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

Sat Dec 8 20:30:28 EST 2007

I have followed this "debate" and one of the problems is that it has become more and more abstract. A protocol without particulars is as Michael suggests, a dangerous think. 

For example. I don't have residents so I am both more likely to be present it someone is going "south" before they arrest than an attending (or other fellow) walking the resident through the drills over the phone. If someone is to open the chest, it will be me not a medical or new surgical resident. Also presumbly we all let patients die without a new operation if we think that it is a dying heart and not a normal ventricle that "suddenly" arrested. One key was also that it was a "partners" case, so less than ideal information. It seems like a bunch of old women arguing about the weather in NYC that have not been outside in decade and currently live in Miami.

tea.  

----- Original Message ----
From: "hgrmd at aol.com" <hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, December 7, 2007 4:12:30 PM
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Dear Z,
? I appreciate the spirit in which this debate was intended.? Head for home in the AM.

Hal

-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 7 Dec 2007 1:04 pm
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Hal, thanks for comments. I think we should put this issue to rest. It is not 
our standard of care to open everyone if we have clear picture showing no 
tamponade. The decision is also based on clinical presentation. I have opened 
many such patients in ICU or OR, most time we endup do more surgeries on a dead 
person.

I do not want to change our practice as well. We are constantly ranked one the 
top programs in New York state by all criterias.

Enjoy your time in Leipsig.

Z Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: hgrmd at aol.com

Date: Fri, 07 Dec 2007 12:31:14 
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Dear Dr. Z,
? I've no doubt that I can open a postop chest in the CVICU much faster than you 
can begin percutaneous ECMO.? I also guarantee you that if a resident answered a 
similar oral board question the way you apprently would, that resident would 
most assuredly fail.? Putting somebody on ECMO without opening a postop chest is 
not standard of care.

Hal

-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 7 Dec 2007 7:11 am
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Hal,

I disagree. ECMO keeps people alive and give you the time to access the brain 
function. In short term, ECMO dose not kill people. It dose not take much time 
to put in. Not affect the CPR while you put in.

For people dose these devices, you can not maintain flow if he has tamponade.

Z Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: hgrmd at aol.com

Date: Fri, 07 Dec 2007 00:32:02 
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Dr. Zhou,

? We've debated this situation ad nauseum, and it won't be resolved.? Like many 
others participating in this thread, I remain steadfast that a patient like 
yours should have been opened in the unit, no questions asked.? TEE is not 100% 
accurate in ruling out tamponade.? Putting the patient on ECMO, etc, is just 
wasting time while the brain dies.?Yes, technical problems can arise if the 
person opening the chest loses their cool or doesn't pay attention.? However, I 
believe most docs reading this thread would agree that the only realistic 
chance, albeit small, is promptly opening the chest in the ICU.

Hal

-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Thu, 6 Dec 2007 7:00 pm
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Hal, I do believe you have more to lose by openning the chest in this case 
unless it is tamponade. ECMO will buy you time for all the options. Just think 
about it and read my previous post.

Z Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: hgrmd at aol.com

Date: Thu, 06 Dec 2007 18:16:40 
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

Michael,

? From what you've said, your CT surgeons could possibly use a little refresher 
course on open resuscitation.? As far as I know, I've never put my thumb through 

anyone's RV.

Hal

-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thu, 6 Dec 2007 6:00 pm
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

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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