated Limb/Organ perfusion 4.1.2. Isolated limb/organ delivery of chemotherapeutics, progenitor cells, gene therapy vectors, ect. 4.1.3. Organ Procurement 4.1.4. Thermogenic lavage 4.1.5. Organ Preservation 4.1.6. Dialy What are included among the Standards and Guidelines set forth by AmSECT? - Answer The Standards and Guidelines set forth by AmSECT provide a standard for professionalism, interprofessionalism, and clinical practice in a wide range. (See In 1898, Jules Bordet won the Nobel Peace prize for what discovery? How was his work expanded upon by Landsteiner in 1900? - Answer Bordet hit upon red blood cell antibody production, providing the earliest initial understandings of blood typing. Landsteiner then identified 3 distinct blood groups, with a fourth identified later by Weiner. Who in 1850 demonstrated the need for oxygenation of the blood outside the body by whipping black blood into red? - Answer Brown-Sequard. In 1882, Von Schroder suggested that bubbling air through black blood from the bottom of a bottle produced "foam". What did this contribute towards? - Answer This assertion could be considered the first description of a "bubble" oxygenator. When was heparin discovered, by whom, and why was it named heparin? - Answer Heparin was discovered in 1915 and its discovery is credited to McLean, who at that time was a medical student. McLean believed heparin to originate from the liver (the prefix hepa(to)- meaning liver) when in fact it originates from the lungs and the GI tract. What was Cutler's contribution to cardiac surgery in 1924? - Answer Cutler used a sternum splitting incision to open the chest. From the years of , what condition did Cutler and Souttar attempt to treat, and how successful were they? - Answer Cutler and Souttar worked on 10 cases of mitral stenosis, of which only 2 survived. How did Charles Lindbergh contribute to organ perfusion and transplantation? - Answer Charles Lindbergh, working with Alexis Carrel, devised a complex glass apparatus referred to as the "perfusion pump." The two worked for five years and successfully managed to keep cat and bird organs alive for as long as 21 days. Working together, the two also sewed the hearts of animals to arteries and veins in the necks of other animals, and unintentionally discovered organ rejection. Forsmann, in 1929, performed a procedure on himself to prove it could be successful. What was this procedure? - Answer The first heart catheterization to measure pressures inside the heart. He would go on to win a Nobel Peace prize for his efforts. How did Harken remove foreign bodies from the heart in 1930? - Answer By running an electromagnet over the heart he attempted with success to remove bullets from the mediastinum in WWII soldier volunteers. Who, in 1937, is credited as the developer of the first heart-lung machine? - Answer John Gibbon Who purported the use of protamine sulfate to neutralize heparin in 1937? - Answer Chargoff and Olson In the 1930's, what were the important milestones in the development of cardiopulmonary bypass? - Answer Gibbon performed his first successful animal perfusion with his heart-lung machine. DeBakey successfully developed the roller pump for use in extracorporeal circulation. Who is responsible for the first valve surgery performed in 1940? - Answer Charles Bailey Though limited in success, what is Hufnagel credited with developing in 1951? - Answer A plastic valve to replace the aortic valve. How did the caged ball valves, developed by Dr. Starr, function? - Answer Blood would push the metal ball into the cage and push the ball back down to prevent backflow. In the 1950's, what were some of the important milestones in the development of cardiopulmonary bypass? - Answer John Gibbon performed the first successful bypass on May 6, 1953. Walt Lillehei performed the first cross-circulation and Richard DeWall developed his inexpensive bypass machine in the form of a bubble oxygenator. What was John Gibbon's May 6, 1953 accomplishment? - Answer The first successful open heart operation, an atrial septal defect repair on cardiopulmonary bypass. Of the 17 patients Gibbon had attempted before, only this last survived. What were Lillehei's contributions in the 1950's? - Answer Lillehei performed the first successful cross-circulation in 1955 on a one year old using the child's father as the donor. Lillehei went on to perform cross circulation in 45 patients and applied the "azygos" principle. What was the azygos principle, as reported by Lillehei in the 1950's? - Answer Cohen and Lillehei discovered that the azygos vein, which provides roughly 10% of the rate of the venae cavae, can safely sustain bodily function--i.e., the venae cavae can be clamped and the pt will be unharmed during surgery. Who successfully developed oxygenators in the 1950's? - Answer DeWall, Lillehei, Clowes and Kloff, Kay and Cross How did the disc oxygenator function? - Answer Discs would rotate into blood and bring blood into an oxygenated chamber. This allowed for easy control of oxygen and carbon dioxide concentration and allowed for easily controlled flow rate. What were some of the 1960's important milestones in the development of cardiopulmonary bypass? - Answer Commercial bubble oxygenators became available. Filtration was introduced to prevent neurological deficits resulting from blood aggregates entering the patient from bypass. From the years of , what were some of the advancements in cardiac surgery? - Answer Non-blood pump prime was instituted due to difficulty obtaining blood or need to prime without blood. Disposable equipment was introduced to cut down on costs, and membrane oxygenators were introduced, if not yet entirely functional. Who performed the first CABG in 1964? - Answer Garrett When did Christian Barnard perform the first successful heart transplant procedure? - Answer 1967 Who, in 1969, is responsible for implanting the first totally artificial heart? - Answer Dr. Denton Cooley What were the important developments in cardiac surgery of the 1970's? - Answer Centrifugal pumps were introduced (not yet perfected--bearings would wear out too quickly). Autotransfusion (recycling of blood) was introduced to cut down on blood requirements. Crystalloid cardioplegia was introduced. The silicone membrane oxygenator was introduced. ACT anticoagulation monitoring was discovered. Mechanical assist devices were developed. Surgery for coronary artery disease was refined. Moderate hypothermia performed to enhance myocardial protection. Blood cardioplegia was introduced. What were some of the advancements brought to cardiac surgery in the 1980's? - Answer Blood cardioplegia was more commonly used. Ventricular assist was performed with centrifugal pump. Microporous membrane oxygenators were introduced. Identification of the "inflammatory response" in which the immune system was activating post-bypass; circumvented by use of medications and surface coatings. Primary repair in newborns is developed; microsurgical techniques were expanded on. Refinement of pediatric surgical techniques was performed, among which were infant heart transplants. Advances in pharmacology, such as Cyclosporine A and hemostatic agents. What were the 1990's milestones in cardiopulmonary bypass development? - Answer Retrograde cardioplegia introduced. New pulsatile ventricular assist devices. Low prime circuits, miniaturization of CPB. Heparin and other surface coatings to reduce "inflammatory response". Minimizing neurological injury--blood gas strategies, reducing embolic load. What were the 2000's developments in cardiopulmonary bypass development? - Answer Continued reduction in pump prime and surface area (for neonates, women, etc.). Adoption of retrograde autologous prime (RAP) to reduce hemodilution. Further development of centrifugal pumps, membrane oxygenators for long term use. Electronic medical record enters standard use. In the development of ECMO, when did extracorporeal life support become viable in medical treatment? - Answer In the 1980's. During the 1970's, there was a 90% mortality for patients undergoing ECLS, but Bartlett managed to bring this down to 20% in the 1980's by adjusting patient selection, reducing ventilation during bypass, and reducing anticoagulation. How did extracorporeal life support change going into the 1990's? - Answer ECLS was expanded to include cardiac patients and adult patients, bridging to ventricular assist devices and allowing for reversal of pulmonary failure. What new technologies were adopted for extracorporeal life support in the 2000's? - Answer Membrane oxygenators without plasma leakage, centrifugal pumps, coated circuits, and reduced prime circuits. What is the fundamental difference between partial and total bypass? - Answer While a patient is on total bypass, his blood flow is entirely provided by the heart lung machine. On partial bypass, the patient partially provides their own cardiac output that is supplemented by the heart lung machine. When might a patient be placed on partial bypass? - Answer During the beginning of surgery (when a patient is first placed on bypass) and during the end of surgery (when a patient is weaned off of bypass). How is a patient placed on total bypass? - Answer 1. Caval tapes are placed on the venae cavae (essentially a suture surrounding the cannulae in the venae cavae to ensure complete venous return to the heart lung machine). 2. If the heart is fibrillating (i.e. cardiac muscle fibers are contracting individually), no blood flow is occurring. 3. The aorta is cross-clamped (X-clamp) to prevent coronary venous return. Draw an ideal perfusion circuit. - Answer See image. (Image does not contain cardiotomy reservoir, cell saver, arterial filter or purge line from arterial filter.) Though each heart-lung machine will be designed differently, what are some design considerations the perfusionist should know to encourage safe perfusion practice? - Answer Simplicity - the less complicated a circuit is the easier it is to control. Safety device implementation. Surgeon requirements - personal to the surgeon but important for surgical effectiveness. Patient requirements - size, other requirements. Pump console requirements. Component requirements. Adherence to a routine - important to maintain a consistent workflow and ensure consistent outcomes. How are different sizes of perfusion circuit selected for a patient based on their size? - Answer Adults (50kg) Pediatric (30-50kg) Infant (4-30kg) Neonate (4kg) How does the heat exchanger control the temperature of blood pumped through it? - Answer An external heater/cooler water source provides temperature controls without exposure to the blood. How is blood cardioplegia administered to the patient? - Answer Oxygenated blood is pumped from the oxygenator through a separate cardioplegia pump, where this blood is combined with cardioplegia solution before being delivered through a cardioplegia heat exchanger/bubble track to the coronary arteries by administering cardioplegia below the X clamp. How are custom tubing packs designed for purposes of CPB? - Answer Design considerations include: - Transparency of tubing - Resilience (ability to reexpand following tubing compression) - Flexibility - Kink resistance - Hardness (ability to resist collapse, tested by durometer) - Toughness (resists cracking and rupture) - Low spallation rate - Non-wettable inner surface, smooth - Toleration for heat sterilization and compatibility What are three common tubing types used in CPB, and which is the most common? Why? - Answer Polyvinyl chloride (PVC), silicone, and latex. PVC is the most common because it is clear, flexible, tough, difficult to collapse, and has low spallation rate. What are some considerations for tubing surface modifications? - Answer Heparin or an alternative? Biopassive? Longevity? (ionic vs. covalent bonding) Expensiveness? Which components can be coated? What are the advantages of a closed venous reservoir (bag reservoir)? - Answer Reduced air-blood interface. Increased safety--the collapsible bag will close and prevent the pumping of massive air. What are the disadvantages of a closed venous reservoir (bag reservoir)? - Answer Limited reservoir volume. Requires separate cardiotomy reservoir. Unable to use vacuum assist. Difficult to determine the volume inside the reservoir. No electronic level alarms. Difficulty managing venous air (in form of microemboli) - requires attention throughout case What are the advantages of an open venous reservoir (hard shell reservoir)? - Answer Entrained venous air, naturally handled (air rises, water sinks). Greater volume capacity than bag reservoir. Can use electronic level alarms. Easy to quantify volume. Integral cardiotomy reservoir. Can use vacuum assist to augment venous drainage. What are the disadvantages of an open venous reservoir (hard shell reservoir)? - Answer Increased risk of pumping massive air into the patient. Increased air and defoamer contact with the blood--less biocompatible as a result. What are some characteristics that should be considered when choosing a blood pump? - Answer Control of pump flow/ability to maintain high pump flow, Ability to change tubing size/calibrate the pump as needed, Durability/reliability, Cost effectiveness, Manual operation/battery backup, Ease of replacement, Ease of use, Inclusion of safety measures, Reduced hemolysis, Ease of sterilization What is a roller pump and how does it work? - Answer Rollers mounted on the ends of rotating arms compress tubing against the "raceway" on a metal backing plate; with compression of the tubing, blood is pushed ahead of the moving roller in order to produce continuous flow. Typically, two rollers are used per roller pump. Roller pumps generate a set volume against backpressure and can be traumatic to formed blood elements. Occlusion (set to fully occlusive for cardioplegia and suction pumps but barely non-occlusive for all other pumps) must be managed via fluid drop, pressure, or dry occlusion methods. What is a centrifugal pump and how does it work? - Answer An impeller with either vanes or a nest of smooth plastic cones is set inside a plastic housing and couples magnetically with an electric motor. As the impeller spins along with the magnet, pressure differential is created causing blood flow. Forward flow is generated from kinetic energy--centrifugal pumps are sensitive to afterload, and tubing will not separate with increases in line pressures. Centrifugal pumps have limited pressure buildup; the pump adjusts to pressure and ceases flow. What are the parts of a roller pump? - Answer Rollers, Backplate (interior aspect of which is referred to as the "raceway") Tubing guides Tubing inserts or "shims" to anchor tubing in place Speed control Display of RPM or LPM - newer pumps have both Occlusion set knob Lift cover - stops pump upon opening Servoregulation cable and battery cable for assistance of safety devices Hour meter to keep track of pump's wear and tear Fan filter of debris from environment Hand crank in case of power failure What are the parts of the centrifugal pump? - Answer Impeller Vanes/plastic cones on impeller Plastic housing Bearing column, shaft Magnet Backplate Preload and afterload ports What are the advantages of the roller pump? - Answer Reusable pump with inexpensive disposable parts Ease of sterilization Simple flow rate determination (stroke volume * RPM) Variable stroke volume for different size patients Capable of pulsatile flow (keeps peripheral vascular resistance low) With time, roller pumps have been made a lot safer and are still used often.