[HSF] Intimal Tears

Mon Feb 4 07:54:38 EST 2008

And your suspicions ?
Prasanna

On Feb 4, 2008 7:50 AM, Michael Firstenberg <msfirst at gmail.com> wrote:

> 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
> >>>>>>>
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> >
> >
> > --
> > Prasanna Simha M
> > _______________________________________________
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-- 
Prasanna Simha M