[HSF] Intimal Tears
Ben Bidstrup
benjamin.bidstrup at bigpond.com
Mon Feb 4 10:06:27 EST 2008
We have had 3 episodes where a sheath has been
placed in the carotid. In one (same anaesthetist
x 2) the Swan Ganz was introduced into the
arterial circulation. Only when he connected it
up did he realise that it was in the left side
!!!. All were explored and the artery closed
prior to CPB. Wound left open. No sequelae from
the neuro perspective. Try and discuss this with
them and they get s#@ty.
So how do you get them to understand or rather
the hospital that this is a potentially lethal
event (near miss in safety parlance) and tray and
do something about it.
I have also seen the IJ multiple puncture
technique of insertion, shear the RIMA from the
subclavian and lead to a lot of bleeding that is
very hard to control.
>I had one emergent case where the anesthesiologist put an introducer through
>the right common carotid artery. We recognized this, left the introducer in
>the artery, did the on pump case, and then I cut down on the carotid,
>removed the introducer after placing a 5-0 prolene purse string stitch. I
>also had the OR staff take a picture and I showed to all his friends.
>
>Ed Bender, MD
>
>
>On 2/3/08 11:21 AM, "Crittenden, Michael" <Michael.Crittenden at va.gov> wrote:
>
>> I have cancelled elective cases for carotid injuries--usually cordis/dilator
>> injuries. Luckily, it has not happened in an
>>emergent case--not sure what to
>> do then...delay, proceed anyway who knows? What I think we don't hear about
>> from Anesthesia is how often the finder needle hits the carotid. Maybe this
>> is "innocent" if the needle size is small?!?
>>
>> -----Original Message-----
>> From: openheart-l-bounces at lists.hsforum.com
>> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Michael
>> Firstenberg
>> Sent: Sunday, February 03, 2008 12:15 PM
>> To: OpenHeart-L at lists.hsforum.com
>> Subject: Re: [HSF] Intimal Tears
>>
>> Right before the STS, I took a partners patient back for a huge right
>> hemothorax. He was 2 weeks post-op (double valve endocarditis), doing fine,
>> and the only thing recent was a new right neck line by the Cardiology team
>> (he was waiting for a pacemaker on their service.....long story and not for
>> now)
>>
>> Which begs the question - if Anesthesia hits the carotid (finder needle,
>> introducer, whatever) - will people postpone the case?
>> (I know an open and vague question - but am interested in the responses)
>>
>>
>>
>>
>> -michael
>>
>>
>> On 2/3/08, Dr. Roberto Battellini <battr at medizin.uni-leipzig.de> wrote:
>>>
>>> Giuseppe,
>>> I had the same experience twice. But if you open the pleura and look at
>>> the
>>> haematoma, you will recognize the problem. Of course, the one who put the
>>> catheter will not...It is a not uncommon complication of jugular
>>> indwelling
>>> catheters.
>>> I agree, it is better for the patient to admit errors.
>>> Roberto
>>>
>>> -----Ursprüngliche Nachricht-----
>>> Von: openheart-l-bounces at lists.hsforum.com
>>> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Macbook
>>> Gesendet: Sonntag, 3. Februar 2008 16:32
>>> An: OpenHeart-L at lists.hsforum.com
>>> Betreff: Re: [HSF] Intimal Tears
>>>
>>> Nasser,
>>>
>>> two weeks ago a did an AVR + PFO closure in a quite young woman
>>> (about 50). My resident opened the patient and did a large opening of
>>> the right pleura. At the end of the procedure I sucked almost 1 liter
>>> of blood from the right pleural cavity (I said to myself that this
>>> was blood collected during the operation). The day after the patient
>>> was extubated and well but there was still some bleeding from the
>>> right chest tube. The patient was reexplored by a collegue who found
>>> nothing. The patient continued to bleed and on postop day 2 I
>>> reexplored the woman. I found a bleeding spot from the apex of the
>>> parietal pleura. It was clearly related to the IJV catheter but the
>>> anesthesist said that it was related to surgery!!! BTW I put two
> >> stitches and stopped the bleeding. However, as the blood was quite
>>> red and I was worried about an arterial lesion I asked the vascular
> >> surgeon to do an intraoperative arteriography that was negative. The
>>> patient luckily did very well. We all make mistakes but it is nice to
>>> admit them.
>>>
>>> Giuseppe
>>>
>>>
>>> Il giorno 01/feb/08, alle ore 07:59, Nasser F. Abou'Seada ha scritto:
>>>
>>>> "Frankly, I'm surprised I've never encountered this complication
>>>> until now"
>>>>
>>>> Hal
>>>> That adds to your critical observance as a surgeon, recognizing the
>>>> fault
>>>> first time seeing it. I faced that situation before in a 55 y old
>>>> female
>>>> having a straight forwards Mitral repair. everything went smoothly
>>>> yet there
>>>> was some bleeding welling up in the pericardium, that we could not
>>>> come off
>>>> bypass ........ all manouvres to find out the source of bleeding were
>>>> evading ..... blood seemed to come from around the SVC upper part,
>>>> where
>>>> nothing was ever touched .... patient passed off after some 5 hours on
>>>> bypass and blood thinning out. On table autopsy, I dissected around
>>>> the SVC
>>>> up to the IJV.... to find the whole area bathing in blood,
>>>> ecchymosed ....
>>>> and blood perculating through the wall of the vein .. down the
>>>> sheath ....
>>>> around the SVC ..... into the pericardium .. !! .... opening the vein
>>>> longitudinally, multiple non peneterating longitudinal tears were
>>>> found in
>>>> the intima of the RIJV ... !!!! ... inquiring in retrospect, the newly
>>>> appointed anaesthesiologist tried many times before securing the
>>>> IJV cannula
>>>> in place .... as usual ... mortality was ascribed to the
>>>> surgeon .... !!!!
>>>> ... a new lesson with a hard price ..!! .. never forgotten ..
>>>>
>>>> NFA
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>> On Jan 31, 2008 7:09 PM, <Hgrmd at aol.com> wrote:
>>>>
>>>>> Don,
>>>>> My assistant is pretty strong, but I'm not blaming him.
>>>>> Frankly, I'm
>>>>> surprised I've never encountered this complication until now.
>>>>>
>>>>> Hal
>>>>>
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--
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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