[HSF] Intimal Tears

Sun Feb 3 21:20:56 EST 2008

According to Anesthesia - the test dose of protamine was not even given
Thanks to our world class legal system, we are now using Amicar
Deairing the LV with a root vent - we also had some hemodyanamic  
instability and I was afraid that I would need to go back on.

-michael

On Feb 3, 2008, at 9:14 PM, Prasanna Simha M wrote:

> Was the protamine drip connected ?
> People have given Protamine instead of Heparin .(could have been  
> given by a
> mislabeled syringe on either the anesthesiology side or perfusion  
> side)
> Was Aprotinin or any other procoagulant used ? (I presume not in  
> the US.)
> Incidentally what were you still deairing with the venous cannula  
> out and
> off CPB after the case is finished ?
> Prasanna
>
> On Feb 4, 2008 7:35 AM, Michael Firstenberg <msfirst at gmail.com> wrote:
>
>> Speaking of anesthesia "issues" - I had a complex case the other
>> day.  We were off pump, the venous cannula was out, but the arterial
>> was still in and we were still de-airing.  No clot in the field (long
>> pump run, circ arrest), but after a few minutes Perfusion told me the
>> oxygenator and arterial line was clotted.  Anesthesia insisted
>> protamine had not been given...... comments?
>>
>> I have my thoughts.....
>>
>>
>> -michael
>>
>>
>>
>> On Feb 3, 2008, at 8:15 PM, Mitch Lirtzman wrote:
>>
>>> I too, have had the unenviable experience. As I suspect we all have
>>> at one time or another. With the same anesthesiologist, he hit and
>>> placed the sheath in the carotid. First case, he pulled the sheath
>>> and as I entered the room, I saw him with two sopping red laps on
>>> the neck. Second case, I told him to leave the sheath in place. I
>>> did a real easy cut down placed a 5-0 purse-string and pulled the
>>> sheath. Went on with the case. Needle punctures don't bother me. I
>>> have since nicknamed him "The Assassin".
>>> Mitch At 11:15 AM 2/3/2008, you wrote:
>>>> 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
>>>>>>>
>>>>>> _______________________________________________
>>>>>> OpenHeart-L mailing list
>>>>>>
>>>>>> Send postings to:
>>>>>>  OpenHeart-L at lists.hsforum.com
>>>>>>
>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>>>
>>>>>> All messages transmitted by the OpenHeart-L are subject to the
>>>>>> policies and
>>>>>> disclaimers posted at:
>>>>>> http://www.hsforum.com/listdisclaim
>>>>>> -----------------------------------------
>>>>>
>>>>> _______________________________________________
>>>>> OpenHeart-L mailing list
>>>>>
>>>>> Send postings to:
>>>>> OpenHeart-L at lists.hsforum.com
>>>>>
>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>>
>>>>> All messages transmitted by the OpenHeart-L are subject to the
>>>> policies
>>>>> and
>>>>> disclaimers posted at:
>>>>> http://www.hsforum.com/listdisclaim
>>>>> -----------------------------------------
>>>>>
>>>>> _______________________________________________
>>>>> OpenHeart-L mailing list
>>>>>
>>>>> Send postings to:
>>>>> OpenHeart-L at lists.hsforum.com
>>>>>
>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>>
>>>>> All messages transmitted by the OpenHeart-L are subject to the
>>>> policies
>>>>> and
>>>>> disclaimers posted at:
>>>>> http://www.hsforum.com/listdisclaim
>>>>> -----------------------------------------
>>>>>
>>>> _______________________________________________
>>>> OpenHeart-L mailing list
>>>>
>>>> Send postings to:
>>>>  OpenHeart-L at lists.hsforum.com
>>>>
>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>
>>>> All messages transmitted by the OpenHeart-L are subject to the
>>>> policies and
>>>> disclaimers posted at:
>>>> http://www.hsforum.com/listdisclaim
>>>> -----------------------------------------
>>>
>>> _______________________________________________
>>> OpenHeart-L mailing list
>>>
>>> Send postings to:
>>> OpenHeart-L at lists.hsforum.com
>>>
>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>
>>> All messages transmitted by the OpenHeart-L are subject to the
>>> policies and
>>> disclaimers posted at:
>>> http://www.hsforum.com/listdisclaim
>>> -----------------------------------------
>>
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>>  OpenHeart-L at lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the  
>> policies
>> and
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>
>
>
>
> -- 
> Prasanna Simha M
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------