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

Thu Dec 6 22:36:17 EST 2007

I cannot give a definite number but I can say that I have opened cases and
they have been saved. You need not rush in to open every case stat. Internal
massage may be considered if there is no effective return of cardiac
activity after a few minutes and definitely by 10 minutes . I think that is
enough time to consider and treat potentially correctable causes like hperor
hyoperkalemia etc etc. Remebere that internal massage gives a higher CIthan
external massage and persisiting with a technique that gives a lower CI
after a few minutes is also detrimental. I haveseen graft kinks, tamponade
blow outs compressive clots  etc etc . Patients with a PH crisis undoubtedly
benefit by releiving cardiac compression by an acutely dilated RV by opening
the chest. I am convinced that it needs to be done.
Prasanna

On Dec 6, 2007 10:24 PM, Michael Firstenberg <msfirst at gmail.com> wrote:

> my point is that the excitement of opening a chest should not preclude
> rational thinking about what the problem is or could be.  Again, my
> question
> to the group (having learned this lesson the painful way) is how many time
> has a chest been opened for a problem that would not have required opening
> the chest (i.e. respiratory arrest from plugging, electrolyte
> abnormalities,
> PE, etc)?  .
>
> -michael
>
>
> On 12/6/07, Prasanna Simha M <prasannasimha at gmail.com> wrote:
> >
> > I strongly disagree. Residents can be taught. In fact I did my first
> > emergency open internal cardiac massage on day 3 of my cardiac
> residency.
> > It
> > is a skill that can be learnt and can be done by any resident. It is not
> > rocket science
> >
> >
> > On Dec 5, 2007 2:09 AM, Michael Firstenberg <msfirst at gmail.com> wrote:
> >
> > > 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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> > --
> > Prasanna Simha M
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-- 
Prasanna Simha M