The Journal of ExtraCorporeal Technology Issue 55-1 | Page 18

10 B . Lohbusch et al .: J Extra Corpor Technol 2023 , 55 , 3 – 22

Table 12 . CPB intraoperative checklist utilization .

Abbreviations : CPB = cardiopulmonary bypass ; VAD = ventricular assist device ; MCS = Mechanical circulatory support .

Table 13 . Percent of CPB practice supported by institutional protocols .

Abbreviations : CPB = cardiopulmonary bypass .

priming in at least half of all CPB procedures . Both interventions are class I recommendations [ 16 ]. Mitigating unwanted variation in clinical practice has been associated with a higher quality of care and lower hospital costs [ 20 , 21 ]. Specifically , several perfusion-related initiatives have highlighted the importance of evidence-based guidelines adherence , outcome reporting , and the reduction in practice variability [ 22 – 24 ].

Most respondents indicated that the large majority of CPB care plans are supported by institutional protocols . One of the primary responsibilities of a professional society is to develop standards and guidelines of practice to guide the community in safe and effective patient care . The AmSECT Standards and Guidelines , first formed in 1993 , aim to define the minimum requirements for safe cardiopulmonary bypass [ 25 ]. These guidelines serve as a framework for developing institutionspecific CPB protocols [ 7 ]. Clinical practice surveys can assist in reporting guideline dissemination and inform key stakeholders of opportunities to support their adoption . For example , Standard 12.1 recommends the discontinuation of CPB cardiotomy suction at the onset of protamine administration to avoid circuit thrombus formation [ 7 ]. However , most respondents reported continued suction use after protamine initiation , despite the inability to predict ACT responsiveness . Jansa et al . reported a 40 % decrease in the ACT value following a partial test dose of protamine , resulting in a value lower than the institutional standard for safe CPB support [ 26 ]. While the decision to continue suction use may not ultimately be at the perfusionist ’ s discretion , reducing these discrepancies in care may require further collaboration and endorsement between surgical and perfusion societies .

The survey results also identify several other areas of noncompliance with professional standards and guidelines . Among them are backup CPB battery availability ( 64 %), backup gas supply ( 81 %), medical gas scavenging of the oxygenator output port ( 83 %), and arterial line bubble detection ( 86 %). Each of these elements is recommended by both AmSECT and the EACTS / EACTA / EBCP guidelines as minimum standards for the safe conduct of CPB . These findings may highlight the importance of understanding the barriers that prevent their adoption . Such barriers may include a lack of awareness of the standards , economic constraints , or perceived benefit of their usage . Professional societies may offer opportunities in facilitating the implementation of these practices at the local level .

Practice surveys may also inform the community about techniques that lack guideline support or clear consensus . Substantial variation is observed across various aspects of cardioplegia use . A recent international survey of cardioplegia practices by Ali and colleagues reported significant variation in myocardial protection strategies [ 27 ]. Although blood substrates were the most frequently reported formulas , the dilution ratios and cardioprotective additives were highly variable . Similarly , our survey found both center-level and procedural differences in formulas . In particular , del Nido cardioplegia was the most frequently reported formula in both CABG and non-CABG procedures . The transition to del Nido solution in adults is a recent phenomenon , with the first reported case in 2014 [ 28 ]. This was preceded by nearly 25 years of experience in pediatric congenital surgery [ 29 ]. The pediatric perfusion survey , first conducted by Groom and colleagues in 1990 , has described both domestic and international pediatric perfusion for over 30 years [ 30 – 35 ]. The 2016 survey reported a 74 % use of del Nido in North America , a 2.3-fold increase from the 2011 survey results [ 34 , 35 ]. Similar opportunities for adult surveys performed serially over time would provide valuable insight into the diffusion of new and emerging techniques . Other reported practices lacking clear consensus in the survey included pulsatile perfusion ( 7 %), heparin concentration monitoring during CPB ( 20.7 %), and albumin as a circuit prime additive ( 47 %).

Practice surveys can help describe current and future requirements regarding workforce and staffing . The expansion of adult ECMO services , MCS device implants , and transplant procurement services may necessitate additional perfusion clinical support resources . Respondents reported an increase in clinical workload over the last three years , and most centers indicated the use of part-time and per diem perfusion coverage for relief . Trends in workforce demographics are essential for perfusion supervisors , hospital administrators , and perfusion education programs . Approximately 38 % of the certified clinical perfusionists that responded to the 2015 – 2016 American Board of Cardiovascular Perfusion ( ABCP ) Perfusion Profile Survey anticipated working 10 more years before retiring [ 36 ]. A 2019 survey of perfusion vacancy and turnover estimated rates of 12.3 % and 14.7 %, respectively [ 37 ]. Both rates exceeded those reported in nursing . Considering the timing of these findings and the unknown long-term consequences of the COVID- 19 pandemic , workforce survey data is paramount in supporting practitioners and optimizing the quality of care .

There are several limitations to our survey . There are recognized sources of bias in conducting survey research such as