AW: [HSF] Intimal Tears

Mon Feb 4 08:36:15 EST 2008

Did the patient get Aprotinin? 
Hard to think it today...
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Michael
Firstenberg
Gesendet: Montag, 4. Februar 2008 03:05
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: [HSF] Intimal Tears

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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