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Book Review - Cardiopulmonary Bypass: A Primer

Friday, August 14, 2015

Cardiopulmonary Bypass: A Primer
University of Washington Division of Cardiothoracic Surgery
Nahush A. Mokadam, MD, Editor

Cardiopulmonary Bypass: A Primer was published by the cardiac surgery team at the University of Washington, using the iBook electronic format. It is available as a free download from the Apple iBook Store. The editor, Dr. Nahush Mokadam, has structured the publication in a very logical format, with chapters describing the circuit components, technical aspects of cardiopulmonary support, myocardial protection, nursing principles, anesthesia management, troubleshooting, and finally a brief summary of the history of cardiopulmonary bypass. The book’s text is supplemented by high quality images and videos.

There will be two aspects to this review: the content and the manner of presentation. The content is presented in an easy-to-understand sequence, starting with a description of the components of the heart-lung machine. Experienced surgeons will recognize these components, and this adds little to their general knowledge. However, for surgical assistants, nursing staff, anesthesia personnel, trainees, and others, the chapter is invaluable. It demystifies what seems to be an incomprehensible tangle of tubes, bags, and machines. The author discusses the use of each major component concisely, and the text is made more understandable by high quality graphics.

Following the description of the machinery, the next chapter discusses how all of this is put in motion. Various techniques of arterial and venous cannulation are described, including both central and peripheral sites. Logically, the subsequent discussion centers around arterial and venous decannulation techniques. Once again, the authors make use of high quality images and videos to demonstrate the procedures in a clear and easy manner.

Protection of the heart is next. The various means of myocardial protection are delineated, both the type of preservation agent and the manner of delivery, including blood and crystalloid cardioplegia, as well as antegrade root, retrograde, and direct coronary ostial delivery.

Surgeons are so frequently immersed in the conduct of the operation that it might be easy to forget about other aspects of caring for the patient in the operating room. Thankfully, the authors do not neglect the nursing care of the patient. This includes identification, positioning, and documentation of all of the activities before, during, and after the episode of cardiopulmonary bypass. Without expert management of the set-up of the operating room, the placement and replenishment of supplies, and the preparation of the patient, surgery would not be possible; or, at least, would be much less effective and safe.

As a surgeon, I found the chapter on anesthesia management very instructive. Although we are well aware of the techniques for establishing, maintaining, and discontinuing cardiopulmonary bypass, we surgeons are sometimes unaware of all the work that goes on across the “blood brain barrier.” I wonder how many of us recognize that unilateral facial blanching is a looked-for condition that might point to improper arterial inflow. The management of analgesia, neuroprotection, hemodynamics, and hemostasis are discussed.

The troubleshooting chapter is the jewel in the crown. It catapults the reader into the role of the surgeon and evokes all of those sinking feelings that experienced operators have felt at some time in their careers. The authors present case scenarios and discuss potential causes and solutions. It is a must read, and I hope that subsequent versions of the book expand on this important content.

Now, I’d like to discuss how this book takes advantage of this exciting, new platform for the sharing of knowledge. Electronic publishing formats are not new. We are all accustomed to viewing journals on a website, or reading individual articles in PDF format on our desktop. Some of us might even read books or scholarly publications on an eReader such as an Amazon Kindle. The iBook electronic publication format is unique in that it seamlessly includes high definition videos “in-line” with the text and static images. Watching the blood flow into and out of the cardiopulmonary bypass machine makes it “real” for the inexperienced reader. Cardiac surgeons take this for granted, but the novice gains much by actually watching it happen. If a picture is worth a thousand words, then a movie must be worth a million. The authors have obviously taken great pains to produce very instructive images and videos.

I enjoyed seeing the videos enhanced with overlays of graphic images. However, this is a very new publication platform, and I’d like to see the authors take advantage of even more sophisticated and engaging techniques in subsequent versions. For instance, in the very first video on circuit description, it would have been even more immersive had the user been able to tap on a “hot spot” of the circuit schematic and have the corresponding pump component be highlighted along with supplementary text. After all, this is a platform that is designed to be touched, tapped, pinched, and swiped.

The book does a very good job as a primer. We know that there was a lot of information and experience that went into producing such a book, and the authors and editor are to be congratulated. It would be nice to be able to take further advantage of their expertise. The iBook format, along with other ePub formats, allows the addition of hypertext either to internal or external assets. Wouldn’t it be a welcome addition to make some of the text “active” by letting the reader link to other sources via hyperlinks? Imagine tapping on John Gibbon’s name to go to Wikipedia or to view the wonderful Vanderbilt History of Cardiac Surgery video on “Recollections about John Gibbon.”

The use of this platform for conveying surgical information is truly neonatal, and as we gain experience with it enhancements will abound. I would encourage others in the academic world to follow suit with the University of Washington Cardiac Surgery Department. Those of us who take care of heart surgery patients, and those who are learning to do so, owe a debt of gratitude to Dr. Mokadam and his team for publishing this and making it available to the world for free.

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