Perfusionist
A perfusionist, also known as a clinical perfusionist or a cardiovascular perfusionist, is a specialized healthcare professional who uses the heart-lung machine during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.
The perfusionist is a highly trained member of the cardiothoracic surgical team which consists of cardiac surgeons, anesthesiologists and Certified Registered Nurse Anesthetists, physician assistants, surgical technologists, and nurses. The perfusionist is solely responsible for the management of the physiological and metabolic needs of the cardiac surgical patient so that the cardiac surgeon may operate on a still, unbeating heart. This is accomplished through the utilization of the heart-lung machine, as well as its associated components of an oxygenator, filters, reservoirs and tubing. The perfusionist is responsible for the management of circulatory and respiratory functions of the patient which has a great effect on the patient systemic condition and allows the cardiac surgeon to focus on the actual surgical procedure and less on the immediate needs of the patient. Other responsibilities include autologous blood collection and processing, implementation and management of the intra-aortic balloon pump, adult and infant extracorporeal membrane oxygenation (ECMO) as well as monitoring of anticoagulation, electrolyte, acid-base balance and blood-gas composition. In many tertiary hospitals, perfusionists are also key personnel in placing and managing patients on ventricular assist devices as bridge to recovery or heart transplantation and supporting patients receiving lung or liver transplants. In some hospitals, perfusionists can be involved in procurement of cardiothoracic donor organs for transplantation.
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Training and certification of perfusionists
In the United States, a bachelor's degree with concentrations in biology, chemistry, anatomy and physiology is the prerequisite to be admitted to a perfusion program. As of 2005, there are 18 perfusion training programs in the United States, most offering a master's degree in perfusion sciences or circulatory sciences. Training typically consists of two years of academic and clinical education. Although the structure and training philosophies of perfusion programs differ, typically a perfusion student will begin his or her training in a didactic fashion in which the student will closely follow instructions from a certified clinical perfusionist in the confines of a cardiac surgery procedure. Academic coursework may be concurrent or precede this clinical instruction and is equally vital for their training. Early in their clinical training, the perfusion student may have little involvement outside of an observational role. However, as time progresses, more tasks may be incrementally delegated to them with the ultimate goal of producing a capable and competent perfusionist. Once a student graduates from a perfusion program, he or she must begin the certification process. In the interim, the perfusion graduate is typically referred to as board-eligible, which is sufficient for employment in cardiac surgery with the understanding that achieving certified status is required for long-term employment. Most employers have stipulations on the duration of board-eligible status.
A two-part exam is required to become certified and use the designation C.C.P. In the United States, this exam is administered and evaluated by the American Board of Cardiovascular Perfusion. Similar governing bodies exist in other countries with comparable examination processes. The first portion of the two-part process is the Perfusion Basic Science Exam, and the latter portion is the Clinical Applications in Perfusion Exam. In order to qualify for this examination process, a perfusion student must have either graduated from or be enrolled in an accredited perfusion program, as well as have participated in a minimum of 75 clinical procedures during the course of their training.[1] A perfusion student may qualify for the Perfusion Basic Science Exam before they actually matriculate from their respective training program. Once employment is provided, and the perfusionist has participated independently in a minimum of 50 clinical procedures, he or she can qualify for the Clinical Applications in Perfusion Exam.[1] Once the Clinical Applications in Perfusion Exam has been successfully passed, a perfusionist can use the designation C.C.P. In addition, there are recertification requirements for perfusionists in which proof of a minimum number of clinical procedures and attendance to scientific or educational meetings must be provided to a certifying body (i.e. American Board of Cardiovascular Perfusion). These recertification requirements and subsequent verification process occur every three years and are mandatory to maintain certified status to use the designation certified clinical perfusionist.
As of February 2010, there were 3,766 certified perfusionists in the United States.[2]
In Canada, there are three training programs: Burnaby in Western Canada, and Toronto and Montreal in Eastern Canada. British Columbia Institute of Technology in Burnaby offers an advanced specialty certificate in cardiovascular perfusion to graduates of its two-year program. Applicants must be certified respiratory therapists, critical care nurses, or cardiac professionals with two years or more of current experience in cardiac critical care. Applicants to the Michener Institute program in Toronto must have a bachelor's degree. The training program is 16 months to two years. The perfusion program of the Université de Montréal is a three-year bachelor's degree of 90 credits in biomedical science of which 27 credits are specific to clinical perfusion and in addition a diplôme d’études supérieurs spécialisées (DESS) of 30 credits in clinical perfusion of one-year at the master level.
In the United Kingdom and Ireland, a bachelor's degree in life sciences is a pre-requisite to enrolment on the perfusion training course. Employment as a trainee perfusionist is also required. Trainees must complete a two-year academic and practical course. They complete academic assessments (essays and exams), while in the workplace moving from a purely observational role to one in which they are capable of managing the patient while they are on cardiopulmonary system with minimal supervision. Once a trainee has been the primary perfusionist in 150 clinical procedures, they must undertake a practical exam. For this exam, the candidate is observed by two external examiners whilst building and priming a cardiopulmonary circuit, then using it during a surgical operation. After the practical exam, trainees must complete a 40-minute viva voce exam, which tests their academic knowledge. After this is successfully completed, they are awarded a postgraduate diploma and the status of qualified clinical perfusion scientist. They must maintain this by performing a minimum of 40 clinical procedures per year.
In China, Egypt, and some South American countries a clinical perfusionist is a medical doctor who has completed subspecialty training.[citation needed]
In Argentina, a perfusionist is a medical doctor, usually a cardiologist, who has undertaken additional sub-specialty training. They are often referred to as "hemodinamistas" (i. e. hemodynamics specialists).
In India a 3 and half year bachelor's degree program is available, which includes 6 months internship.
Clinical procedures
Perfusionists can be involved in a number of cardiac surgical procedures, select vascular procedures and a few other surgical procedures in an ancillary role. In the realm of cardiac surgery, perfusionists perform cardiopulmonary bypass in adult and pediatric surgical procedures, which constitute the majority of procedures that perfusionists perform. Perfusionists may participate in curative or staged palliative procedures to treat the following pediatric pathologies:
- atrial septal defects,
- ventricular septal defects,
- tetralogy/pentalogy of Fallot,
- truncus arteriosus,
- transposition of the great vessels,
- cardiac transplants,
- lung transplants,
- coarctation of the aorta,
- interrupted aortic arch,
- hypoplastic left/right heart,
- subaortic membrane,
- mitral valve repair/replacement,
- aortic valve disorders,
- anomalous/single coronary artery,
- vascular ring,
- extracorporeal membrane oxygenation (ECMO)
Adult surgical procedures may include:
- coronary artery bypass,
- aortic valve replacements,
- mitral valve repair/mitral valve replacement
- tricuspid valve repair
- aortic root replacements
- atrial myxomas
- dissections/aneurysms/trauma of the aorta (ascending, arch & descending)
- renal cell carcinoma/obstructive vena cava
- veno-venous bypass (e.g. during liver transplants)
- cardiac/lung transplants
- implants of ventricular assist device and ECMO.
Select ancillary procedures in which perfusion techniques and/or perfusionists may be involved include isolated limb perfusion, intraperitoneal hyperthermic chemoperfusion and tracheal resection/repair.
