Bloodless Cardiac Surgery: 'What is a Perfusionist, What is His Role in Bloodless Medicine?'
Bloodless Surgery is much more than just a cooperative surgeon. William Gil, a perfusionist at Allegheny General Hospital explains the role of the Perfusion Department.
What is a perfusionist and what is his training?
A perfusionist is a health care-professional who specializes in the operation of the heart-lung machine in open-heart surgery procedures. Along with this primary responsibility, we are also involved with the artificial heart program and any number of blood conservation procedures. Perfusionists come from varied backgrounds, but in general, we have at least a B.S. degree in science. Our academic training is followed by two years of clinical and further academic training in the art of perfusion.
In what types of surgical procedures might a perfusionist be involved?
The use of the heart-lung machine is necessary for a large percentage of open-heart surgery cases. As specialists in the heart-lung machine, this is the major part of our profession. In addition to this main function, we are involved with insertion and operation of ventricular assist devices (artificial hearts). Our role as blood conservationists allows us to participate in a large variety of cases where maintenance of the patient’s blood count is critical. The major devices used in blood conservation tody are the cell savers. We can use the cell saver in a large variety of cases, including open-heaert surgery, orthopaedic surgery and trauma.
What is a cell saver? How is it used?
Simply put, the cell saver is a device that collects blood that would otherwise be discarded. The red blood cells that are in the collected blood are separated from the plasma, washed and returned to the patient (blood collection) back to the patient (blood infusion). The circuit is easily built before the operative procedure has begun and is maintained until the end of the case. A good comparison would be the continuous circuit of the heart-lung machine and the hemodialysis machine.
Describe the changes you have been a part of that decrease transfusion requirements in open-heart surgery.
Hemodilution is the term used to describe the decrease in the patient’s concentration of red blood cells due to the infusion of clear solutions, i.e. saline. Surprisingly, hemodilution is a key contributor to the need for transfusions in open-heart surgery.
Until about nine years ago, the major source of hemodilution in open-heart surgery was the heart-lung machine. The heart-lung machine must be primed with 1.5 to 2 liters of clear solutions. These solutions would routinely be infused into the patient when they were placed on the heart-lung machine for open-heart surgery. Interestingly, it was while I was involved with a series of Jehovah’s Witnesses patients that I started experimenting with ways to eliminate the priming solution of the heart-lung machine. Eliminating the priming solution would minimize hemodilution and thus maintain the red blood cell concentration at a higher level. Initially, the results were encouraging, so I continued to perfect my technique. As time went on, it became very apparent that my techniques to minimize hemodilution made a significant difference. Using the techniques I developed, we were able to decrease hemodilution by 50 to 60 percent. These techniques worked so well that we now employ them on all open-heart surgery patients at Allegheny General Hospital.
The Jehovah’s Witnesses community provided the impetus to develop techniques to diminish hemodilution and transfusions. These techniques have benefitted the entire community of open-heart surgery patients. The role I played in developing these techniques and having them used universally was a very rewarding experience.
What is a CardioPAT?
The CardioPat is a specialized cell saver. (PAT stands for Perioperative Autotransfusion) As with the normal cell saver, the CardioPAT collects blood that would ordinarily be lost and returns the red blood cells back to the patient. It is used after open-heart surgery in the same way that the cell saver is used during open-heart surgery. The CardioPAT is designed to be applicable to small volumes of blood loss over long periods of time (24 hours). There is always a certain amount of bleeding that occurs in the post-operative period. The CardioPAT is intended to be used during this period. Like the cell saver, the CardioPAT can be set up in a continuous circuit to be used for Jehovah’s Witness patients.
What is your observation of the attitude at Allegheny General Hospital toward treating patients who refuse transfusions?
This is an interesting question. As you may have gathered from my response to your question about my involvement in decreasing transfusion requirements, Allegheny General Hospital is committed to doing everything we can to provide bloodless surgery for all patients. This commitment involves the integration of the open-heart surgery team: perfusion, anesthesia and surgery. Dr. Kim, the director of anesthesia, Dr. Magovern, the director of cardiovascular surgery, and staff from the Perfusion Department have worked together for many years and rely on each other’s expertise to ensure the best outcome possible for each patient.
When presented with a patient that refuses transfusions, very little changes in our everyday technique. Some may find this disconcerting, but, in reality, it should be comforting. Day in and day out, every open-heart patient is treated like a patient who refuses transfusions. When we are caring for a patient who refuses transfusions, we do not have to vary our technique. Thus we can proceed with the case in a comfortable setting, ensuring the utmost quality for our patient.
