[HSF] Intimal Tears

Mon Feb 4 21:20:26 EST 2008

In a young girl of 14 undergoing PDA ligation,I have seen chylothorax in 
chest drain.This happened after insertion of central line on the left side.
Shahid Malik
----- Original Message ----- 
From: "Michael Firstenberg" <msfirst at gmail.com>
To: <OpenHeart-L at lists.hsforum.com>
Sent: Monday, February 04, 2008 5:35 PM
Subject: Re: [HSF] Intimal Tears

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> > > > > >>> > > > > >
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