[HSF] Aortic dissection and CPR

Tue Sep 18 12:20:05 EDT 2007

The main issue I was hoping to discuss was: when you
have a prolonged resuscitation, when do you abort,
when you have the bypass machine in the room? 20 min?
30 min? 40 min? or do you just leave the patient and
tell the family you tried everything?

With bypass being available to resuscitate a patient,
and cooling the brain immediately, longer periods of
brain ischaemia can be tolerated, so perhaps we give
up too soon.

The other side is that once you have done this, any
further period of ischaemia to the brain will not be
tolerated. So if you are dealing with a dissection (I
was not specifically only referring to dissection) you
may then need to tailor your operation, and however
you do it, avoid any further brain ischaemia.

Dave

--- Michael Firstenberg <msfirst at gmail.com> wrote:

> I must agree with Hal on this one, not finishing
> what you started,  
> particularly if you are concerned about wasting
> resources and  
> potential donor organs sounds like a medical-legal
> path, at least  
> here in the U.S., I really do not want to go down.
> 
> At least let the family think that everything was
> done, and if they  
> dont wake up - they know you tried your best to fix
> their problem
> 
> -michael
> On Sep 17, 2007, at 8:09 PM, hgrmd at aol.com wrote:
> 
> >
> > Dave,
> >
> > ? If you aren't recommending aborting repair of
> the dissection  
> > while on CPB, then I guess I don't understand what
> you are saying.?  
> > To me, if you ever accept a patient for surgery,
> you should finish  
> > the job unless you think it will endanger the
> patient.? Other than  
> > the cost of the graft, what are you really
> saving?? At least in my  
> > community, you'd still get dinged for the
> mortality once you'd  
> > placed the patient on CPB.? Repectfully, I just
> don't follow your  
> > rationale.
> >
> > Hal
> >
> >
> > -----Original Message-----
> > From: David Harris <drdharris at yahoo.co.uk>
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Mon, 17 Sep 2007 9:50 am
> > Subject: Re: [HSF] Aortic dissection and CPR
> >
> >
> >
> >
> > No, Hal, that`s not what I`m recommending.
> >
> > Only for those cases where you have resuscitated
> for a
> > while, say 20 to 30 mins, and they are
> unresponsive,
> > and you revive them back from the basement by
> putting
> > them back on bypass (where some may have bailed
> out
> > already).
> >
> > What then? We know that after prolonged resus,
> they
> > may already be in a vegetative state. But some may
> not
> > be. Is then worth wasting resources further by
> then
> > proceeding with hypothermic arrest and repair? I
> think
> > that`s why the mortality for dissection repair is
> so
> > high, on average.
> >
> > If you already have the patient in the OR, the
> only
> > additional expense would be the disposables for a
> pump
> > run, which in S Africa is cheap. Once you have
> > resuscitated the patient and sorted out the
> immediate
> > cause of death, such as tamponade or RCA
> occlusion,
> > patient can be weaned off (only off the dissection
> > itself looks stable). If there is no brain
> function
> > later on, you could also consider for ?organ
> donation
> >
> > Dave
> >
> > --- Hgrmd at aol.com wrote:
> >
> >> Dave,
> >>   I can't believe you are actually recommending
> >> aborting a dissection  repair
> >> (while on CPB no less!) to see if the patient
> wakes
> >> up enough so that you
> >> can take him back for Round 2.  I've never heard
> of
> >> this approach.  I
> >> understand the rationale in that it would
> minimize
> >> nonsurvivors from getting a
> >> definitive repair.  However, the added pain and
> >> wasted supplies would be
> >> unjustifiable.  BTW, regardless of your last
> success
> >> with this approach, I  would be
> >> surprised if there is much support for this
> >> algorithm.
> >>
> >> Hal
> >>
> >>
> >>
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> >
> >
> > Dr. David G. Harris, FCS, MMED,
> > Cardiothoracic Surgeon
> > Suite 207
> > Kuils River Private Hospital,
> > PO Box 1200, Kuils River, 7579, Cape Town, South
> Africa.
> > Tel +27-21-9006411
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=== message truncated ===

Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
Fax +27-21-9006412      Mobile +27-83-3309587