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

Michael Firstenberg msfirst at gmail.com
Sun Nov 25 21:20:48 EST 2007 

oh, not complaining at all - any business is good business......


-michael



On Nov 25, 2007, at 9:14 PM, John Schor wrote:

> To relate to the "holiday transfer", I was NOT on call this  
> weekend, but got 4 consults....3 of whom need surgery Monday.  
> That's in addition to my scheduled VATS Lobectomy.
> When it rains it pours...
> John
> John Schor, MD
> Verde Valley Medical Center
> Cottonwood, AZ
>
> On Nov 25, 2007, at 5:51 PM, Michael Firstenberg wrote:
>
>> 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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