[HSF] Pre op room air blood gases.

[erdinç naseri]

1.yes I would do a chest Ct and sure ABG
2.anastomosis of RA  to OM1 was technicaly very difficult due to extreme calcification of the artery which obliged me to do an open endarterectomy of 3-4 cm.even in a still heart it took about 15 minutes to finish it.
3.Here an ABG costs between 3- 8 USD according to the device.( ın my opinion it worths)
erdinc
erdinc> Date: Sun, 24 Jun 2007 20:24:52 +1000> To: OpenHeart-L at lists.hsforum.com> From: benjamin.bidstrup at bigpond.com> Subject: RE: [HSF] Pre op room air blood gases.> CC: > > > Based even on a retrospective assessment of the CXR would you do a CT > chest? or even an ABG? I suspect his ABG would not have been too bad > - PO2 normal or sl low and PCO2 N. What might have been of some help > is a forced expirogram looking at possible reduction in FEV1.0. That > may have made you a little more suspicious.> > In away it is better you did him off as a CPB run may have > exacerbated things even more.> > For every +ve finding like that, how many would be -ve? That is the > question about screening tests.> > >Ben,> >WRT your question let me share my experience with a patient of mine > >who underwent CABG 3 weeks ago:52 y/O male smoker( 20 pack-year) > >diabetic and athletic build up,CAD( 3 vessel disease),Nothing > >special on physical exam,CXR: aortic arch calcification, increased > >in bronchovascular marking.Forgot to take ABG preop.> >OP:CABG X 4 ( Lima,RA,RGEA),whole upper lobe and upper segments of > >the llower eft lung full of bullaes.decided not to touch the > >lung,Reoperation for bleeding in the 5.th hour and extubated the > >same day with PO2 60.s and transfered to the normal ward on postop > >2.nd day.Air leak in the 3.rd day with falling PO2 and > >S%O2.Transfered to ICU and reintubated.(Tidal vol.ins 450 cc ,Tidal > >vol.exp 250 cc) taken to the operation room and repair one major > >leak in the upper lobe.uneventful day and night and extubated with > >no air leak, transfererd to normal ward.Postop 5.day massive facial > >emphysema ( left thoracic tube working properly),CXR:complete > >collapse of R lung,Tube thoracostomy with massive air leak and > >deteriorating hemodynamic and neurologic status,transfered to ICU > >reintubated ,TV ins 410 TV exp 280,PO2 50 mmHg, hemodynamic > >deterioration worsens ,BGL at 500.s despite daily 100 units of > >insulin).Taken to OR,Resternotomy and open R mediastinal pleura to > >see severe adhesion of> > the lung and bubbles coming deep from hemithorax.Release of the > >adhesions and complete inflation of the lungs but no air leak > >detected .Taken to ICU andverything normailzed. finally discharged > >at postop 10.th day.> >Retrospectively there was a minimal hyperaeration of the left lung > >on CXR corresponding to a big air sac in the upper lobe( missed by > >me)> >Had some trouble to explain to family about 4 times OR visit and > >lung problem.> >Lesson:ABG +/- thoracic CT preop if required .Explain accordingly > >about mortality and morbidity to the family.> >erdinc> >> Date: Sun, 24 Jun 2007 13:48:09 +1000> To: > >>OpenHeart-L at lists.hsforum.com> From: benjamin.bidstrup at bigpond.com> > >>Subject: Re: [HSF] Pre op room air blood gases.> CC: > > We should > >>list the tests that get done preop and then rank them in > order of > >>value for management.> e.g. My Sunday pm start of the list.> > EKG> > >>CXR> ABG> RFTs (basic spirometry)> RFTs (lung volumes, DLCO)> CT > >>Chest> Full blood count> Electrolytes> Liver Function> Cardiac > >>Enzymes> Renal function (BUN, Cr)> > How many of these are > >>defensive tests and how many really influence management?> What is > >>the cost of these tests?> > > > >If it showed one or more lung > >>tumors it would certainly change my > >plan for management. John > >>Flege> >> >> >-----Original Message-----> >From: Michael > >>Firstenberg <msfirst at gmail.com>> >To: > >>OpenHeart-L at lists.hsforum.com> >Sent: Sat, 23 Jun 2007 11:05 > >>am> >Subject: Re: [HSF] Pre op room air blood > >>gases.> >> >> >> >> >> >> >I dont think anyone is arguing against a > >>pre-op CXR. Although,> > > >> >interestingly - how does that EVER change management. But, > >again - one of > >> >those "expensive tests" that is probably > >useless until the first post-op CXR > >> >is abnormal and you are > >quickly looking for the pre-op > >baseline. > >> >> >> >-michael > >> >> >> >On 6/23/07, Michael > >Firstenberg <msfirst at gmail.com> wrote: > >> >>> >> >>Actually, the > >real problem that we see is the opposite.> >> >>Patients get labeled > >as having COPD, bad lungs, etc as a function > >of> >their > >> >>smoking histories and so they get extubated > >(usually at the> >insistence of > >> >>the Fellows) with mariginal > >blood gases (i.e. some degree of hypoxia> >or > >> >>hypercarbia) > >and everyone then says: "oh, Sats in the mid 80's > >is> >fine, > >> >>they are smokers" - fine until they get > >obtunded,> >hypoxic/hypercarbic, and > >> >>need reintubation under > >sometimes less than idea clinical > >situations.> >> >>> >> >>-michael> >> >>> >> >>> >> >> On 6/23/07, > >Ani Anyanwu <anianyanwu at hotmail.com> wrote:> >> >> > > >> >> >> > Michael> >> >> >> >> >> > Surely you do not need an > >ABG to confirm, refute, or even elucidate> >> >> > severity of COPD? > >Also, in what way does a preop ABG help in> >getting you > >off > >> >> > the ventilator? What exactly are your criteria for > >extubating> >patients and > >> >> > where does the ABG come in the > >decision making? That a test is easy> >to get > >> >> > and easily > >accessible does not indicate its usage.> >> >> >> >> >> > Sounds > >like a real interesting population you have down there - > >are> >they > >> >> > just dumping the crap on the new guy or is it > >typical of your> >entire > >> >> > center's > >practice?> >> >> >> >> >> > Ani> >> >> >> >> >> >> >> >> >> >> >> > > >----- Original Message -----> >> >> > From: Michael > >Firstenberg> >> >> > Sent: Saturday, June 23, 2007 10:38 AM> >> >> > > >To: OpenHeart-L at lists.hsforum.com> >> >> > Subject: Re: [HSF] Pre op > >room air blood gases.> >> >> >> >> >> > As this discussion hopefully > >continues.> >> >> > We have point of ca> > re ABGs - which means the RT on the floor can> >walk to > >> >> > > >the> >> >> > bedside, draw the gas, and walk to the lab 10 meters > >down the hall> >and > >> >> > get> >> >> > the results in 5 > >minutes.> >> >> >> >> >> > I advocate that many of our patients do > >have multiple risk factors> >- > >> >> > long smoking > >histories> >> >> > history of "COPD" - often never proven just > >assumed over the years.> >> >> > shortness of breath is often a > >major complaint> >> >> >> >> >> > large operations are planned - we > >do a lot of VADs (bridge, DT,> >salvage) > >> >> > and> >> >> > low > >EF's with valves.> >> >> > Even our simple CABGs these days have > >multiple medical problems> >> >> >> >> >> > In fact the healthiest > >patient I have operated on in the past> >couple of > >> >> > weeks > >was no medical problems other than bad multiple sclerosis > >for> >> >> > which> >> >> > she needed frequent interferon > >treatments (and now CAD and CHF due> >to > >> >> > her> >> >> > > >acute left main thrombosis)> >> >> > > >> >> >> > Many of our patients do not have cardiologists nor > >have the seen a> >> >> > doctor in> >> >> > years (if ever)> >> >> > > >Histories are unreliable -> >> >> > One patient I did, also for bad > >left main disease, already had a> >lung > >> >> > biopsy for IPF and > >still smoked, according to her 8 cigs/day -> >although > >> >> > > >the> >> >> > rest of her family (including her husband) all insisted > >it was more> >like > >> >> > 3> >> >> > packs a day! She did fine > >and when I saw her in follow-up and> >asked her > >> >> > about her > >smoking - she said she was down to 8 a day - her > >husband> >in > >> >> > the> >> >> > corner just rolled her > >eyes......> >> >> >> >> >> > I find that having a pre-op ABG is very > >helpful in it gives us some> >> >> > sense of> >> >> > what to shoot > >for in trying to get these patients off of the vent -> >> >> > > >particularly if they dont fly off right after > >surgery.> >> >> >> >> >> > In addition, granted not everyone needs > >them, but it is probably> >ea> > sier > >> >> > to> >> >> > have a pre-op protocol to get them in > >everyone rather than> >selectively > >> >> > pick> >> >> > and > >choose.> >> >> >> >> >> > > >-michael> >> >> >> >> >> >> >> >> >> >> >> > On 6/23/07, > >prasannasimha <prasannasimha at gmail.com> wrote:> >> >> > >> >> >> > > > >Something I wanted to ask too.> >> >> > > > >Prasanna> >> >> > >> >> >> > > Ani Anyanwu wrote:> >> >> > > > It is > >interesting as you move around different hospitals > >and> >speak > >> >> > to> >> >> > > different surgeons you get to > >realize how much of what you do is> >a > >> >> > waste of> >> >> > > > >time or unnecessary. I would actually go to the extreme of > >saying> >> >> > there is> >> >> > > no patient that NEEDS an ABG > >before elective heart surgery. It> >may be > >> >> > a> >> >> > > > >helpful guide in some patients but not a necessity. I trained > >in> >some > >> >> > > hospitals where we got PFTs, and sometimes > >room air ABG on every> >> >> > patient who> >> >> > > had ever > >smoked, was elderly or was high> > risk. However in my> >present > >> >> > > hospital, and we do much > >sicker patients and we have practically> >never > >> >> > got > >a> >> >> > > room air ABG and very rarely PFTs. The truth is > >somewhere in> >between > >> >> > but> >> >> > > either test is > >certainly not a necessity.> >> >> > > >> >> >> > > > What I would > >ask those who do or rely on these tests is to> >think > >> >> > back > >as> >> >> > > to how many times the results of this test has changed > >management> >and > >> >> > how?> >> >> > > >> >> >> > > > > >Ani> >> >> > > >> >> >> > > > ----- Original Message > >-----> >> >> > > > From: prasannasimha> >> >> > > > Sent: Saturday, > >June 23, 2007 7:46 AM> >> >> > > > To: > >OpenHeart-L at lists.hsforum.com> >> >> > > > Subject: Re: [HSF] Pre op > >room air blood gases.> >> >> > > >> >> >> > > > Michael , if the > >patient has an OK pulse oximetry value on room> >air > >> >> > > >he> >> >> > > > doesn't need a preop ABG. If he has an abnormal one > >he needs a> >PFT > >> >> > etc> >> >> > > > etc e> > tcand not just an ABG.> >> >> > > > We do a preop ABG > >selectively.> >> >> > > > Incidentally PFT's ABG's etc etc will all > >have a confounding> >value > >> >> > if> >> >> > > > the patients > >lungs are full of water eg MS or MR. or even an> >ASD. > >> >> > > > > >Prasanna> >> >> > > > Michael Firstenberg > >wrote:> >> >> > > >> >> >> > > >> We are in the midst of a heated > >discussion. I agrue that like> >> >> > basic> >> >> > > labs and > >chest xray a room air abg is needed before heart> >surgery. > >My > >> >> > > partners advocae that it is a waste of money unless > >clearly> >> >> > indicated. But> >> >> > > no one gives > >indications.> >> >> > > >>> >> >> > > >> Thoughts?> >> >> > > >> > >Practice patterns?> >> >> > > >> Bob - i am sure you wrote a few > >papers on this.> >> >> > > >>> >> >> > > >>> >> >> > > >> Michael > >Firstenberg <msfirst at gmail.com>> >> >> > > >>> >> >> > > >> > >-----Original Message-----> >> >> > > >> From: "John Schor" < > >johnschor at mac.com>> >> >> > > >> To: OpenHeart-L at lists.hsf> > orum.com> >> >> > > >> Sent: 6/22/2007 9:00 PM> >> >> > > >> > >Subject: Re: [HSF] CABG in Patient with HIT > >Antibodies> >> >> > > >>> >> >> > > >> Hal:> >> >> > > >> One dose > >of heparin for CPB is usually OK....believe it or> >not. > >The > >> >> > > >> prolonged administration of heparin, ie the flush > >in an> >Arterial > >> >> > > >> line, is much worse.> >> >> > > >> > >John> >> >> > > >>> >> >> > > >> John Schor, MD> >> >> > > >> PO Box > >4445> >> >> > > >> Cottonwood, AZ > >86326> >> >> > > >>> >> >> > > >>> >> >> > > >> On Jun 22, 2007, at > >4:50 PM, Hgrmd at aol.com > >wrote:> >> >> > > >>> >> >> > > >>> >> >> > > >>> >> >> > > >>> Dear > >Members,> >> >> > > >>> I need a little advice. My group was > >consulted on a 53 yo> >man > >> >> > > >>> with SEMI> >> >> > > >>> > >who was found to have 3VD with an EF of 25%. His past> >history > >is > >> >> > > >>> significant> >> >> > > >>> for severe > >thrombocytopenia after a PCI in '02. During this> >> >> > > >>> > >admission, he> >> >> > > >>> received Lovenox.> > Angiomax was used during the cath. He> >has HIT > >> >> > > >>> > >antibodies.> >> >> > > >>> I suggested an OPCAB with Angiomax to my > >partner.> >Supposedly, it > >> >> > > >>> has the> >> >> > > >>> > >shortest half life and is hepatically excreted. > >Does> >anybody > >> >> > have> >> >> > > >>> a > >specific> >> >> > > >>> protocol for Angiomax and CABG? Are other > >agents better?> >> >> > > >>> Claudia, where are> >> >> > > >>> > >you?> >> >> > > >>> > >Hal> >> >> > > >>>> >> >> > > >>>> >> >> > > >>>> >> >> > > >>> > >************************************** See what's free > >at> >http:// > >> >> > > >>> www.aol.com.> >> >> > > >>> > >_______________________________________________> >> >> > > >>> > >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 m> > essages 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 s> > ubject 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 > >> >> > 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 > >> >----------------------------------------- > >> >> > > >> >> >> >> >________________________________________________________________________> >AOL > >now offers free email to everyone. Find out more about > >what's > >free from AOL at > >AOL.com.> >=0> >_______________________________________________> >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> >-----------------------------------------> > > > >-- > Ben Bidstrup FRACS FRCSEd FEBCTS> Consultant Cardiothoracic > >Surgeon> _______________________________________________> > >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 OpenHear> > t-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> >-----------------------------------------> > > -- > Ben Bidstrup FRACS FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> _______________________________________________> 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> -----------------------------------------