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

Nasser F. Abou'Seada nfaabouseada at gmail.com
Fri Dec 7 00:00:12 EST 2007 

Totally agree ...... in every singl word
NFA
On Dec 6, 2007 8:08 PM, Edward Bender <ebender001 at charter.net> wrote:

> Can we agree that it is possible to save a patient (both
> hemodynamically and neurologically) by opening the chest and doing
> open cardiac massage when closed chest CPR has failed?
> Can we also further agree that there a certain circumstances where
> opening the chest can be done expeditiously, and others times when the
> time to get the equipment together or to have someone at the bedside
> to re-open is prohibitive?
>
> I have had patients in full arrest a few days after heart surgery in
> whom I have opened the chest when the time and place were conducive to
> doing so.  If I remember correctly, most are still dead, but not all.
> Timing, equipment, and personnel that are available are necessary but
> not sufficient criteria for success.  Conversely, I have never seen a
> living patient in whom, after failed closed CPR, the decision was made
> to NOT open the chest.  I have personally done open chest massage in a
> non-cardiac, non-trauma patient with a successful outcome in whom
> closed CPR has failed.
>
> Sometimes closed CPR provides inadequate circulation to promote a
> successful resuscitation.  There are no ACLS guidelines for when to
> open the chest.  That does not mean that one should not do it
> however.  Guidelines are for lawyers, for the unfamiliar, and for
> those that care more about following rules than achieving a goal.
>
> Ed Bender, MD
>
>
> On Dec 6, 2007, at 5:00 PM, Michael Firstenberg wrote:
>
> > 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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