RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATEADDRESS / Ms. DAWN HELEN SEBASTIAN
GAYATHRI COLLEGE OF NURSING.KOTTIGEPALYA BANGALORE.
2 / NAME OF THE INSTITUTION / GAYATHRI COLLEGE OF NURSING.KOTTIGEPALYA BANGALORE.
3 / COURSE OF THE STUDY AND
SUBJECT / FIRST YEAR M.Sc NURSING
MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO COURSE / 09-06-2011
5. TITLE OF TOPIC
“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME (STP) REGARDING PERFUSION TECHNOLOGY AS A SUPPORTIVE MODALITY IN TERMS OF KNOWLEDGE AMONG STAFF NURSES OF A SELECTED PRIVATE HOSPITAL AT BANGALORE.’’
6.BRIEF RESUME OF AN INTENDED WORK
INTRODUCTION
In physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."
Perfusion technology majors learn how to run machinery that assists or replaces a patient’s own respiratory or circulatory system during an operation or other medical procedure. Topics of study include equipment operation, patient monitoring, and the physiology of respiration and circulation. They go on to work under the supervision of doctors and nurses.
Cardiovascular Perfusion Technology involves the study of physiology, pathology and associated equipment used to support and/or assume the function of the heart and/or lungs during medical procedures. The perfusion technologist prepares and operates the heart-lung machine and other sophisticated equipment as directed by healthcare physicians. The perfusionist measures various blood and other parameters to identify appropriate mechanical, pharmacological and thermal manipulation to maintain tissue viability. To perform these tasks the perfusionist must have a thorough understanding of the both respiratory and circulatory systems and be able to operate complex equipment. Additionally the perfusionist must be capable of handling stressful situations, pay great attention to detail, communicate effectively, and be willing to stay abreast of new developments in the profession.
While most perfusionists are employed by medical centers they may also be hired by individual surgeons, or perfusion company's. Clinical perfusion often requires on-call responsibilities at night, on weekends and holidays. Perfusionists also work in educational institutions as teachers and/or researchers. Further, some perfusionists are hired by industry that manufacture various perfusion related supplies and equipment.
Perfusion Technology has developed an ultrasound system that uses a headset with ultrasound transducers directed at the penumbra, the region surrounding the tumor, in order to penetrate the blood brain barrier (BBB) and allow the delivery of drugs to the healthy brain tissue. The system is designed to address the challenges of treating malignant brain tumors, which are difficult to reach because of the cancerous cells that have migrated away from the bulk tumor and can neither be removed surgically nor accessed by most therapeutics. The low intensity, unfocused ultrasound penetration is noninvasive and reversible, allowing for the procedure to be conducted in an outpatient setting for regular drug infusion treatments.
Ailments that use perfusion technology include coronary heart disease, heart attack, heart failure, heart valve disease, respiratory failure, kidney failure and heart, lung or kidney transplants. Perfusionists insert sterile tubes called cannulas into the patient's bloodstream. These cannulas are attached to the perfusion machine, which regulates the circulation of blood during surgery. The perfusion machine acts as an artificial organ--heart, lungs, liver or kidney--and controls the rate of circulation. Perfusion technology can be used to stop blood flow to a limb when drugs must be injected directly into the bloodstream.
6.1 NEED FOR THE STUDY
Perfusion technology is not a major supportive technique which is using in all the
medical intervention .Instead it is a fastly moving and growing economy in the hospital scenario.
The next phase of cardiopulmonary bypass enhanced the skills of the perfusionist
and enabled cardiac surgery to grow by leaps and bounds .Because of complexity of artificial
circulation and the importance of the science perfusion technology , we have gained respect in
the surgical arena ,but at the same time our risk is regarded as insidious ,owing to its effect on
inflammatory response .
The aberrations of normal physiology associated with cardiopulmonary bypass
often bring criticism to its use ; however , the fact that some patients have no ill effects from the
procedure complicates this perception . After years of clinical investigation and publication ,
cardiopulmonary bypass has been deemed necessary in a controlled environment involving
perfusionists , surgeons ,and anesthesiologists .
Though knowledge in cardiovascular perfusion technology enables the proffessionels to provide the detailed foundation and analytical skills that are necessary to understand the
interplay between the science of extracorporeal technology and the related anatomic and
physiologic principles necessary to consider during the initiation, maintenance, and termination
of both temporary extracorporeal circulatory support, as well as long-term circulatory support.
They will understand the basic diagnostic principles involved in determining the nature and
extent of the disease process necessitating surgical intervention. Primarily, the cardiac, renal, and
pulmonary systems are covered in this course. Students will examine the relationship between
blood flow within and outside of the body, and the cardiovascular devices utilized to facilitate
extracorporeal circulatory support.
These findings impaired the researcher to take topic for the study so as to provided
these information.
6.2 REVIEW OF LITERATURE
The review of literature is a board, comprehensive in depth, systematic and critical review of the scholarly publications, unpublished scholarly print materials, audio-visual material and personal communication
A Review of Literature involves a systematic identification, location, scrutinization and summary of written materials that contains information on a research problem.
According to Pilot and Beck, Review of literature is a written summary of the existing knowledge on a research problem.
The review of available literature was organized under the following headings
· Studies related to perfusion technology.
· Studies related to effectiveness of perfusion technology.
· Studies related knowledge of staff nurses regarding perfusion technology.
1. STUDIES RELATED TO PERFUSION TECHNOLOGY
Ogella D A (1999) conducted a study regarding Advances in perfusion technology . The introduction of minimally invasive approaches to cardiac surgery offered the opportunity to reduce patient's pain associated with median stemotomy as well as infection and postoperative bleeding. This technique required the use of one small venous cannula necessitating the implementation of kinetic assisted venous drainage (KAVD). However, KAVD proved costly due to the use of a centrifugal pump and could be de-primed if air was introduced into the venous line. Vacuum assisted venous drainage (VAVD), an easy to learn technique, was proved to be a better, safe and less expensive alternative as it required lower prime and small cannulae. Blunt trauma could also be avoided as large cannulae were not us 1
Robert O Bonow (2008) was done a study on High speed myocardial perfusion imaging . The purpose of this study was to compare myocardial perfusion imaging (MPI) with high-speed single-photon emission computed tomography (SPECT) with conventional SPECT imaging for the evaluation of myocardial perfusion in patients with known or suspected coronary artery disease. A total of 44 patients (39 men) underwent same-day Tc-99m sestamibi stress/rest MPI. High-speed SPECT images were performed within 30 min after conventional SPECT. Stress and rest acquisition times were 16 and 12 min for conventional imaging and 4 and 2 min for high-speed SPECT, respectively. Myocardial counts/min (cpm) were calculated for both conventional SPECT and high-speed SPECT. Images were visually analyzed, and the summed stress score (SSS) and summed rest score (SRS) were calculated. Image quality and diagnostic confidence were qualitatively assessed.High-speed SPECT provides fast MPI with high image quality and up to 8 times increased system sensitivity. The amount of perfusion abnormality visualized by high-speed SPECT is highly correlated to conventional SPECT, with an equivalent level of diagnostic confidence.2
Candace L Palmer (2000) conducted a study regarding Perfusion-assisted direct coronary artery bypass. Hemodynamic instability during multivessel off-pump coronary artery bypass grafting can lead to hypotension, progressive myocardial ischemia, further hypotension, and the need for urgent cardiopulmonary bypass. Myocardial perfusion was successfully enhanced via one or two grafts in all 10 patients with an average graft flow of 98 ± 8 mL/min. In 3 patients, a 27% increase in perfusion pressure led to a 59% increase in perfusate flow. All patients were hemodynamically stable after initiation of selective graft perfusion. Based on this preliminary patient series, the selective perfusion of grafted vessels seems to facilitate multivessel off-pump coronary artery bypass grafting by promoting rapid recovery of grafted segments, by enhanced hemodynamic stability during subsequent anastomoses, and by providing increased flexibility in the sequence of grafting.
Michel A (2002) conducted a study regarding successful extracorporeal procine liver perfusion extracorporeal porcine liver perfusions were performed, each with a duration of 72 hr. Hepatectomy was performed, followed by cold preservation, cannulation of vessels, and initiation of perfusion with normothermic, oxygenated porcine blood. Organ viability was assessed by metabolic, synthetic, hemodynamic, and histologic parameters. After 72 hr of normothermic, extracorporeal perfusion, the isolated livers demonstrated maintenance of normal physiological levels of pH and electrolytes. Continued hepatic protein synthesis (complement and factor V) was maintained throughout the perfusion. Hemodynamic parameters remained within normal physiological range. Histology demonstrated good preservation of the liver with no overall architectural change.4
2. STUDIES RELATED TO EFFECTIVENESS OF PERFUSION TECHNOLOGY
Christian Algermissen (2008) conducted a pilot study regarding Visualization of Brain Perfusion With Harmonic Gray Scale and Power Doppler Technology. It is unclear which harmonic imaging mode (power Doppler or gray-scale imaging) is superior and which measuring method is the most robust for the description of brain perfusion. With harmonic gray-scale imaging, a homogeneous increase in echo contrast of the brain parenchyma was observed. The effect was dose dependent, resulting in a significant increase in PI as well as an insignificant increase of the AUC with 0.3 mL versus 0.15 mL contrast agent (P=0.03 and P=0.65, respectively; n=5). With harmonic power Doppler, injection of the 3 different doses resulted in a nonsignificant increase in PI and AUC P=0.17, n=6 for both). After normalization of the brain signal to the peak arterial signal in individual dogs, a significant increase could be demonstrated (P=0.03 and P=0.01, respectively; n=6). The signal pattern of harmonic power Doppler was inhomogeneous, with stronger signal increases in the anterior part of the brain. 5
Dirk.j.Grunhagen ( 2005 ) studied utility of TNF--based isolated limb perfusion to avoid amputation of irresectable tumors of the extremities. Isolated limb perfusion (ILP) with melphalan is effective in the treatment of small multiple melanoma intransit metastases and is utilized widely for this indication. The treatment is much less effective against bulky melanoma metastases and has uniformly failed in the treatment of irresectable extremity soft tissue sarcomas. The addition of tumor-necrosis factor- (TNF-) to this treatment approach has changed the situation dramatically. High response rates and limb-salvage rates have been reported in multicenter trials that combined ILP with TNF- plus melphalan; these trials resulted in the approval of TNF- for bulky melanoma metastases and soft tissue sarcomas in Europe in 19986
Harrigan, Mark R. (2005) was done a study on Computed Tomographic Perfusion in the Management of Aneurysmal Subarachnoid Hemorrhage. A total of 17 CT perfusion studies were performed. Five studies showed evidence of cerebral ischemia, leading to endovascular treatment of vasospasm. Eight studies excluded cerebral ischemia, and two studies identified cerebral hyperemia, resulting in adjustments in hyperdynamic therapy. CT perfusion was used to help predict a poor prognosis and withhold aggressive intervention in two patients with poor Hunt and Hess grades. Time-to-peak values identified regions of cerebral ischemia more readily than CBF or cerebral blood volume values.7
Claudio Marcassa (2005) conducted a study on Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy. Myocardial perfusion scintigraphy (MPS) provides a highly cost-effective tool for the early detection of obstructive CAD in symptomatic individuals and contributes substantially to stratification of patients according to their risk of cardiac death or nonfatal myocardial infarction. MPS also provides valuable information that assists clinical decision-making with regard to medical treatment and intervention. A large body of evidence supports the current applications of MPS, which has become integral to several guidelines for clinical practice. 8
Wight J and Chilcott J (2003) conducted a study on the clinical and cost-effectiveness of pulsatile machine perfusion versus cold storage of kidneys for transplantation retrieved from heart-beating and non-heart-beating donors. The baseline analysis indicated that in the long-term MP would be expected to be cheaper and more effective than CS for both HBD and NHBD recipients. A definitive study of the clinical benefit of MP in order to establish its effect on DGF and longer term graft survival would be valuable, together with an economic evaluation of the benefits. While direct evidence relating to improvements in graft survival would be preferable, the small predicted improvement indicates that a very large sample size would be required. In addition to seeking direct evidence of the impact on DGF, research quantifying the impact of DGF on graft survival in this technology is required.9
3. STUDIES RELATED TO THE KNOWLEDGE OF STAFF NURSES REGARDING PERFUSION TECHNOLOGY
David A.Palanzo CCP(1997) conducted a study regarding Perfusion safety: Past, present, and future. Safe cardiopulmonary bypass has been paramount from its first use in the early 1950s until the present. The original perfusion circuits incorporated complex feedback loops and multiple safety devices. As circuits improved and became simpler to operate, advances in safety did not always keep pace. Surveys have illustrated areas that needed improvement and extra attention has been focused on those problems. As the field of perfusion evolved, so has the perfusionist. Perfusion has progressed from on-the-job training to formalized training, certification, and accreditation, and is now approaching national standardization. As the computer age proceeds, the use of safety devices and feedback mechanisms whose developments have been aided by the newly available technologies increases. As the 21st century approaches, cardiopulmonary bypass will continue to become safer, but the perfusionist must continue to stay up-to-date in education and remain vigilant while in the operating room.10