Trident Health Resources, Inc. sponsors and requires all of its employees to annually attend at least one regional or national perfusion-related conference. They are requested when they return to prepare and share their impressions of the meeting with their Trident colleagues.
Posted here is one of our manager's impressions of the Cardiothoracic Surgery Symposium held in San Diego this month. A thanks to Kris for a job well done.
When apropo we will post future summaries and we welcome reader comments and any reflections from those who attend these perfusion-related conferences.
Ralph E. Jordan
CEO & President
CREF 2008 Summary
by Kris Cleveland, CCP
by Kris Cleveland, CCP
The San Diego Cardiothoracic Surgery Symposium: Science and Techniques of Perfusion was held at the San Diego Marriott Hotel & Marina February 14-17, 2008. In their continuing goal to provide the very best educational experience, this years symposium topics were designed around suggestions made by the prior year’s attendees.
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The activity director Julie Swain MD along with the conference organizer Karen Morgan designed CREF 2008 to meet the specific educational needs of medical professionals involved with treating cardiac disease: anesthesiologists, biomedical technicians, cardiac surgeons, cardiologists, nurses, perfusionists, physician assistants, and technology researches and developers. They continue to provide timely talks on perfusion challenges and changes, but also added many others as well: cutting-edge cardiac care, blood and bleeding, and neurological and end-organ function.
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Past meeting attendees asked for more informal opportunities to learn about best perfusion practices in hospitals around the world. The CREF 2008 followed the American Academy of Cardiovascular Perfusionists (AACP) direction in offering Fireside Chat sessions on Friday afternoon and an International Panel of Perfusionists on Sunday morning. Fireside chats are moderated discussion groups giving participants a chance to discuss specific topics with course faculty and other attendees in an intimate, round-table setting. The International Panel discussed differences in perfusion practice and how & why each would respond to challenging cases.
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Last year’s overwhelming success with four different workshops was once again offered: Cerebral Monitoring, presented by Somanetics; Electronic Charting and Patient Management, presented by Terumo; Myocardial Protection, presented by Quest Medical; and Optimal Perfusion Circuit, presented by Sorin. The 45 minute workshops ran concurrently, and repeated after a 15 minute break, which allowed participants to attend two of the four workshops.
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Those who like to plan ahead should mark their calendars: the 29th Annual San Diego Cardiothoracic Surgery Symposium will be held February 12-15, 2009.
I should mention that daily parking charges for the San Diego Marriott are $20 per day. Right next door is the San Diego Convention Center which offers parking at $8 per day. This alternative is especially attractive for those of us wanting “more bang for their buck”. The daily room rate at the Marriott is $236 plus taxes; however there are many close-by alternative hotels that offer substantial savings. I stayed just down the road at the Sheraton and saved $200 for the three nights lodging.
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Thursday afternoon’s scientific agenda was entitled Perfusion: Challenges & Changes. Ian Sherer from Duke University Medical Center-Durham, NC provided insight into a potential role for the perfusionist in the application of isolated limb infusion, an evolving area of cancer therapy. Isolated limb perfusion with the administration of cytotoxic drugs has been successfully used to treat melanomas of the extremity since it was first introduced in 1958. The use of hypothermia combined with chemotherapy agents, primarily Melphalan, has resulted in greater cytoxicity in laboratory studies which lead to the application of hyperthermia in clinical studies during the 1960’s. The effectiveness of this regional technique and the absence of any good systemic therapy has made hyperthermic isolated limb perfusion (HILP) the main treatment for patients with regionally advanced melanoma. Regional limb therapies, while palliative, improve the quality of life for patients and reduce the need for disfiguring and debilitating amputations. I would like to talk to anyone having clinical experience using HILP as there is a good chance we will be utilizing this technique soon at our hospital. My e mail address is: kcleveland@landmarkmedical.org
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Robert Groom from the Maine Medical Center-Portland, Maine once again provided his insight into Controversies in Perfusion: What Should We Do About Them? He defined a controversy as a disagreement that is typically prolonged, public, and heated. It is not surprising that there have been controversies in our field with regard to practices. Bob stressed the importance of evaluating the available evidence. Gathering data is important, but unless we can provide an analysis of this data and share it with others to provide positive change we are collecting worthless data. He quoted Anton Checkhov as saying “Knowledge is of no value unless you put it into practice.” Bob noted that there is a wide variation in how perfusion is practiced across the perfusion community. He posed these questions: Should we be concerned about this variation? What should we do when we encounter controversies in care? He feels that patients expect that what is done to them in the operating room will be based on the best knowledge that is available at the time of their surgery.
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Every heart center is capable of improving the care that it provides. 17 of the more notable controversies are: centrifugal blood pumps vs. roller pumps, normothermic vs. hypothermic CPB, high vs. low hematocrit, transfusion triggers, open vs. closed reservoirs, pulsatile vs. continuous flow, antegrade vs. retrograde cerebral perfusion, hollow fiber vs. silicone rubber membrane oxygenators, beating heart surgery vs. use of cardioplegic arrest, alpha Stat vs. pH Stat, cold storage vs. machine perfusion of donor organs, low flow hypothermic CPB vs. DHCA, low dose heparin vs. full anticoagulation, measurement of heparin levels vs. activated clotting time monitoring, 4:1 blood cardioplegia vs. all blood cardioplegia, cerebral oxygen saturation monitoring vs. pulse oxymetry, and point of care coagulation monitoring vs. standard laboratory coagulation tests.
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Friday morning’s topic Cutting edge Cardiac Care I began with George Despotis MD Washington University School of Medicine-St. Louis, MO speaking on transfusion-Related risks. We can rest assured that although our blood bank supply is safer than ever from what it is tested, the inherent risk of transfusion is great. Improvements in blood screening and administration techniques has led to a reduction in serious adverse events related to transfusion. However the literature is describing new l transfusion-related problems in addition to new potential pathogens. The three current, leading causes of transfusions related mortality include: TRALI, bacterial contamination of platelets units leading to sepsis and transfusion errors resulting in catastrophic hemolytic reactions secondary to ABO incompatibility. He stressed the importance re-iterated with the literature that we must cut down on giving blood products at all costs. Inappropriate use of blood and blood products can potentially lead to or aggravate blood shortages which may limit our ability to adequately manage our anemic and bleeding patients.
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Cardio-Aortic disease: Open vs. Percutaneous Procedures was given by Lars Svensson MD Cleveland Clinic Foundation-Cleveland, OH. His interests are minimal invasive valve surgeries, percutaneous cardiovascular surgery, and brain & spinal cord protection during cardiovascular surgery. They have found that homografts were no better than biological valves and have switched to inserting biological valves in younger patients. He went on to present a series of 388 aortic valve repair procedures. For the aortic valve, most of their patients have on pump minimally invasive repairs. Their high risk and inoperable patients have been managed with a percutaneous transcatheter valve from the femoral artery or transapically into the aortic annulus. They utilize a primed pump stand by for all their off pump valve procedures, and he feels that a pump is still needed for many of the patients.
.Terumo unveiled a new heater-cooler-HX2 Temperature Management System that will give the new Sorin Stockert Heater Cooler System 3T a run for the money. The HX2 supplies temperature controlled water to arterial and cardioplegia heat exchangers. Each temperature channel has a touch pad that precisely adjusts the mix of water flow between cooling and heating sources. The outlet water flow is 25 L/min at zero head and allows for a temperature set point control range from 1-42 degrees C. The Terumo HX2 is a much new and improved version of the old style Sarns heater cooler that is my old-time favorite. Dual and independent control of temperature is a nice improvement and will be on many perfusionists capitol expense budget wish list for next year. The only disadvantage over the Sorin 3T is that the Terumo Unit must utilize ice to cool below room temperature. The Sorin unit provides for cooling without ice during routine operation due to the strong performance of the compressor assembly. Wouldn’t it be nice to have one device that can do the work of two big & bulky C-subzero units? Yes!!!
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In conclusion, it is evident we as perfusionists must do our part to reduce CPB prime volume and avoid blood products if at all possible. The risk of blood and blood product transfusion is greater than ever and the literature is full of examples to follow. Data collected must be analyzed and put into a readable report that should then be passed along to the entire cardiac team. Together we can all make a difference in raising the standard of care that we provide as perfusionists.
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Kris J Cleveland, CCP Chief Perfusionist .
Trident Health Resources, Inc.
