[HSF] Massive hemorrhage in a chold

[Nasser F. Abou'Seada]

Autopsy Results ? .... have you performed any autopsy in OR ?

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of Prasanna Simha M
> Sent: Friday, November 17, 2006 2:52 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Massive hemorrhage in a chold
> 
> Actually the child had an angio and there is no AVM in it.
> The blood was coming bilaterally at last from what we could make out - it
> was poring so how much ws spill and how much was truly coming was a bit
> difficult - in the ully heparinised patient.
> What I could not get was why the PA was filling despite a collpased LA. An
> AVM should still collapse on full CPB if it is a pulmonary arter to vein
> fistula. If it is a systemic collateral then the LA return should have
beeen
> high .
> On epicardial Echo the LA and left heart were collpased. RV was collpased
> but the PA was full. When I vented the PA on stabbing blood spurted out.
> TAPVC was an anatomical impossibility anyway.
> What do I do now if faced with the same thing again - I have yet to make a
> battle plan.
> In adults I have managed this before with endobronchial intubation or a
> double lumen tube and instillation of adrenaline/phenylephrine in
> thebleeding lung if cannot seeany cause on bronchoscopy and blocking the
> relevant bronchus with a fogarty. Doing that in a small child (No 4 ET
tube)
> sounds pretty impossible !!
> Prasanna
> 
> 
> On 11/17/06, Ben Bidstrup <benjamin.bidstrup at bigpond.com> wrote:
> >
> > >1 year child with multiple VSD's isosystemic PH but left to right
> > >shunt undewent VSD closures. small apical VSD 2mm could not be
> > >visualised and left .
> > >Weaned off CPB with PA pressures 60 % of systemic and then when he
> > >started developing massive hemorrhage from the lungs - continuous
> > >and failed to maintain gas exchange. (Intubation was non traumatic
> > >and no blood previously)
> > >I looked for residual; shunts- only the small apical VSD which was
> > >hardly 2mm in width . No PDA - confirmed by dissection and ligation
> > >of ligamentum arteriosum. No coarct (had both radial and femoral
> > >lines).
> > >Continued massive hemorrhage. despite full CPB collapsed LA and
> > >venting LA. PA was full despite empty LA and empty RV in the second
> > >run so I vented the PA. Despite this same problem persisted and we
> > >could not have a stable wean Kept the patient on CPB for 4 hours but
> > >to no avail and patient died . (ECMO not a really practical option
> > >for me). Patient continued to bleed from the lungs while on CPB
> > >though it reduced a bit after venting from both LA and PA.
> > >Not sure what went wrong.
> > >Tempted to say CPB induced lung injury.
> > >Causes management and prevention ?
> > >Prasanna
> >
> > Bad luck for all. Particularly tough in  a child.
> > So what are the possible causes of intrapulmonary haemorrhage. (with
> > or w/o L to R shunt)
> > AVM would be my first suggestion. Tough to pick. Other unknown
> > systemic pulmonary connections. Will you be able to get an autopsy?
> > Pump lung unlikely as the PA was full despite empty LA.
> > At that age only possible suggestion is to put ETT down one side
> > only. FO bronch whilst on CPB see which side. Blocker in bleeding
> > side if unilateral. (use a 3 or 4 Fogarty. Tube down other side. (If
> > bleeding from R it is a bit easier to jam the tube into the LMB.
> > All this is very difficult in these circumstances.
> >
> > Prevention ? Well if it is something like an AVM, do not operate. (No
> > operate, no complications)
> >
> > Later thought - maybe pul HTN has created some areas that have
> > behaved like an AVM. Add systemic heparin and they rupture.
> >
> >
> >
> > --
> > Ben Bidstrup FRACS FRCSEd FEBCTS
> > Consultant Cardiothoracic Surgeon
> > _______________________________________________
> > OpenHeart-L mailing list
> >
> > Send postings to:
> > OpenHeart-L at lists.hsforum.com
> >
> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> > http://mmp.cjp.com/mailman/listinfo/openheart-l
> >
> > All messages transmitted by the OpenHeart-L are subject to the policies
> > and
> > disclaimers posted at:
> > http://www.hsforum.com/listdisclaim
> > -----------------------------------------
> >
> 
> 
> 
> --
> Prasanna Simha M
> _______________________________________________
> OpenHeart-L mailing list
> 
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
> 
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
> 
> All messages transmitted by the OpenHeart-L are subject to the policies
and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------