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

[hgrmd at aol.com]

With this additional information, it now sounds like the patient may have died from inadequate protection.? My only suggestion would have been to use warm retrograde blood during the terminal phases of the clamp.? In addition, the air could have been lessened by running CO2 into the field during the entire case.? Again, I doubt it would have made much difference.



Hal


-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Mon, 26 Nov 2007 10:15 am
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?




I did, very briefly think about non-operative management and discussed the
entire plan with my Boss prior to starting, I was very concerned about his
on-going pain and that is was neuro/renal intact.  I know some places (which
better or worse will go nameless) sometimes watch and work-up these people
to see who may self-select into survivors - but I did not have the courage
to watch and do nothing.  Watching "viable" people die when there is
something to be done (even if near futile) is very painful.  We had a woman
in her 60's come in with a Type A and a moderate stroke - she was alert
enough and her entire extended family refused surgery - see eventually
extended her stroke, resp failure, intubation (another discussion), coded
and died.  Very hard to watch since I think she would have done well........

During the case - since I never found the LIMA the heart was being fed the
entire time and I was a little surprise coming off pump was as hard as it
was - but there was tons of air that was hard to get rid of and it kept
going down the coronaries........


-michael


On 11/26/07, Mark Levinson <mmlevinson at hsforum.com> wrote:
>
>
> On Nov 25, 2007, at 5:47 PM, Michael Firstenberg wrote:
>
> >
> > Please comment as I know many of you have been there (either on-
> > line or in private)..........
>
> I would have handled this case the same...and the outcome would be
> the same.....you did everything right and
> to the best of your ability.     The cards were dealt before he
> arrived.     Acute aortic dissections have
> a high mortality rate...
>
> Non-operative therapy has been recommended in some cases of acute
> type 1 as discussed by Tom Martin, but most
> of us are not in the position to defend this decision and quote the
> odds to the family....whereas we know the outcomes
> with surgery.      I reserve non-operative therapy for patients who
> have organ death on arrival (dead bowel, brain, liver)....and
> these patients die soon thereafter.     If you decide against
> surgery, you will have to defend this decision with some
> evidence that it is better than trying to fix it.
> Controversial....
>
> I think you handled this case as best it can be....
>
> Mark
>
> Mark Levinson, MD.
> Founder, Editor-in-Chief
> The Heart Surgery Forum(R)
> Multimedia Cardiothoracic Journal
> URL: http://www.hsforum.com
> URL: http://newoptionsinheartsurgery.com
> Emali:  mmlevinson at hsforum.com
>
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