AIIMS CRE Perfusionist - Complete Syllabus

Exam Overview

SUBJECT 1: Applied Anatomy & Physiology

Cardiovascular System

• Gross anatomy and structural features of the heart (chambers, valves, conduction system)
• Great vessels - structure and organization of blood vessels
• Coronary artery anatomy and circulation
• Cardiac cycle, cardiac output, cardiac index
• Blood pressure regulation, hemodynamics
• Wigger's diagram, action potentials, EKGs

Respiratory System

• Organization of the respiratory system
• Gross structure of trachea, bronchial tree, lungs
• Pulmonary circulation - pulmonary arteries, veins, bronchial arteries
• Mechanics of breathing, respiratory physiology
• Acid-base balance, blood gas interpretation

Nervous System

• Brain - gross features, functional areas, cerebral blood circulation
• Spinal cord anatomy
• Autonomic nervous system (ANS) - relevant to perfusion

Renal System

• Renal anatomy and physiology
• Fluid and electrolyte balance
• Acid-base regulation by the kidneys

Hematology & Coagulation

• Blood composition, blood groups (ABO, Rh)
• Coagulation cascade (intrinsic, extrinsic, common pathways)
• ACT (Activated Clotting Time), heparin mechanism of action
• Platelet function, fibrinolysis

SUBJECT 2: Basic Biochemistry & Pharmacology

Biochemistry

• Carbohydrate, lipid, and protein metabolism
• Glucose management during CPB (target 120-180 mg/dL)
• Organ chemistry relevant to cardiac surgery

Pharmacology for Perfusionists

• Heparin and protamine - dosage, reversal, complications
• Cardioplegic drugs and solutions (St. Thomas, del Nido, etc.)
• Vasopressors and vasodilators (noradrenaline, nitroglycerin, SNP)
• Inotropes (dopamine, dobutamine, milrinone, adrenaline)
• Antiarrhythmics (amiodarone, lidocaine, magnesium)
• Diuretics during CPB
• Anesthetic agents relevant to CPB
• Hemostatic agents and antifibrinolytics (tranexamic acid, aprotinin)
• Drug pharmacokinetics altered by hemodilution and hypothermia

SUBJECT 3: Physics for Perfusionists

• Fluid mechanics - pressure, flow, resistance
• Gas laws (Boyle's, Henry's, Dalton's)
• Heat transfer principles (relevance to heat exchangers)
• Electricity and biomedical instrumentation basics
• Roller pump mechanics and occlusion settings
• Centrifugal pump mechanics
• Pressure-flow relationships in CPB circuits

SUBJECT 4: Applied Pathology & Hematology

Cardiovascular Pathology

• Atherosclerosis and ischemic heart disease
• Valvular heart disease (mitral, aortic, tricuspid)
• Cardiac hypertrophy and hypertensive heart disease
• Cor pulmonale and pulmonary hypertension
• Myocarditis, cardiomyopathies
• Pericardial disease
• Congenital heart defects (ASD, VSD, TOF, TGA, PDA, Fallot's)

Hematology

• Anaemia types and management during CPB
• Coagulopathies: DIC, primary fibrinolysis, platelet disorders
• Thrombocytopenia, cold agglutinin disease
• Heparin-induced thrombocytopenia (HIT)
• Vitamin K-dependent factor deficiencies
• Blood transfusion: indications, grouping, crossmatch, Rh factor
• Blood component therapy (PRBC, FFP, platelets, cryoprecipitate)
• Cell salvage and autologous transfusion techniques

SUBJECT 5: Clinical Diagnostics & Monitoring

Diagnostic Modalities

• Chest X-ray interpretation
• ECG interpretation (arrhythmias, ischemia, blocks)
• Arterial blood gas (ABG) analysis
• Angiography, 2D Echo, TEE (Trans-Esophageal Echocardiography)

Monitoring During CPB

• Hemodynamic monitoring (arterial line, CVP, PAP, PCWP)
• Hemostatic monitoring - ACT, TEG/ROTEM
• Oxygen and CO2 monitoring, acid-base status
• Temperature monitoring (nasopharyngeal, rectal, blood temp)
• Cerebral oximetry (NIRS)
• Aortic line pressure monitoring
• Venous oxygen saturation (SvO2)
• Glucose monitoring

Equipment & Instrumentation

• ECG machines, pressure transducers
• Syringe and peristaltic pumps
• Ventilators, pulse oximeters
• Defibrillators
• Intra-aortic balloon pump (IABP) - principles and management

SUBJECT 6: Principles of Perfusion Technology (Core CPB)

History & Role

• History of CPB - John Gibbon (first CPB, 1952)
• Role of the perfusionist in the cardiac surgical team
• Medicolegal considerations and record keeping in perfusion

CPB Circuit Components

• Pumps: Roller pumps (occlusion settings) vs. centrifugal pumps
• Oxygenators: Bubble oxygenators vs. membrane oxygenators (assessment and comparison)
• Heat exchangers - principles, function, complications
• Cardiotomy reservoir and venous reservoir
• Arterial filter and bubble trap
• Connecting tubes and connectors
• Vents and suckers
• Cardioplegia delivery system
• Venous drainage systems

Priming the Circuit

• Priming fluids and hemodilution (crystalloid, colloid, blood prime)
• Calculating prime volume
• De-airing the circuit

Cannulation

• Aortic cannulation techniques
• Venous cannulation (bicaval, single two-stage)
• Arterial/femoral cannulation for re-operations
• Cannula sizes and flow dynamics

Initiation & Conduct of CPB

• Pre-bypass checklist
• Initiation of bypass (surgical-anesthetist-perfusionist communication protocol)
• Flow rates: calculation of cardiac index (2.2-2.4 L/min/m²)
• Pump flow calculation: BSA, oxygen delivery
• Venous drainage management
• Arterial line pressure monitoring
• Confirming satisfactory bypass

Temperature Management

• Normothermic vs. hypothermic CPB
• Moderate hypothermia (28-32°C), deep hypothermia (18-20°C)
• Deep Hypothermic Circulatory Arrest (DHCA)
• Rewarming protocols

Myocardial Protection / Cardioplegia

• Principles and types of cardioplegia: crystalloid, blood, warm, cold
• Cardioplegic drugs - history and composition
• Antegrade vs. retrograde cardioplegia delivery
• Aortic cross-clamping
• Complications of cardioplegia
• Non-cardioplegic methods (beating heart, fibrillatory arrest)

Weaning from CPB

• Step-by-step reversal of bypass
• Restarting the heart and lungs
• Defibrillation (5-20 J biphasic) for ventricular fibrillation
• Protamine administration and heparin reversal
• Decannulation

Acid-Base Management

• Alpha-stat vs. pH-stat management during hypothermia
• CO2 management in adults vs. pediatric patients

SUBJECT 7: CTVS Surgical Techniques & Case Management

Adult Cardiac Surgery Procedures

• CABG (Coronary Artery Bypass Grafting) - on-pump and off-pump
• Valve replacement/repair (aortic, mitral, tricuspid)
• Aortic surgery (aneurysm repair, dissection)
• Combined procedures

Congenital Heart Defect Surgery (CPB in Pediatrics)

• ASD, VSD, TOF, TGA, TAPVC, PDA, coarctation of aorta
• Specific perfusion considerations for each defect
• Pediatric circuit selection, ECC components
• Pediatric priming, blood flow management
• Modified ultrafiltration (MUF)
• Acid-base management in neonates and infants

Non-Cardiac Procedures with CPB

• Liver transplantation (veno-venous bypass)
• Isolated limb perfusion (for sarcoma/melanoma)
• Lung transplantation support

SUBJECT 8: Advanced Perfusion Techniques

Mechanical Circulatory Support

• IABP (Intra-Aortic Balloon Pump) - indications, timing, weaning
• ECMO (Extra-Corporeal Membrane Oxygenation) - VA-ECMO, VV-ECMO, circuit management, indications, complications
• VAD (Ventricular Assist Devices) - LVAD, RVAD, BiVAD - principles and management
• Counterpulsation devices

Minimally Invasive Cardiac Surgery (MICS)

• Perfusion setup for minimally invasive procedures
• Port-access surgery
• Endo-aortic balloon occlusion

Special Clinical Situations

• Perfusion in pregnant patients
• Malignant hyperthermia during CPB
• Re-operations (redo sternotomy)
• Emergency perfusion scenarios

SUBJECT 9: Complications of CPB & Their Management

Air Embolism

• Prevention: arterial filter, bubble detector, de-airing
• Management: retrograde perfusion, Trendelenburg position
• Battle plan for massive air embolism

Systemic Inflammatory Response

• CPB-induced SIRS
• Complement activation, cytokine release
• Strategies to minimize (biocompatible circuits, MUF)

Coagulopathy

• Heparin resistance
• Protamine reactions
• Post-CPB coagulopathy management
• TEG/ROTEM-guided transfusion

Organ Dysfunction

• Renal dysfunction - prevention, ultrafiltration
• Neurological complications (stroke, cognitive dysfunction)
• Pulmonary complications
• Gastrointestinal complications

Equipment Failures

• Oxygenator failure - signs and changeout
• Pump failure - manual cranking, backup pump
• Power failure protocols
• Loose connections, tubing rupture

Other Complications

• Massive hemolysis
• Hypovolemia / low venous return
• High arterial line pressures (aortic dissection risk)
• Protamine reactions (anaphylaxis, pulmonary hypertension)

SUBJECT 10: Biomedical Waste Management

• Biomedical waste categories and segregation (color-coded bins)
• Handling of blood products, sharps, disposable circuit components
• Hospital transfusion committee protocols
• Infection control in the perfusion setting
• Sterilization of reusable components

Exam Pattern Summary

Key Topics to Prioritize (High-Yield)

1. CPB circuit components - oxygenators, pumps, heat exchangers
2. Cardioplegia types and delivery (antegrade/retrograde, warm/cold)
3. Heparin/protamine pharmacology, ACT monitoring
4. ABG interpretation and acid-base management (alpha-stat vs pH-stat)
5. ECMO and IABP - principles, indications, circuit management
6. Congenital heart defect anatomy and CPB considerations
7. Complications of CPB - air embolism, oxygenator failure, coagulopathy
8. Temperature management during CPB - hypothermia levels
9. Blood component therapy and cell salvage
10. Weaning from CPB - step-by-step protocol

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