[HSF] Packing

[Ani Anyanwu]

Prasanna
 
Could you please give me more details of your packing procedure regarding the removal of the pack.
 
Is this done percutaneously? If so how long do you leave it in (assuming no hemodynamic indication to remove), are patients intubated and anesthesized to take the pack out? Is this done at the bedside or in the OR? How often have you used this and have you ever seen problems during extraction? Finally I presume after taking the pack out there will be clots in the mediastinum - why would you not prefer open removal to wash out all the clots.
 
I think packing and percutaneous removal would be a useful strategy in LVAD cases (these bleed more than any other cardiac operation) and also they would tolerate packing better (because of no requirement for LV contraction) so is something worth exploring. 
 
Thanks a lot
 
Ani



> Date: Fri, 7 Sep 2007 17:29:01 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> CC: > Subject: [HSF] Packing> > I got quite a few queries about packing off list so I thought I will > post one reply. Judging from the number of queries we all have to spend > sleepless nights waiting for the dreaded reexploration call !! ;-)> > I bet that you have all done it before -basically it is a long roller > gauze (The type that the gynecologists use for packing the vagina for > massive Post Partum Hemorrhage. (Like liver packing for trauma) I put a > layer of gel foam and Surgicel over the area to be packed and the layer > and jam the gauze (impregnated with protamine . calcium , Aprotinin and > if available some platelet and plasma as a goo) and it should be layered > so that it opens out in a concertina fashion to ease removal and prevent > knotting. This should be wedged in tightly at the base and then once > "hemostasis" is achieved layered on loosely and then passed out through > a stab in the lower end of the incision (just like a drain) . I then > try to approximate the pericardium over the packed area for additional > compression. Then I check that there is no coronary compression or > systemic tamponade and close the chest (and pray !!) I also suture the > end of the gauze to the skin (In one case the gauze slipped off inside > and I could luckily just grab it by extending the skin incision) . I > keep a re-exploration set and an addition pair of wire cutters and a > scalpel by the bed side with instructions to the residents to > immediately draw out the gauze or reopen if there is any evidence of > coronary Ischemia or systemic tamponade. Correct packing does not cause > these though in one case I had to withdraw a few feet of pack because > there was some ST's which resolved with partial pack withdrawal (I think > the gauze swelled a lot with absorbed tissue fluid).> It can also be enhanced by placing a catheter in the center of the pack > mass and applying a relatively high vacuum suction and this catheter > must be separately brought out via a different stab. (Or else it will > cause high negative suction in the entire mediastinum which will be > undesirable.)> It has got me out of some sticky wickets !!> The picture does not do justice as the tightly wedged portion of the > pack cannot be seen and is actually retro/para aortic> > Prasanna
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