AW: [HSF] Intimal Tears

Ben Bidstrup benjamin.bidstrup at bigpond.com
Wed Feb 6 00:48:41 EST 2008


Roberto, Prasanna
Can you give me a theoretical basis for aprotinin 
leading to clotting in the pump circuit after 
decannulation?



>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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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon


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