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

Fri Dec 7 23:12:31 EST 2007

Dr Zhou

I am still curious to know how you did a TEE to exclude tamponade while CPR was being undertaken.

I do disagree though with the ability to exclude tamponade non-surgically. We can review our probability based on TEE but if pre-op index of suspicion was high then TEE if negative will at best make the suspicion moderate. If indifferent suspicion negative TEE will make probability low but will not exclude it. Left atrial tamponade has been mentioned. I had one such patient last month and the only clue was a rising LA pressure, in a patient with a VAD. Echo did not show classical tamponade but a picture of RV dysfunction (because of high LA pressure increasing RV aftrload). On re-exploration the mediastinum was largely free   of clot except by the LA where there was a clot causing localized tamponade (in retrospect on TEE one could see isolated LA compression).

I vaguely recall a patient who died during my training and we never reopened the chest. Autopsy showed tamponade. Echo's were done in that case.

Ani 

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient> From: zzhoumd at pol.net> Date: Fri, 7 Dec 2007 00:54:06 +0000> CC: > > > This patient is not on anticoagulation. I have clear echo picture showing no tamponade. > > 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.Ask the> 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?> > >> _______________________________________________?> > >> OpenHeart-L mailing list?> > >>?> > >> Send postings to:?> > >> OpenHeart-L at lists.hsforum.com?> > >>?> > >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:?> > >> http://mmp.cjp.com/mailman/listinfo/openheart-l?> > >>?> > >> All messages transmitted by the OpenHeart-L are subject to the?> > >> policies and?> > >> disclaimers posted at:?> > >> http://www.hsforum.com/listdisclaim?> > >> -----------------------------------------?> > >?> > > _______________________________________________?> > > OpenHeart-L mailing list?> > >?> > > Send postings to:?> > > OpenHeart-L at lists.hsforum.com?> > >?> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:?> > > http://mmp.cjp.com/mailman/listinfo/openheart-l?> > >?> > > All messages transmitted by the OpenHeart-L are subject to the >> > policies and?> > > disclaimers posted at:?> > > http://www.hsforum.com/listdisclaim?> > > -----------------------------------------?> > > _______________________________________________?> > > OpenHeart-L mailing list?> > >?> > > Send postings to:?> > > OpenHeart-L at lists.hsforum.com?> > >?> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:?> > > http://mmp.cjp.com/mailman/listinfo/openheart-l?> > >?> > > All messages transmitted by the OpenHeart-L are subject to the >> > policies and?> > > disclaimers posted at:?> > > http://www.hsforum.com/listdisclaim?> > > -----------------------------------------?> > ?> > _______________________________________________?> > OpenHeart-L mailing list?> > ?> > Send postings to:?> > OpenHeart-L at lists.hsforum.com?> > ?> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:?> > http://mmp.cjp.com/mailman/listinfo/openheart-l?> > ?> > All messages transmitted by the OpenHeart-L are subject to the policies> > anddisclaimers posted at:?> > http://www.hsforum.com/listdisclaim?> > -----------------------------------------?> >> >> > ________________________________________________________________________> > More new features than ever. Check out the new AOL Mail ! -> > http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp00050000000003> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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