[HSF] Intimal Tears

Mon Feb 4 13:00:50 EST 2008

Ani,
  Just curious, was the doc who injured the artery a resident?

Hal
Sent from my Verizon Wireless BlackBerry

-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>

Date: Mon, 4 Feb 2008 12:44:02 
To:<openheart-l at lists.hsforum.com>
Subject: RE: [HSF] Intimal Tears

I they usually used a combination of inhalational and intravenous anesthesia so presumably something was getting in. It was a young child so we don't know if there was awareness.

Ani

> Date: Mon, 4 Feb 2008 07:35:00 -0500> From: msfirst at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Intimal Tears> CC: > > Ani -> Does that mean that your patient was not getting any anesthesia during the> case?> > -michael> > > On 2/4/08, Ani Anyanwu <anianyanwu at hotmail.com> wrote:> >> > > 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> > 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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>> > -----------------------------------------> >_________________________________________________________________> > Telly addicts unite!> >> > http://www.searchgamesbox.com/tvtown.shtml_______________________________________________> > 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 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