[HSF] Intimal Tears

Mon Feb 4 11:49:59 EST 2008

> and close the rent with a purse string. The last option is remove the> dilator , compress and cancel the case for 24 hours.

Prasanna

This last option has two advantages - 1) It will differentiate a carotid puncture related stroke from a surgeon related stroke - you never know what the anesthesiologist has done and if any drugs have been given. We recently had a patient stroke after direct administration of norepinephrine and propofol into the carotid artery (this was in an ICU patient with the line placed by a surgeon). 2) Avoids a neck incision.

We had a similar case to yours in a child when I was at Harefield, where we could not get the ACT to rise despite boluses and boluses of heparin. In the end doing it the old fashioned way worked (directly injecting into the RA). At some point in the surgery the right pleura was opened to reveal white fluid (propofol) - all the medication had been going straight into the pleural cavity where the tip of the line resided.

Ani

> Date: Mon, 4 Feb 2008 07:41:16 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Intimal Tears> CC: > > This is well described in Wileys text ook of anesthesiology and In Kaplan.> If only a needle puncture or guide wire has been passed then removal and> compression is to be done. If a dilator or sheath has been passed there are> three options - open and surgically close the artery. Heparinize , go ahead> with cardiac surgery and at the end before heparin reversal open the artery> Incidentally there is another type of injury. A decade back we had a case> in the OR. Routine ASD , neck line placed after multiple> attempts.Childcollapses and I was called in from another OR by the> cardiac surgeon who had> just passed his MCh as the child had nearly arrested pressures in the 20's.> We went hurriedly on CPB and on opening the pericardium there was an empty> heart and some bruising in the upper left thymic area. We kept having "loss> of volume on CPB so I opened up the right pleura and there was nearly a> liter of blood there. I then had tp excise the bloated thymus and> surrounding tissue and saw a lacerated subclavian artery. The tear was> repaired but the child died.(Period of hypotension CPB establishment> difficulties and perfusion difficulties all added up) In retrospect the> anesthesiologist used to "fast jab" and turn the needle to seek the artery> while still having a substantial amount of needle in the tissues. We decided> that maneuver should never be used (ie full withdrawal and repositioning of> the needle at all times should be used) We have so far not had a repeat of> the same. Incidentally another cause for a right upper shadow is hemorrhage> from needle stick injury of the apex of the lung.> Prasanna> > On Feb 4, 2008 6:53 AM, Mitch Lirtzman <drmitch at cox.net> wrote:> > > Actually, a covered stent is an excellent solution. We had to do that for> > a> > cachectic old lunger for whom surgery was not an option. This was when the> > Viabahn( ? sp) was still investigational and we had to get a compassionate> > use permit for it. Just a little ancient history.> > MitchAt 11:30 AM 2/3/2008, you wrote:> > >I was involved with a heart-lung transplant where an excellent team put> > an> > >introducer into the subclavian artery (she had abnormal anatomy to begin> > >with) - we just left it in for a day or two then vascular put in a> > covered> > >stent (would not have been my first choice - as I would have done a> > primary> > >repair in the OR - but that is since we deal with axillary artery> > >cannulation all of the time). She did fine> > >> > >> > >-michael> > >> > >> > >On 2/3/08, 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> > > > > >>> > > > > > _______________________________________________> > > > > > 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 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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> -----------------------------------------
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