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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