[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?

Sun Nov 25 19:51:11 EST 2007

Could not get ahold of the surgeon (who I know and see every once in  
a while).  Got called from a 2nd year GenSurg resident from the  
hospital he was admitted to (not the one where he had his  
surgery)....... she knew NOTHING about the management of aortic  
dissection - had him on cardizem, no betablockers, she was going to  
heparinize him (not sure why???), and didnt think his prior CABG was  
an issue.   Thank you ACGME 80 hour work week.

-michael

On Nov 25, 2007, at 7:34 PM, Edward Bender wrote:

> Its not just the academic centers.  Even our lowly community  
> hospital gets transfers from other community hospitals (surgeon and/ 
> or cardiologist is out of town or its after 5pm or its a weekend).   
> Luckily, a case like that is pretty rare for us.  Unfortunately,  
> when you said the patient had had a recent CABG, I thought the  
> etiology was either a graft proximal, a clamp injury, or the aortic  
> cannulation site.  Did you try shaming the surgeon of record into  
> re-thinking the transfer?
>
> Ed Bender, MD
>
>
> On Nov 25, 2007, at 5:47 PM, Michael Firstenberg wrote:
>
>> The wonders of holiday in the U.S. is that we (academic medical  
>> centers) seem to get all of transfers.
>> This was my case from yesterday and would be very interested in  
>> comments (besides shipping to a better surgeon......).
>>
>> 61 year/old, hypertensive, diabetic, severe abdominal obesity (BMI  
>> 48, 300 lbs, around 5' 4')
>> presents to outside hospital with refractory chest/back pain,  
>> radiating to legs.
>> CT Angio - aortic dissection, just about the valve to the iliacs.
>>  head/visceral/renal/femorals off true lumen (but very small)
>> Surgery resident from outside hospital calls me for transfer (on  
>> cardizem drip for BP control, no beta-blockers, not working,  
>> should we heparinize...... discussion for another time!!!)
>> "oh, I forgot to mention, he had a CABGx4 in June of this year)
>>
>> My response - esmolol and ship quickly
>> Upon arrival, still having pain, BP OK, neuro intact, faint  
>> femoral pulses, strong radials (no A-line)
>> Reviewed still with our local Cardiology CT expert (lucky he was  
>> in house)
>> - confirm dx
>> - all grafts patent, LIMA-LAD, SVG->PDA, SVG->Dx, SVG->Om
>> - 3 proximals coming off the ascending aorta
>> - LIMA lateral to sternum
>>
>> Taken emergently to OR
>> Axillary cannulation (nice artery)
>> Wire in right femoral vein (ugly groin, lots of fat, yeastly)
>> Intra-op TEE shows bicuspid aortic valve with mild/mod AI.
>> Open the chest (they missed midline on the CABG and went through a  
>> bunch of ribs on the right- close to the RIMA)
>> Got in OK
>> tons of mediastinal fat plastered to pericardium, plastered to  
>> epicardial fat.
>> NO, and I mean NO identifiable planes!
>> Finally found aorta after about an hr of digging - found old  
>> cannulation site
>> aorta looks ugly as I exposed.
>> Finally found SVG to PDA graft - completely plastered to small  
>> right atrium
>> cannulated right vein - went on, cooled
>> could not find "the heart/apex/etc) to vent - fortunately arrested  
>> without fibbing (LV didnt look too bad on TEE while cooling)
>> Cooled to 18C (didnt even look for the LIMA - way laterally and  
>> everything was a mess) -> kept feeding heart with cold blood
>> Finally got around aorta - circ arrest, opened up, trimmed to hemi- 
>> arch - contained rupture, tear at right vein graft site
>> found "something to sew to" distally in arch (30 min of circ  
>> arrest time)
>> went back on, started warming - blood coming from grafts, left  
>> main and right (all good, I assumed)
>> aortic valve - bicuspid ->fused, but leaflets normal -> separated  
>> left and non-cor leaflets and appeared to co-apt ok and hold water  
>> went closed
>>   (mobilzing for AVR would have been very difficult - at least for  
>> me!)
>> On/off circ arrest, low flow, etc to fix leaks, mobilize,  
>> visualize, etc....
>> Bioglue to proximal aorta layers and dissection plane.
>> Sewed proximal
>> root vent - cardiopledgia
>> Sewed on very scarred, friable SVG buttons (got the right mobilzed  
>> off the RA once empty and repaired/resected tear)
>>
>> Took of x-clamp - slowly developed junction rhythm as warming more
>> came off pump eventually with lots of drugs, inhaled nitric
>> over an hour de-airing
>> TEE - still mild AI
>> - felt addressing would be futile
>> - 6 hours on pump.....30 min DHCA, 4 hr cross clamp (on and off)
>> Anesthesia up and down with tons of drugs/fluids/products/bicarb
>> big chest - wet lungs, hard to ventilate, very unstable, up/down  
>> acidosis......(thought making urine???)
>> Very coagulopathic (would have liked to have had Aprotinin) but  
>> used TA.....
>> Tons of products (INR>6, PTT unmeasurable, ACT after  
>> protamine>999, platelts=18), but not bleeding too bad
>> re-enforced graft site and potential space to co-seal, flow-seal,  
>> fibrilar, NuKnit, anything that I was allowed to leave in the chest
>> (although no potential space - other than right pleural space - to  
>> bleed into)
>> Closed chest (modified weave and lots of wires through ribs)
>> meta-stable
>>
>> went out to talk to family.......called back in....became brady  
>> cardiac as getting ready to move to bed....pulseless.....
>> chest open - heart dead.....open CPR....intra-cardiac epi/vaso...
>> TEE showed LV empty......(rupture into left chest?  abd?   
>> something else?)
>>
>> "the end"
>>
>> Please comment as I know many of you have been there (either on- 
>> line or in private)..........
>>
>>
>> (fyi, this is the second post-CABG dissection we got this week -  
>> the first one was only a month out and the redo was much easier)
>>
>> -michael
>>
>>
>>
>>
>>
>>
>>
>>
>>
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