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

Michael Firstenberg msfirst at gmail.com
Thu Dec 6 18:00:53 EST 2007 

Although I do not disagree with what is being said - I vividly recall  
opening the chest of an elderly women post-op day 2 after an  
ascending/hemi-arch who arrested.  We coded her for a while before I  
opened her chest (with the approval of the Attending over the phone)  
and a junior Vascular attending assisting who agreed.  While it  
looked like tamponade the finding were not clear and probably a  
respiratory arrest in the retrospect - the Attending never forgave me  
(the patient did survive to discharge but was neurologically  
impaired).  I felt clearly hung out to dry.  I also remember watching  
a CT surgeon fellow put his thumb thru a friable RV - game over.   
Seen grafts ripped off, attempts at repairs only to make things  
worse.... my point is that these thing must be well controlled,  
organized, and orchestrated.

-michael



On Dec 6, 2007, at 4:40 PM, Prasanna Simha M wrote:

> Why was the rhythm asysole  one of the points is a possible RCA graft
> occlusion. at least if you had opened the chest that could have  
> been ruled
> out. You (and all of us) are now neither wiser nor have been able to
> formulate a secondary plan if the same thing repeats again  
> tomorrow. That is
> also another reason to reexplore.patients do develop tamponade   
> upto weeks
> after cardiac surgery. You yourself said that the patient was  
> having low
> mixed venous sats etc even after day 3. Something was not right and he
> needed to have further monitoring.
>> Prasanna
>
> On Dec 6, 2007 10:23 PM, <zzhoumd at pol.net> wrote:
>
>> Thanks! I have done that in the past. For immediate open heart  
>> patients,
>> it make sence. For patients in post-op day 5 with no TEE evidence of
>> tamponade, and the rythm is asystole, it is usually not a salvagable.
>> because open chest dose not solve the problem.
>>
>> Z
>>
>> Sent via BlackBerry by AT&T
>>
>> -----Original Message-----
>> From: "Prasanna Simha M" <prasannasimha at gmail.com>
>>
>> Date: Thu, 6 Dec 2007 21:54:35
>> To:OpenHeart-L at lists.hsforum.com
>> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
>>
>>
>> Rule in my ICU - one wire cutter and scalpel are kept in a sterile  
>> ETO
>> pack
>> at all times. That is all that is required to open the chest.  
>> Chests can
>> be
>> opened by any  resident and internal massage can be instituted. It  
>> doesn,t
>> need a consultant to come from home to inititate it. I tell my  
>> residents
>> to
>> open and inititate massage and they do so well before I even come.  
>> In my
>> hospital we tell our residents to open the chest if we do not get an
>> effective rhythm within a few minutes and definitelyby 10 minutes.  
>> I have
>> reexplored patients etc (as I am sure all of us must have done) in  
>> the
>> ICU.
>> Zhou, if you cannot do it in your ICU then a radical change neeeds  
>> to be
>> done. If you can initiate fem fem ECMO or install a Bivad but cannot
>> reeplorein your ICU (and I bet I have less resources in my set up  
>> than
>> yours) your hospital needs to critically readdress this problem.  
>> Every
>> cardiac surgical ICU should be able to reexplore a patient andd  
>> should in
>> fact be able to place a patient on CPB also if required there).
>>
>> Prasanna
>>
>> On Dec 4, 2007 11:44 PM, Edward Bender <ebender001 at charter.net>  
>> wrote:
>>
>>> 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
> _______________________________________________
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