Re: [HSF] Gangrenous bowels post uneventful CABG

Sun Jan 6 14:46:37 EST 2008

From?my first case as an attending I asked the perfusionists to aim at 2.5 - 3.0 L/min/m2. Why? Because that is normal. This was theory not proven good practice. However when others were adding sod. bicarb. to keep the pH normal? and seeing rises in pancreatic enzymes post bypass this did not happen to us. 
At low flows (1.8-2.2 L/min/m2)? pulsatile bypass? improves perfusion. At 2.5-3.0 L/min/m2 pusatility does not add to the quality of perfusion. We did a small randomised study of this looking largely at the endocrine response to extracorporeal circulation. (Published in JThor and CV Surg in the 80's).
Unfortunately I don't have access to these references at present.
The message is give your patients a normal flow on bypass as far as you can ( + many other things of course)
Bob

-----Original Message-----
From: alsadd <alsadd at ksu.edu.sa>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 6 Jan 2008 3:11 pm
Subject: RE: [HSF] Gangrenous? bowels post uneventful? CABG

Bob:
Thank you for very interesting information I will look into it. Any specific
recommendations would be appreciated. How do you run the pump in your setup?
True that case in question did not have pulsatile CPB.
Ahmed

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
rwmfglycar at aol.com
Sent: Saturday, January 05, 2008 11:45 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Gengrenous? bowels post uneventful? CABG

What was unusual about this patient was that he was apparently up and
walking around when the gut necrosis became evident.This suggests that a
post traumatic hypercoagulable state may hve been part of the problem in a
vasculopath who has had many other parts of his cardiovascular system
roughed up and perturbed in the previous few days .
One? other fact to remember is that at the flows that some units run the
bypass machine the mesenteric flow gets to very low levels. At the commonly
used?2.2 L/min/ m2 the patient is in borderline shock.? (There were numerous
studies of mesenteric flow during bypass 30-40 years ago).?The patient
almost certainly already?had a reduced cardiac output preoperatively. A
lowflow nonpulsatile bypass? on top of that could easily?have produced
pregangrenous ischemic bowel, especially if he already had mesenteric
arterial disease.??Anything extra on top of that can tip the scale.
What I and others are saying is that this was not gangrenous bowel after
uneventful cardiac bypass. 

Bob

-----Original Message-----
From: alsadd <alsadd at ksu.edu.sa>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 6 Jan 2008 11:40 am
Subject: RE: [HSF] Gengrenous? bowels post uneventful? CABG

Thank you I will look it up soon

Ahmed

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of CSPassik at aol.com
Sent: Saturday, January 05, 2008 3:04 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Gengrenous? bowels post uneventful? CABG

There was some old literature on concommitant intrarterial priscoline and 
salvage surgery.   Look up some old papers from Boley, SJ et al dating from
the 
early 1980's. We used to follow this protocol and had what was stated at the

time was the lowest mortality rate from embolic bowel infarction.
Basically, 
an angio catheter was placed by interventional radiology in the SMA and
infused 
priscoline to offset the concomitant spasm that went along with the emboli.

The patient was explored, the SMA embolectomized ,   and the bowel was 
reexamined at 24 hours if I remember correctly.   Sometimes some questinable
bowel   
that initially looked non viable was saved.   I don't think many hospitals 
besides ours(Montefiore in NY)   did this and very few others seem to
remember 
this work. Even if it is too late for this patient it might be worth
thinking 
about when one of our poor patients gets this devastating complication.
Cary Passik

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