A Graduatte Level Immersive-Simulattion Program for Teaching and Assessing Fundamental Skills in Entry Level Clinical Perfusionists.

Background: The clinical perfusionist is a member of the open-heart-surgery team and responsible for operating the life support equipment that replaces the function of the patient\u27s heart and lungs and arrests and restarts the patient\u27s heart in the course of a Cardiopulmonary Bypass (CPB) procedure. In the perfusionists scope of practice, the consequence of unskilled actions, inaccurate understanding or delayed decision making may result in significant patient morbidity or even death. Historically, perfusion students have learned and practiced their skills within a clinical preceptorship program in which an experienced clinician allows the novice student to operate the life support equipment under their direct supervision and consultation. While there is clinical evidence from numerous surgical specialties which establishes that learning curve associated errors have a negative effect on patient outcomes, this has not been researched for clinical perfusionists. Despite this evidence gap, the professions leaders have been instrumental in driving educational innovation and the development of medical simulation models that may reduce the patient\u27s exposure to learning curve associated morbidity by developing competence with high-risk clinical skills prior to patient contact. The purpose of this research is to develop, validate and apply novel medical simulation techniques and technologies to the preparation of entry level clinical perfusionists and demonstrate pre-clinical competence with the fundamental perfusion skills.Methods and Results: To inform the development of a skills curriculum we conducted two national surveys using online survey tools. Through these surveys we validated a list of fundamental skills, and the deconstructed sub-elements involved in the conduct of these skills. Additionally, we identified the typical ranges of physiologic and technical parameters that clinicians maintain during clinical procedures. With this foundational benchmark data we validated the performance of a simulated patient to establish that the patient surrogate generates data that is substantially similar to the physiologic and technical data that a perfusionist would manage during a live clinical procedure. This validated simulation technology was then incorporated into a high-fidelity simulation suite and applied to an innovative immersive curriculum which included hands on repetitive practice, live and video supported self, peer and expert observation and feedback as well as a battery of high-stakes assessments. The validity and fidelity of the simulated experience was established through analysis of over 800 opinions generated over 10 years by novice and expert perfusionists after performing simulated cases. Finally, the efficacy of the simulation curriculum was assessed by comparing our simulation trained students to a national pool of their peers from other schools and expert clinicians. Through this process we generated the first measurements of the typical learning curve for the fundamental skills of CPB, the first estimates of error rates for students navigating the learning curve and the first benchmark measures of competent performance in a simulated environment. This data establishes that students learning in traditional clinical training programs conduct three-fold more errors than experts and will have approximately 99 high-risk patient encounters prior to developing competence with fundamental skills. By comparison, simulation trained students demonstrated competence with fundamental skills that was similar to the experts with almost no high-risk patient encounters. Discussion: The implications to patient safety are clearly implied. These studies establish that there is a high level of agreement among clinicians regarding the skills that are necessary to operate perfusion equipment and that realistic simulation environments can be designed and applied to the development of student\u27s fundamental perfusion skills without exposing patients to the threat of students learning curve associated errors. This data may catalyze a larger national dialog regarding Entrustable Professional Activities for perfusionists and influence national accreditation standards for educational programs

Human PXR Forms a Tryptophan Zipper-Mediated Homodimer †

The human nuclear receptor pregnane X receptor (PXR) responds to a wide variety of potentially harmful chemicals and coordinates the expression of genes central to xenobiotic and endobiotic metabolism. Structural studies reveal that the PXR ligand binding domain (LBD) uses a novel sequence insert to form a homodimer unique to the nuclear receptor superfamily. Terminal β-strands from each monomeric LBD interact in an ideal antiparallel fashion to bury potentially exposed surface β-strands, generating a ten-stranded intermolecular β-sheet. Conserved tryptophan and tyrosine residues lock across the dimer interface and provide the first tryptophan-zipper (Trp-Zip) interaction observed in a native protein. We show using analytical ultracentrifugation that the PXR LBD forms a homodimer in solution. We further find that removal of the interlocking aromatic residues eliminates dimer formation but does not affect PXR's ability to interact with DNA, RXRα, or ligands. Disruption of the homodimer significantly reduces receptor activity in transient transfection experiments, however, and effectively eliminates the receptor's recruitment of the transcriptional coactivator SRC-1 both in vitro and in vivo. Taken together, these results suggest that the unique Trp-Zip-mediated PXR homodimer plays a role in the function of this nuclear xenobiotic receptor

Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork: A Scientific Study from the American Heart Association

The cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade. Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. Refined techniques, advanced technologies, and enhanced coordination of care have led to significant improvements in cardiac surgery outcomes

Tables for Estimating Dilutional Hematocrits and Blood Flow Rates from Total Blood Volume and Body Surface Area Formulae

This paper provides a historical look at the development of formulae for predicting body surface area and total blood volume. A variety of experimental methods used for the development of body surface area and total blood volume formulae are briefly reviewed. The varying results of different formulae and nomograms are considered in relation to their impact on calculations typically used for the cardiopulmonary bypass patient. Charts are provided which will aid the clinician in the determination of body surface area, relative perfusion output, total blood volume, and resultant hematocrit

Preserving ECMO Cannulae Patency

Extracorporeal membrane oxygenation (ECMO) is often managed using minimal anticoagulation. This can make the circuitry susceptible to thrombosis. The ECMO cannula may be particularly vulnerable to thrombosis if flow is interrupted for an undetermined but prolonged period of time. Therefore, under conditions where cannula blood flow stasis may be prolonged and flashing, the cannulae is not an option (e.g., air in circuit) it is imperative to have an emergency plan available, which can be rapidly implemented that will provide a means of cannula patency preservation. The following outlines a system to preserve cannula patency in these instances

Vacuum-Assisted Venous Drainage: A 2014 Safety Survey

Despite the widespread use of vacuum-assisted venous drainage (VAVD) and case reports describing catastrophic incidents related to VAVD, there is a lack of data cataloging specific safety measures that individuals and institutions have incorporated into their VAVD practices for the prevention of these incidents. Therefore, the purpose of this study is to survey the perfusion community to gather data on VAVD practices, and to compare these current practices with literature recommendations and the American Society of ExtraCorporeal Technology (AmSECT) Standards and Guidelines. In September 2014, a survey was distributed via PerfList and PerfMail, and by direct e-mail to members of the New York State Society of Perfusionists, targeting certified clinical perfusionists in New York State. Survey topics pertaining to VAVD practice included 1) equipment, 2) pressure monitoring and alarms, 3) protocols, checklists, and documentation, and 4) VAVD-related incidents. Of ∼200 certified clinical perfusionists who live and/or work in New York State (NYS), 88 responded (42%). Most respondents (90.1%) report they use VAVD. Of these, 87.3% report that they monitor VAVD pressure, with 51.6% having audible and visual alarms for both positive and excessive negative pressures. At the institutional level, 61.2% of respondents reported that there is a protocol in place at for their team limiting negative pressure in the reservoir, 28.4% document VAVD pressure in the pump record, and AmSECT’s three recommended VAVD checklist items are met with 53.7%, 55.1%, and 33.8% compliance. In conclusion, the results of this study reveal that the use of VAVD has increased and has become nearly universal in 2014. There is high compliance to some of the literature recommendations and AmSECT Standards and Guidelines, however, there are still some gaps between current practices and these recommendations. Continued improvement, both at the individual and institutional levels, will help to improve patient safety by preventing untoward events from occurring while using VAVD

A 2013 Survey on Pressure Monitoring in Adult Cardiopulmonary Bypass Circuits: Modes and Applications

Pressure data acquired from multiple sites of extracorporeal circuits can be an important parameter to monitor for the safe conduct of cardiopulmonary bypass (CPB). Although previous surveys demonstrate that CPB circuit pressure monitoring is widely used, there are very little data cataloging specific applications of this practice. Therefore, the purpose of this study is to survey the perfusion community to catalog 1) primary CPB circuit site pressure monitoring locations; 2) type of manometers used; 3) pressure monitoring interface and servoregulation with pump console; and 4) the rationale and documentation associated with pressure monitoring during CPB. In June 2013, a validated 27-question online survey was sent directly through an e-mail link to the chief perfusionists in the northeast United States. Completed surveys were received from 75 of 117 surveys deployed yielding a 64% response rate. Arterial line pressure monitoring during CPB is reported by 99% with six distinct circuit site locations identified. Cardioplegia system pressure was monitored by 95% of the centers. For vacuum-assisted venous drainage (VAVD) users, the venous pressure was measured by 72% of the responding centers. Arterial line pressure servoregulation of the arterial pump was indicated by 61% of respondents and 75% of centers record arterial line pressure in their perfusion record. Most centers (77%) report the use of a transducer that is integrated into the pump console providing a digital pressure display, whereas 20% combine an aneroid gauge manometer with the integrated digital transducer. This study demonstrates that the practice of arterial line pressure monitoring during CPB is nearly universal. However, the selection of the pressure monitoring site on the circuit, modes of monitoring pressure, and their applications are highly variable across the perfusion community