Saturday Morning Brunch X

Peer Review

Last Week of April, 2011

To see all the of the Saturday Morning Brunch series click here.

Typically,

Peer Review is associated with scientific publication and an established process for providing a baseline reference point by which to judge the legitimacy of research, the veracity of  a scientific point of view, and due diligence on the part of the author(s).

Most of the articles and posts submitted here have a demonstrated relevance to perfusion as a science.  The rest involve or relate to perfusion concepts, perfusion life, and a medium to promote discussion.

Trying to not be ultra scientific, yet relevant at the same time- that is a fine line with this group.  I get some hate mail sometimes that is over the top.  My position is to deliver articles and posts that reflect nuances and trends, rather than “set in stone principals” in regards to our profession.

What a lot of people don’t get is that a blog is a a train of thought that leads to options and otherwise diverse directions (certainly unanticipated but negotiable).

So today I was prompted by a surprising email that positioned me to make some things less opaque.

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I don’t even know this person or what his issue is- but it could have been stated in a lot of different ways.

The message to “Get off Perflist”  was short and sweet.

That was a shot off the left Bow I didn’t expect.  Like what really is the take home message on that?

1. Is he saying I don’t belong?
2. Am I not allowed to post on Perflist?  (I have been on there since it was started)
3. Am I less than equipped to be a perfusionist because I wrote an essay on what it’s like to be one?
4. Should I stop interacting? 
5. Is my opinion less validated because it’s posted on a blog?
6. Am I not being scientific enough?
7. Have I somehow invaded some sort of cyberspace I should not have ventured into?

There are a lot of questions of substance that could be raised regarding the venues of  information we have out there in front of  us.

Perflist

Perfmail

Perfusion.com

Perfline

CircuitSurfers

ALL have their pluses and minuses.

But NONE of them are forwarded by groups or individuals that don’t have a vision to improve and and offer substance to our community as a whole.

I sent back a 3 word reply that probably wasn’t appropriate- but I was so shocked with the abruptness of it all- that was my first instinct.  It was just so rude.

In just two and a half months of a lot of work, some people just get mad because they can.

I guess to explain myself-

This site does not represent itself as any sort of standard or mouth piece for perfusionists or the practice of perfusion.

It represents only what the contributors put on it.  Any article or submission can easily be evaluated in terms of it’s position in the hierarchy of relevance to our profession.  It’s designed as a tool- nothing more and nothing less.

Understanding that the majority of visitors that come here are related in some form or fashion to the profession, I assume the readership has the academic wherewithal and medical background to easily discern what information to accept and what there is to reject.  As perfusionists we rely on our instincts and experience as much or more so than the literature in front of us.  At least I hope so.

But this isn’t literature.  It is an Internet Blog.  It is as trustworthy as we make it.  Nobody uses “I read it on a Blog- or in a book” as an excuse for their personal decision making process during or after a pump run.  That’s what your Board Certification is for.

If you have a question about something- well you talk about it with your peers, the MDA, the Surgeon, or the Chief Perfusionist.  That’s what I would do.  That’s what we all do.

Is there a perfusion article out there written about how, when, and why to change out an oxygenator?  I am sure there are a lot of protocols- but advanced position papers?  I doubt it.   It’s unscientific and has too many variables.   As long as you did what it takes- I guarantee you it wasn’t written in a book or a step-by-step protocol- it was from you knowledge base, experience, and your gut instinct.  None of that is measurable in any peer reviewed article.  So way to go.  You saved a life- bring on the critics.

I don’t take anything seriously unless it’s vetted by the history of the site, or my own personal research.

Personally, I think it’s clear that I want this site to have a history, to be a trusted resource, and to be vetted as such.  I want people to come here and know that what’s online isn’t last minute garbage or second hand information.

So without going further- I thank you for visiting, and thought perhaps to render a synopsis of some of the results we have had so far in under 3 months.

Who We Reach:

95 Countries

200 cities (not counting US)

All 50 States in the US

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So What has been gained?

To start with, there are so many countries represented here, and it is so refreshing as well as surprising in terms of some of the exotic places where some of our colleagues have come from.

I just think it’s important to see that our community as a whole is ready for more- and this just happens to be one more option.

Not all of us have the luxuries of the equipment and resources that a perfect and modern operating room suite might have under the best of circumstances.

Resources to pertinent perfusion related information, in order to answer questions on the horizon- may not be available to a Google search on the spur of the moment.  But they may be available here, as a result of discourse.

Obviously the sites I mentioned above warrant much more respect– and honestly there is no comparison to a brief flash in the pan- to what  has been accomplished as a result of some long term serious effort over a decade and a half,  to  establish their credentials.  There is no way to set a value on what these established websites have delivered consistently to the community.

That’s not what this is about.  It’s just a different bubble- that’s all.

So this is for all of us.

Comments (a few of the 287)

J

Submitted on 2011/04/29

Frank,

I am a second year perfusion student and I’d just like to comment that this is an incredible site and a great way for students such as myself to get a sense of what the world of perfusion is like outside of our regular rotations.  I especially enjoyed the post that went up recently about the failing oxygenator.  In our catastrophic events management class we were taught what to look for when we must determine whether the oxygenator is failing.  It was great to see such a detailed account from someone working in the field, especially since the technique of piggy backing an oxygenator hadn’t occurred to me prior to reading this article (or using a hemoconcentrator for gas exchange as mentioned in the comments).  I also found it extremely interesting because it shows the cooperation and communication necessary between us, the surgeon, and the anesthesiologist, to work through this kind of situation and it also gives the reader the sense of how stressful this kind of situation is.  Further, I found it interesting getting a glimpse of how to deal with the panicky, fearful thoughts associated with having to deal with an oxygenator changeout and the process of staying level-headed in a stressful situation..   After reading that I regularly visit the site.  In closing, I wanted to let you know that I’m very fascinated with this blog and I’m excited to see more from it in the future.  I hope that someday I can also share a meaningful experience on this blog that others might learn from.

Thanks,
Harry

It seems I have been talking about Dr. Paul Friday a lot recently. I am going to start with him because he is known to a lot of perfusionists, at least the older ones.
Paul used to hypnotize himself before giving one of his lectures. He thought it helped his effectiveness, and he was a VERY effective speaker. One thing he often talked about was a hemophiliac patient who needed dental surgery. That is, the guy NEEDED surgery, but no one wanted to do it because of the terrible bleeding attendant to the operation. Solution? They hypnotized the man. And filmed the operation so we could see and believe. The patient was obviously awake and responsive during the surgery, and he had been told not to bleed. I’ve lost more blood shaving than he was losing during his dental surgery. There are, of course, loads of other material on hypnosis.
Secondly, and I am keeping this brief by assigning tasks, some web work, including MedLine, etc., will bring up a largish body of work on shaman (see e.g. Waite, Dennis), brain injured people (see e.g. Damasio; Sacks), and numerous individual case studies where mind power brought about predicted results. Remember, the key here is that we are not talking about predicting the winning lottery number, but about individuals who exercise control over their own fate by seemingly abnormal means.
As in everyday life, a premonition can simply be an unconscious recognition of something no one else has noticed. I submit these events are being scientifically investigated and we will eventually learn some more important, perhaps useful, lessons.

Thanks for listening, if you got this far,
Dan

Great job Gary, the more I read about this the more I want to learn. I practice somewhere in the middle with my po2s but think that there should be strategic hyperoxic strategy during these cases. We use delnido cardioplegia with extended ischemic periods. Our group believes in using higher po2 before the x clamp for exactly this reason. If you circa arrest why not deliver higher po2 for the entire body. Teach us more!

I think this is an interesting discussion – and appreciate the forum to allow such a conversation.
1. While this topic has the ability to stray away from science, correct me if I am wrong but I believe that there is evidence out of there of links between anxiety/stress and lower immune response/healing. Should a case be canceled because of this, no I don’t think so – however the patients feelings can be acknowledged and appreciated.
2. As for keeping this forum scientific and educational only…. we may utilize top notch evidence based practice on every case we pump – but how many of us have also tried to will our patients to pull through – when someone crashes and the heart won’t come back, and/or the pressure bottoms out? Or the babies that we still hope will come off ECMO despite miserable odds? And how many of us will never shake the image of the first patient we lost? Our job is not just about science and education – the human condition has an effect on us as clinicians as well. I support a forum that allows all types of conversation pertaining to the issues we may come across in our profession.

OK, this is getting to be a bit much. No offence but we should keep this site open to educational and scientific endeavors only. I don’t want to be insensitive to others beliefs, but this type of discussion could be done elsewhere. No, I do not think that this is science.

Submitted on 2011/04/21 at 7:31 pm

I was going through a particularly difficult time in perfusion life a couple of years ago. We had an episode of aggression in the OR, Also in that time period I experienced a co worker that was having a substance abuse problem. Meditation pretty much saved my life, arrythmias surfaced, tachycardia on a daily basis along with high blood pressure. The Natural Stress Relief meditation technique is TM. It is easy to learn, over the course of a few days. There is a teacher available via forum, or skype. I’m happy to say that my BP is normal, no more pvc’s, and HR is back to 60 b/m. Check it out if you like.

Great idea since I work alone. I have had to ask anesthesia for a little help prior to coming off CPB on a really large patient (300+lbs). Quick easy and no real air worries. Thanks for teaching this old dog a new trick.

Sent from my iPhone

I read through all the blogs and i enjoy listening to all of you fellows and i try learn from you.
I liked franks idea as i mentioned in my last blog about using the recirc.line although never thought of it before and i don’t see why not if it works, this is almost similar to partially opening the recirc.line to hyperoxygenate the blood as one of the alternatives when PO2 drops after exhausting all other means to raise the PO2.
As far as L to R shunting using this technique, i would diagree with Skeptical, because this is in vitro and not in vivo. L to R shunt inside the human body will cause and alter hemodynamics but this could be avoided in our circuit when you place your flow probe past the ALF and measures exactly the flow to the pat.
Changing out an oxgenator is an option (last option) when you are certain you are having a failed oxygenator and the pts heart is beating ( before X-clamp),then you can put the volume back in the pt and ask anesthesia to ventilate until you exchage the old oxygenator with a new one or you may parrellel it. othewise i would limb off if the heart is arrested and cool down.
my two cents and i might be wrong, once again thank you for sharing this case with us.

Reread the case synopsis, and I do realize that sometimes the time elements do get skewed when you are trying to trouble shoot things.

But IMHO, I would not have blinked with a pCO2′s of 60 with a ~ 0.6:1 GBFR and a saturation of 99.5% with less than 100% FiO2.

Much less making a decision to to splice in an oxygenator with blood gas data taken 4 mins after a barely getting to a 1:1 GBFR and 100% FiO2…

Sorry just my opinion

Great case report Frank. Thank you for sharing your experience. Never tried the tandem oxygenator like that but will keep it in mind as it sounds like a great option. I’ve had the same problems the others have listed above about the vaporizer clogging the system and as soon as we turned it off there was a visible difference in the blood even before we were able to test it.

It’s always much easier to think these things through when you’re sitting back plucking away at a keyboard! I think that’s a great idea cutting the tandem oxygenator in. There are two things though that I would consider.
First, I run RX15′s on about 95% of my cases and I admittedly push them to the limit. What I have found is this oxygenator does not perform well when you push it’s upper end (flow) with Hct > 30. I have found the optimum Hct is around 26-28. Having a minimal boundary layer is critical to maximizing the performance of this oxygenator. I have even diluted patients down to a Hct of 28 when I have experienced this. We get so focused on running high Hct’s I think we forget about capillary perfusion and oxygenator performence in the setting of high Hct’s.
Second: did you actively cool to 32 degrees? If so you may have had platelet aggregation lay down on the membrane. Warming a bit may have reversed the platelet aggregation and then just allow your temp to drift down to your desired target.
Thanks for sharing your case.

Kashmir A.

Wonderful job. It is an easy read piece. I especially like the referrals to Area 51 and of course, Scream3.

All together that was a very good “collective piece”. The photos are really good!

I know I have told you before, but I think it is worth repeating- I think this website is amazing. I think it is a wonderful thing that you are doing. I will always support what you do. but I feel wholeheartedly that this an extraordinary venture.

We use the CentriMag at our facility and like that it is small, portable, light weight and the availability of the flow alarms but our biggest concern is that we have had 2 console disable on us in the past 6 months so we don’t go anywhere without a back up.

A question I would like to ask the group is what cannula do you use with your LVAD and RVAD. We have been using the AbioMed, 10mm out flow cannula and 32 Fr. infllow cannula, nice cannula to use but we have been informed by AbioMed that we can no longer purchase just the cannula, you now have to purchase the pump with the cannula, so we are now in search of a vendor who can provide a 10mm graft/cannula.
Thank you

Thanks so much for sending along. Your site if very insightful and have added it to my favorites list to refer back to.

Frank,

I finally had a chance to really check it out. I’m very impressed. Thank you.

Hi Amanda,

First I want to say good luck with your job search. I know it can be scary and sometimes it takes awhile to get the responses you are looking for. It seems as though the Perfusion field has grown and there are more students graduating so it may seem like the competition is fierce, but hang in there and something will come your way!!

Secondly, I think your resume and the information in it is great but my only suggestion is maybe to find an alternative way to format the information and to make it more appealing to the eye. What I mean by appealing is, make it stand out above the rest!! Use your own creativity

I remember very early on in clinicals being quizzed prior to a case and was asked about patient allergies and I said “only to pineapples.”

The preceptor looked at me completely serious and said “so you didn’t prime pineapple juice correct?”

The Certainty of Uncertainty

The alarm clock goes off at 5am and I begin yet another morning of clinicals. Day after day I grow and learn with increasing admiration for my field. I am humbled and honored by what I see and get to do each day in the OR heart rooms. I feel cozy at home at my clinical sites but in the back of my mind there is this clock that ticks louder and louder as time goes by. I have less than three months until graduation and I have no idea where I will live or who I will work for. I have to be willing to go anywhere and once again start over with the hopes of building a future somewhere. I have learned to be at peace with the certainy of uncertainty.

Steve, this should be required reading for all perfusionists. Thank you! Thanks also to Frank for providing this website that allows in-depth presentations of this sort. As perfusionists, we cannot fail to keep up with the advances in our field and around us. We do about 500 hearts at my center and of those, we do about 5 with Angiomax. Our protocol is quite similar to those already published and so far our results are good. My question today is this. We are considering going 100% Carmeda; is there anyone with experience using carmeda circuits on HIT pts? It seems to me I read a blurb about this somewhere but I can’t relocate it. The jist of the article was that it appeared to be OK. Maybe I’m dreaming… However, we’re not changing our protocol until we know for sure. FYI, the CDI510H sensor is heparin-coated.
Thanks again for easy access to this site.

Submitted on 2011/03/14 at 10:37 am

Hi

You might want to add Newmarket -Ontario Canada under the Canadian flag.

Its great that you’ve started a blog related to perfusionist’s.

I’m not sure how but either we as a community or our professional organizations should do a better job at public relations.

Make us look good

Greetings from St. Croix, USVI!

Looking forward to watching this online community grow.

Sincerely,

Submitted on 2011/03/12 at 12:39 pm

Your blog is some intense medical info!!! Very specialized. I sure hope it will be a place for “you all” to expand your field! A place where you “oldies” can bring the new ones up to speed and what you have had to learn to get there.

I was very impressed with the blog and did some refresher thinking while there. I congratulate you on your goal of improving your profession! Do you have a Union?

Keep it quiet or they will be after you too! 🙂

I have missed you Teut, but knew you had bigger and better things to keep you occupied. Good luck with your undertaking.

Do stop by and say “hey”! You give me hope that because of your effort, if I ever need heart surgery, your blog will be available to those on that end of my body, are doing it right and have your info at their fingertips during the surgery!!!

Makes you want to ask everyone working on you if they are R or D to know which ones really care about your outcome!!!

hai every body, very happy to hear this type of event is very unique ,really personally i apreciat for this

I love seeing different ways to skin a cat!

I feel like an old-timer saying this but, “I’ve been doing it the same way for…” well, you know the rest. I have a very standard way of pumping cases and while I’ve considered RAP and low-prime circuits, they’ve never fit well with my program or had the impact I expected.

I am now cross-training at another hospital and seeing them RAP, start with a dry venous line, and giving no prime drugs until on pump, has been very enlightening for me; but I still see them giving blood products. Is it a fluke for the few cases I’ve seen? What could be the reason for this?

Something I think people overlook when considering blood utilization is thier blood gas analyzer. What method are you using to determine hematocrit and/or hemoglobin? That alone can greatly impact how you treat your patients with blood pruducts.

So far, my solution to reducing my blood utilizaion is to get new blood gas analyzers in the OR. After two years of fighting the good fight, I am FINALLY seeing my dream come to fruition! The GEM will be gone soon and the RapidPoint will be here – HURRAH!

I’ll let you know how that works out!

Hi frank,

I visited your chat on Saturday and I enjoyed it. I didn’t really have anything to say, but I enjoyed the interaction. This is a new concept for the perfusion group as a whole and I think it will work well. Nice job.

It could entertain a broader audience than other electronic forums. It’s more social than PDC (a lot more). It is Perfusion focused but not exclusively perfusion. It’s laid back and relaxed yet very professional – a refreshing change!

I’ve got to say…you’ve really got something here. This is a breath of fresh air. The site is so smooth and well planned, and you sir are a great writer. I can’t wait to see how this continues to develop and evolve.