RN first assistants expand their perioperative role.

At the Cleveland Clinic Foundation, the RN first assistant (RNFA) role has expanded to include radial artery (RA) harvesting for coronary artery bypass surgery. This new role encompasses preoperatively assessing the RA with the Allen's test and perfusion index; intraoperatively removing the RA, dissecting the RA as a pedicle, and maintaining hemostasis and wound closure; and postoperatively collaborating with the postoperative muse clinician during patient care and management in the intensive care unit. This article outlines the RNFA's expanded role in this detailed surgical procedure.

Venovenous extracorporeal life support for patients after cardiotomy.

Pulmonary edema and acute lung injury are common sequelae after cardiopulmonary bypass. Increased ventilatory support improves gas exchange, but may compromise ventricular function. From July 1994 to February 1997, nine patients were supported with veno-venous (V-V) extracorporeal life support (ECLS) for post cardiotomy respiratory failure. The mean age was 53 +/- 13 years (range: 37-80 years), and eight (89%) were men. Pre-operatively, five of nine (56%) were intubated, three (33%) were supported with an intra-aortic balloon pump, and five (56%) were on veno-arterial ECLS. Four patients were post left ventricular assist device (LVAD) implantation, one each after resection of an aortic aneurysm, mitral valve replacement and bypass grafting, aortic valve replacement, and pulmonary embolectomy and heart transplantation. Mean duration of support was 2 +/- 1 days (range: 1-4 days). Patients were intubated for a mean of 2 +/- 22 days (range: 4-71 days). One patient (11%) required mediastinal re-exploration secondary to bleeding, two patients underwent hemodialysis or ultrafiltration, and seven (77%) developed bacterial pneumonia. All patients were weaned from ECLS. Six patients (67%) survived to hospital discharge. Cause of death was multiple organ failure in two patients; one died from respiratory failure. V-V ECLS is a useful alternative to open sternotomy for ventilatory induced hemodynamic compromise post cardiotomy, especially in patients with LVADs.

Extracorporeal life support as a post left ventricular assist device implant supplement.

Extracorporeal life support (ECLS) is indicated following left ventricular assist device (LVAD) implant for right heart failure or pulmonary dysfunction. From December 1991 to December 1996, 100 patients were supported with the implantable HeartMate LVAD. Of these, 12 patients were supported with ECLS post LVAD implant. Pre-operatively, 10 patients (83%) were on an intra-aortic balloon pump, 9 patients (75%) were intubated, and 8 patients (67%) required ECLS bridge to LVAD implant. Six patients (50%) were men, and patient age ranged from 28 to 63 years (mean 46 +/- 10 years). Duration of ECLS averaged 3 +/- 2 days (range, 1-9 days). Eight patients (67%) required a right ventricular assist device (RVAD) with an ECLS circuit, three patients (25%) required peripheral veno-venous ECLS, and one patient peripheral veno-arterial ECLS. Forty-five percent supported with ECLS post LVAD survived to transplant compared with the 81% supported with LVAD only. Early in this experience, three patients had RVAD support only and all three patients died. RVAD support (with or without ECLS) was 11% overall and declined from 14% in the first 50 patients to 8% in the second 50. ECLS post LVAD is relatively uncommon and its use is associated with reduced survival, but helps salvage these critically ill patients.

Cardiopulmonary bypass (CPB) for lung transplantation.

Surgeons have often been reluctant to use cardiopulmonary bypass (CPB) during single (SLTx) and double lung (DLTx) transplantation surgery because of the potential adverse sequelae of CPB including haemorrhage and activation of complement leading to sequestration of neutrophils and platelets in the pulmonary capillary bed, endothelial damage, increased capillary permeability and pulmonary oedema. To clarify the effect of CPB on lung transplant recipients, we reviewed our last four years' experience in 74 patients of whom 30 required CPB support. Indications for CPB were mean pulmonary artery pressure of greater than 50 mmHg, haemodynamic instability, hypoxia or hypercarbia. Patients undergoing SLTx were placed on CPB via the femoral artery and vein, while those undergoing DLTx were cannulated in the standard fashion using the ascending aorta and right atrium. All patients were administered aprotinin prior to CPB. Intraoperatively and postoperatively, haemorrhage was not a major problem. The 30-day mortality in the CPB group and the non-CPB group were 20% and 4.6%, respectively which was not statistically significant (p = 0.06). We conclude that CPB during lung transplantation is a safe, effective method to support these severely ill patients and should not be avoided because of concerns over adverse sequelae of CPB on postoperative graft function.

The RN first assistant's role during inferior epigastric artery harvesting.

At the Cleveland Clinic Foundation, RN first assistants (RNFAs) have replaced inexperienced interns and rotating general surgery residents as surgical first assistants. Their new role includes harvesting inferior epigastric arteries (IEAs) for coronary artery bypass procedures. The RNFAs remove the IEAs through paramedian incisions that extend from below the umbilicus to the groin, dissect the IEAs as pedicles, and complete wound closure. This is one example of the expanded role of RNFAs during complex surgical procedures.

The role of the registered nurse-first assistant in the implantable left ventricular assist device program.

Successful support of patients using the implantable left ventricular assist device requires sustained and coordinated efforts by physicians and medical personnel. The authors describe the role of their registered nurse-first assistant (RNFA) as it has evolved through caring for 43 implantable pneumatic left ventricular assist device patients and 8 vented-electric left ventricular assist system patients during a 3 year period. Intraoperatively, the RNFA is responsible for pump assembly, including pre sealing all grafts and connecting areas of the pump using a combination of cryoprecipitate and thrombin. The RNFA assists with pump insertion during surgery. At device explantation, the RNFA dismantles the pump according to the FDA protocol for disassembly. Post operatively, the RNFA assesses and maintains patient hemodynamic stability and intervenes to manage hemodynamic and mechanical problems. Of the 51 patients, 13 are still on support, 9 died before transplantation (17.6%), and post transplant survival is 96.0%. In conclusion, an active left ventricular assist device program requires skilled personnel to manage complex problems and contributes to a successful patient outcome.