[HSF] Cardiac arrest after redo CABG in a young patient

[Michael Firstenberg]

Very true but it should not be the first thought and you opening a chest is much different than a junior resident.  In retrospect in how many cases does opening the chest help?

Michael Firstenberg <msfirst at gmail.com>

-----Original Message-----
From: hgrmd at aol.com
To: OpenHeart-L at lists.hsforum.com
Sent: 12/5/2007 12:21 AM
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Michael,
? If the patient is obviously going to die with current intervention, there is nothing to lose by opening the chest in the bed.? Yes, you can screw things up even worse.? However, you will occasionally salvage someone who was other wise going to bone it for sure.

Hal


-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 4 Dec 2007 8:09 pm
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient


I would beg to differ - while many of you who have been around the block a few times may be quick to open the chest. We were always trained that unless clear tamponade, opening a chest emergently usually leads to more trouble - in the midst of chaos, grafts (esp IMAs) get pulled off, manual CPR results in RV thumb holes, critical pacing wire get torn. My question to the group is, in my limited experience tamponade comes up quickly but not instantly - the tubes slow down, or even stop, the PA pressures go up, CVP goes up, systemic pressures go down, increasing drips doesnt work, unless a true disaster - like a hole in the aorta or similar, usually there is sometime. While the comments about how no open heart patient should die without having their chest open has some merit, it should not be the first intervention, not in my opinion be performed lightly without the input of the attending (or very senior) surgeon.?
?
We have lost a few very obese patients and I suspect PEs (or mucus plugging from poor pulm mechanics) - which may be in this case. Very obese, dont move around much, these patients are often chronically dry, etc.?
?
-michael?
?
On Dec 4, 2007, at 6:16 PM, zzhoumd at pol.net wrote:?
?
> Ed,?
>?
> I agree with you that it is probably graft related. How do you > access the grafts in ICU or in OR. I used to do OPCAB with flow > probe. When patient arrest, none of the grafts have good flow and > heart is so big, every graft become stretched. If you put them on > bypass, flow got better but when you come off bypass, flow goes > down again in all grafts.?
>?
> This patient did have problem came off bypass, with IABP he did OK. > The IABP was removed 2 days later, but SVO2 was never good. Before > he arrest, PA pressure was high which dose not consistent RV infarct.?
>?
> Z Zhou?
>?
>?
>?
> Z Zhou?
>?
>?
> Sent via BlackBerry by AT&T?
>?
> -----Original Message-----?
> From: Edward Bender <ebender001 at charter.net>?
>?
> Date: Tue, 4 Dec 2007 16:44:01?
> To:OpenHeart-L at lists.hsforum.com?
> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient?
>?
>?
> I would bet that this was right coronary graft occlusion. Not?
> necessarily due to the anastamosis, but perhaps due to mediastinal?
> compression in the very obese. I think this sort of event demands re-?
> opening the sternum as the first act after you have arrived in the?
> icu. Let the other people do closed chest CPR while you are on your?
> way to the hospital. On my cell phone, in the car, I tell the ICU?
> personnel to have the re-opening tray at the bedside, open with a pair?
> of gloves ready for me to put on. I have not saved many like this,?
> but I have saved some. Especially in morbidly obese patients, open?
> cardiac compression is better than closed chest compressions. You?
> also get to definitively rule out tamponade.?
>?
> Ed Bender, MD?
>?
>?
> On Dec 3, 2007, at 10:41 PM, zzhoumd at pol.net wrote:?
>?
>> To forum members,?
>>?
>> This weekend I was on call. One of my partners patients developed?
>> cardiac arrest. He is only 57 year old had redo CABGx5 4 days ago.?
>> Weight about 300LB. After 30 minutes CPR, he is still asystole.?
>> Considering his young age, I placed him on ECMO. I thought about?
>> BiVAD, but I just do not know if his brain will come back. Just?
>> wonder if anybody will do anything different. I did not reexplore?
>> him as TEE show no tampnade and he has no more conduit.?
>>?
>> Thanks!?
>>?
>> Z Zhou?
>> Sent via BlackBerry by AT&T?
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