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

Fri Dec 7 16:09:42 EST 2007

Usually the medicine residents have very little role in our ICU (we are
actually in a completely different building)
http://www.medicalcenter.osu.edu/patientcare/hospitals_locations/hospitals/rossheart/

but this was on a weekend, and thanks to the ACGME our fellows/surgeons were
out of the hospital at the time so they were the first to respond.

-michael

On 12/7/07, Nasser F. Abou'Seada <nfaabouseada at gmail.com> wrote:
>
> Hal:
> Totally agree in Style and Content, word by word ..
>
> NFA
>
> On Dec 7, 2007 11:27 AM, <hgrmd at aol.com> wrote:
>
> > Dear Z,
> > ? As best as I can remember, I've yet to open a chest in the ICU and
> found
> > nothing remiss.? If it did, I wouldn't anticipate torturing myself,
> because
> > I would have had solid indications to open. Most of the time not much
> can be
> > done, primarily because the heart is dying.? However, I've definitely
> > relieved important tamponade.? Once I successfully repaired in the unit
> a
> > blown out IVC cannulation site.? In that case, waiting around for ECMO
> would
> > have been?profoundly unsuccessful.
> >
> > Hal
> >
> >
> > -----Original Message-----
> > From: zzhoumd at pol.net
> > To: OpenHeart-L at lists.hsforum.com
> >  Sent: Fri, 7 Dec 2007 6:40 am
> > Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
> >
> >
> >
> > Hal,
> >
> > In our practice, we do not routinely open patient chest unless we think
> it
> > is
> > tamponade. I have worked in many hospitals and I see pretty much the
> same
> > pattern. What we do and not to do has a lot to do with our training and
> > our
> > practice.
> >
> > Just wonder if you open chest and then found no tamponade, what is the
> > next
> > step?
> >
> > Z Zhou
> >
> > Sent via BlackBerry by AT&T
> >
> > -----Original Message-----
> > From: hgrmd at aol.com
> >
> > Date: Fri, 07 Dec 2007 00:36:58
> > To:OpenHeart-L at lists.hsforum.com
> > Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
> >
> >
> >
> > Z,
> >
> > ? I've seen clinically significant tamponade present when TEE didn't
> pick
> > it
> > up.? For example, a posterior clot behind the left atrium can cause
> > hemodynamic
> > collapse, and not be easy to demonstrate on TEE.?
> >
> >
> >
> > Hal
> >
> >
> > -----Original Message-----
> > From: zzhoumd at pol.net
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Thu, 6 Dec 2007 6:20 pm
> > Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
> >
> >
> >
> >
> > Prasanna,
> >
> > If someone has tamponade to the point has cardiac arrest, TEE should
> tell
> > the
> > story.
> >
> > Z Zhou
> > Sent via BlackBerry by AT&T
> >
> > -----Original Message-----
> > From: "Prasanna Simha M" <prasannasimha at gmail.com>
> >
> > Date: Thu, 6 Dec 2007 22:07:43
> > To:OpenHeart-L at lists.hsforum.com
> > Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
> >
> >
> > SorryZhou, patients can develop late tamponade days to weeks later.Askthe
> > coumadin adminstrators for mitral rings and they will tell you horror
> > stories !!
> > Prasanna
> >
> > On Dec 5, 2007 12:47 PM, <zzhoumd at pol.net> wrote:
> >
> > >
> > > May be for early post op patients you know he is bleeding or
> > tamponading.
> > > If someone is 5 days out, and chest tube is not wet, TEE no tamponade,
> I
> > > just think unlikely.
> > >
> > > May be I could have done is to open a subxyphoid window to see if any
> > > clots or blood in the pericardium.
> > >
> > > A year ago, a patient like this arrested 5 days after mtral repair,
> ECHO
> > > show blood around the heart, I happened to be in the ICU even she is a
> > > patient of the other group. I opened the subxyphoid part of the
> > incision,
> > > relieved tamponade, took to the OR, she had ruptured inferior wall
> > likely
> > > from Cx occlusion. Never made out of OR.
> > >
> > > Z
> > >
> > >
> > > Sent via BlackBerry by AT&T
> > >
> > > -----Original Message-----
> > > From: hgrmd at aol.com
> > >
> > > Date: Wed, 05 Dec 2007 00:21:30
> > > To:OpenHeart-L at lists.hsforum.com
> > > 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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> > > >>?
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> > > >>?
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> >
> > --
> > Prasanna Simha M
> > _______________________________________________
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