Cardiac Surgery Simulation - Part II: Cannulation.

Our group has previously described how dedicated practice outside the operating room can improve surgical technique and enhance intraoperative performance. We have also recently developed a "do-it-yourself" simulator to practice a variety of operative scenarios in cardiac surgery. This video tutorial demonstrates our Cannulation Module, which is designed to hone skills in aortic, right atrial, left ventricular vent, and bicaval cannulation for cardiopulmonary bypass.

Multimodal Cardiopulmonary Bypass Skills Assessment Within a High-Fidelity Simulation Environment.

BACKGROUND: A high-fidelity simulator that uses a perfused porcine heart, cannulae, and tubing has been demonstrated to be a useful training adjunct. We hypothesized that multimodal assessment of cardiopulmonary bypass (CPB) skills within this high-fidelity simulated environment could discern expert from trainee performance. METHODS: Three traditional fellows (postgraduate year 6-8) and 3 attending surgeons each performed 3 aortic cannulations. The third sequence included venous cannulation, commencement of CPB, and placement of a cardioplegia catheter and aortic cross-clamp. Performance across 20 cognitive and 21 technical domains was evaluated. Surgeon and assistant hand movements and economy of motion were assessed by electromagnetic motion sensors worn under sterile gloves. RESULTS: Analysis showed a significant difference in cognitive (6.7 ± 2.3 vs 4.6 ± 2.7, P = .03) but not technical (6.2 ± 2.5 vs 5.8 ± 2.2, P = .7) scores favoring the experts. In addition, experts showed higher efficiency by spending 64 ± 14 seconds to construct a nonpledgeted aortic purse-string suture and secure it with a Rummel, while trainees spent 82 ± 30 seconds to complete this task (P = .03). Motion analysis revealed similar path lengths between experts and trainees for cannulation and CPB but significantly shorter path lengths for experts in cross-clamp (47.5 ± 15.5 m vs 91.9 ± 20.3 m, P = .04). CONCLUSIONS: Multimodal assessment using cognitive, technical, and motion analysis of basic CPB tasks using a high-fidelity simulation environment is a valid system to measure performance and discriminate experts from trainees. This construct may allow for development of "competence thresholds" with important implications for training and certification in cardiothoracic surgery.

Current status of perfusionists in Brazil: a 2018 survey.

Perfusionists have a fundamental role in multi-professional teams involved in cardiopulmonary bypass procedures. The main objective of this study is to outline the profile of Brazilian perfusionists in the labor market by considering the evolution, current scenario, and future perspectives of this profession. Data from socio-demographic and professional profiles in active duty in Brazil were obtained through an electronic survey. The sample consisted of 157 perfusionists and showed that most of the professionals are female (58%), have up to 35 years of age (47.8%), and are married or are in a stable union (60%). Nurses make up 44.6% of the sample, followed by biomedical scientists at 31%. The salary range is related to the hours worked: the more hours worked, the higher the salaries (p = 0.007). Complementary training shows a period of transition and improvement in this specialty: 94% have a higher education level, 97% of whom are graduates in one of the six courses that recognize the role of professional perfusionists. There was no association between the time of professional performance and complementary training (p = 0.252). The professional profile of perfusionists is in clear evolution in terms of qualification since knowledge from the past, current scenario, and future projections trace new actions and professional insertion into different areas.

Low-fidelity simulator for technical connection to the cardiopulmonary bypass.

The technical simulator proposed in this study is a low-cost, reusable, reproducible and portable tool to guide trainees at all levels in order to improve their surgical skills in connection with the cardiopulmonary bypass (CPB) circuit. The simulator is a self-made portable box that can be used for an unrestricted number of procedures. It is supplied with self-made anatomical replicas that have been tested to simulate the flexible property of the real anatomy. The building process is detailed in this study.

Influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery.

OBJECTIVE: We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures. METHODS: Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival. RESULTS: Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability (R(2) value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R(2) following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio [HR], 0.85; P < .0001), mitral valve repair (HR, 0.73; P < .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09). CONCLUSIONS: In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.

Emergent Cardiopulmonary Bypass during Cardiac Surgery.

During orientation to the cardiac surgery operating room, new staff may not be exposed to emergent situations. Allowing team members the opportunity to practice their roles during less common, high-stakes emergency cardiac surgical scenarios may better prepare them when crises do arise in the OR. The Emergency Cardiopulmonary Bypass Course was developed to meet the needs of new staff starting in cardiac surgery. Recently, the course has expanded to include experienced staff. This communication describes a high fidelity simulation based course that includes four emergent cardiac surgery scenarios.

Assessment of team training in management of adverse acute events occurring during cardiopulmonary bypass procedure: a pilot study based on an animal simulation model (Fouilloux, Team training in cardiac surgery).

BACKGROUND: Successful cardiac surgery is highly dependent upon effective and efficient teamwork. Practical training and development will further enhance the team ability to react to a series of low-frequency occurring adverse events during cardiopulmonary bypass (CPB). One of our specialized educational programs focuses on training the whole team. This training is based on an original animal simulation model. The objective of this pilot study was to assess our method of training and learning in an attempt to optimize and improve team management and functioning. METHODS: Four members of the same cardiac surgery team joined our program. They performed a common procedure, with a cardiopulmonary bypass (CPB) circuit set up to produce several adverse incidents. Events management was analyzed and debriefed in technical and non-technical perspectives. RESULTS: Management of the adverse events was significantly improved. Discussion and debriefing time was fundamental in identifying the most appropriate management for each event. Rescue procedures were assimilated and team training was found to be effective, with the time reduced by up to 50% for 3 events and by up to 70% for air embolism. CONCLUSION: Our pilot program is an innovative, low-cost tool for the improvement of the management of adverse events occurring during CPB. It includes the different components of surgical education and training. Such an educational tool might be relevant for training. To confirm those encouraging results, it should be assessed in a larger surgical team panel. Further investigations are required for assessing efficiency in real conditions.

Cumulative team experience matters more than individual surgeon experience in cardiac surgery.

OBJECTIVES: Individual surgeon experience and the cumulative experience of the surgical team have both been implicated as factors that influence surgical efficiency. We sought to quantitatively evaluate the effects of both individual surgeon experience and the cumulative experience of attending surgeon-cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures. METHODS: Using a prospectively collected retrospective database, we analyzed all medical records of patients undergoing isolated CABG procedure at our institution. We used multivariate generalized estimating equation regression models to adjust for patient mix and subsequently evaluated the effect of both attending cardiac surgeon experience (since fellowship graduation) and the number of previous collaborations between attending cardiac surgeons and cardiothoracic fellow pairs on cardiopulmonary bypass and crossclamp times. RESULTS: From 2001 to 2010, 4068 consecutive patients underwent isolated CABG procedure at our institution performed by 11 attending cardiac surgeons and 73 cardiothoracic fellows. Mean attending experience after fellowship graduation was 10.9 ± 8.0 years and mean number of cases between unique pairs of attending cardiac surgeons and cardiothoracic fellows was 10.0 ± 10.0 cases. After patient risk adjustment, both attending surgical experience since fellowship graduation and the number of previous collaborations between attending surgeons and cardiothoracic fellows were significantly associated with a reduction in cardiopulmonary bypass and crossclamp times (P < .001). The influence of attending-fellow pair experience far exceeded the influence of surgical experience with beta estimates for attending-fellow pair experience nearly three times that of attending surgeon experience. CONCLUSIONS: Cumulative experience of attending cardiac surgeons and cardiothoracic fellows has a dramatic effect on both cardiopulmonary bypass and crossclamp times, whereas attending cardiac surgeon learning curves following fellowship graduation are clinically insignificant. Taken together, these findings suggest that the primary driver of operative efficiency in CABG procedure is the collaborative experience of the attending surgeon-cardiothoracic fellow operative team, rather than the individual experience of the attending surgeon.

Perfusion practices and education of perfusionists for open heart surgery in Turkey--current practices and future suggestions.

Our objective is to compare our current findings with the findings of our former study in 2004 and to make new suggestions for the development of cardiovascular perfusion in Turkey according to the results of the survey in 2011.

A systematic evaluation of the core communication skills expected of a perfusionist.

BACKGROUND: The objective of this systematic evaluation was to identify the sentinel standards necessary to obtain a core level of communication required of a clinical perfusionist during cardiopulmonary bypass (CPB). Once these sentinel standards were identified and a core level of communication was established (via four simulated case scenarios), a team of cardiac healthcare professionals was assembled to interpret both the accuracy of response and the speed of response encountered in each case scenario. METHODS: Four simulated case scenarios were utilized in order to replicate the typical patterns of verbal exchange that occur during surgeries using extracorporeal technology. The simulated case scenarios included CPB interactions associated with preparation, initiation, maintenance, termination and post CPB. For all CPB interactions, two variables were measured: accuracy of the perfusionist's response and speed of the perfusionist's response. The cases took place in a controlled setting within an empty operating room at The Children's Hospital of Philadelphia. Four clinical perfusionists each represented the role of the "perfusionist" in all simulated case scenarios. RESULTS: When analyzing the accuracy and speed of the responses, each clinical perfusionist recorded an average score of 96.3% or higher with all case scenarios. Since the clinical perfusionists who participated in the scenarios were primarily pediatric perfusionists, the scores were best during the pediatric case scenario, 99.3% (Case Scenario #4). The lowest scores were captured during Case Scenario #3 (96.3%) which involved a more intense adult patient scenario. CONCLUSION: The systematic evaluation of both response accuracy and response time (presented in various adult and pediatric patient case scenarios) can be beneficial within the realm of perfusion education. Students will be introduced to core communication concepts within the clinical realm. This study supports the idea that simulation and evaluation may ease the transition for students from the didactic to clinical realm in terms of communication. Further studies need to be developed in order to define "standard" CPB communication guidelines for perfusion students.

Cardiopulmonary bypass simulation at the Boot Camp.

OBJECTIVE: At Boot Camp, we evaluated a modular approach to skills mastery related to cardiopulmonary bypass and crisis scenarios. METHODS: With 32 first-year cardiothoracic surgery residents divided into 4 groups, 4 consecutive hours were devoted to cardiopulmonary bypass skills by using a perfused nonbeating heart model, computer-controlled CPB simulator, and perfused beating heart simulator. Based on the cardiopulmonary bypass simulator, each resident was assessed by using a checklist rating score on cardiopulmonary bypass management and 1 crisis scenario. An overall cardiopulmonary bypass score was determined. Economy of time and thought was assessed (1 = unnecessary/disorganized to 5 = maximum economy). At the end of the session, residents completed a written examination. Residents rated the sessions on cannulation skills, cardiopulmonary bypass knowledge, and cardiopulmonary bypass emergency and crisis scenarios on a 5-point scale (5 = very helpful to 1 = not helpful). RESULTS: Thirty residents completed cardiopulmonary bypass simulator exercises. For initiation and termination of cardiopulmonary bypass, most residents performed the tasks and sequence correctly. Some elements were not performed correctly. For instance, 3 residents did not verify the activated clotting time before cardiopulmonary bypass initiation. Four residents demonstrated inadequate communication with the perfusionist, including lack of assertiveness and unclear commands. In crisis scenarios management of massive air embolism (n = 8) was challenging and resulted in the most errors; poor venous drainage and high arterial line pressure scenarios were managed with fewer errors. For the protamine reaction scenario, all residents (n = 7) identified the problem, but in 3 cases heparin was not redosed before resuming cardiopulmonary bypass for right ventricular failure. The score for economy of time and thought was 3.83 ± 0.6 (range, 3-5). The score of the written examination was 90.0 ± 11.3 (range, 60-100), which did not correlate with the overall cardiopulmonary bypass score of 91.4 ± 7.1 (range, 80-100; r = 0.07). The session on acquiring aortic cannulation skills was rated 4.92, that for cardiopulmonary bypass knowledge was rated 4.96, and that for cardiopulmonary bypass crisis scenarios was rated 4.96. CONCLUSIONS: This Boot Camp session introduced residents early in their training to aortic cannulation, principles and management of cardiopulmonary bypass, and crisis management. Based on a modular approach, technical skills and knowledge of cardiopulmonary bypass can be acquired and assessed by using simulations, but further work with more comprehensive educational modules and practice will accelerate the path to mastery of these critical skills.

An inexpensive cardiac bypass cannulation simulator: facing challenges of modern training.

The importance of surgical simulation has grown in the quickly changing climate of modern surgical training. As the expectation of basic skills acquisition has shifted to forums outside the operating room, residency programs have struggled to provide realistic teaching simulations for their trainees. We have developed and tested a realistic and low-cost porcine cannulation model. This model provided a platform for both technical and cognitive skills acquisition at the first session of the cardiothoracic or "CT Surgery Boot Camp" during the summer of 2008.

[Survey on the training and organisation of cardiopulmonary bypass for cardiac surgery in France]. / Enquête française sur la prise en charge de la circulation extracorporelle et la formation des perfusionnistes en 2008.

INTRODUCTION: Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined. OBJECTIVES: The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997. TYPE OF STUDY: Professional practice assessment. METHODS: A questionnaire was sent to all perfusionists in activity in France. RESULTS: There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units. CONCLUSION: An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres.

The successful application of simulation-based training in thoracic surgery residency.

OBJECTIVE: We developed and tested a clinical simulation program in the principles and conduct of cardiopulmonary bypass with the aim of improving confidence and proficiency in this critical aspect of cardiac surgical care. METHODS: Fifteen residents from 6 resident-training programs who reported no prior cardiopulmonary bypass observation or simulation-based perfusion experience participated in a cardiopulmonary bypass course involving both didactic lectures and hands-on simulation. A computer-controlled hydraulic model of the human circulation was used in a specifically designed multidisciplinary simulation center environment to give the participants hands-on training with both basic operations and specific perfusion crisis scenarios. Pretraining and posttraining assessments concerning confidence, knowledge, and applications with regard to cardiopulmonary bypass were administered and compared. RESULTS: Likert scale scores on confidence-related items increased significantly (P < .001), from 59% +/- 16% to 92% +/- 8%. Pretraining versus posttraining scores (72% +/- 14%) on similar cognitive items were not significantly different (P=.3636). Scores on similar open-ended application items before and after training improved from 62% +/- 25% to 85+/-10% (P < .0001). All subjects agreed that simulation-based cardiopulmonary bypass training was superior to classroom- and clinic-based education and that the scenarios enhanced their learning experience. CONCLUSIONS: Simulation-based cardiopulmonary bypass training appears to be an effective technique to build the confidence of thoracic surgery residents regarding knowledge and applications. Scenario-based practice in a specifically designed simulated environment is a valuable adjunct to traditional educational methods and has the potential to improve the training of thoracic residents.

Distribution of certified perfusionists in core training institutions accredited by the Japanese Board of Cardiovascular Surgery in Japan.

In 2008, the 22nd qualifying examination for certified perfusionist was conducted on extracorporeal circulation techniques. A total of 647 people had passed the qualifying examination and become certified perfusionists by the end of 2008.