[HSF] Sympathy anyone.......

[Michael Firstenberg]

Ed - Thanks for the reassurance - I still feel pretty new at this, but often
find myself jumping in head first.  I feel very lucky to have great help.

Tea - but they had a very short door to needle time (and even shorter time
to OR).......

Prasanna - ahhh, intra/post-op bleeding.  In cases like this, where I know
it is going to be a problem.  I think the key is anticipation of the
problem.  As I was making incision, I called the blood bank and told them
that whatever they have, order more.  We have a good relationship with the
blood bank - but we have to notify them in advance.  I usually get the stuff
in the room right before I talk the cross-clamp off.  Ince I am off pump, I
will pack the chest while the protamine and products kick in (hopefully)
while I am putting in chest tube and waiting.  I think you need to give the
products right away, if you wait for coagulopathy to start, then it can be
too late.  If they are really wet, and I am convinced that it is not a
proline deficiency, then we also use a lot of hemostatic agents - Bioglue,
CoSeal, FloSeal, Fibrilar, Surgicell, NuKnit, Arista - anything.  Since we
are not allowed to leave packs in the chest then I will tend to fill
potential spaces to some of this biodegrable stuff.  If still wet then an
extra chest tube or 2 in the mediastinum and bring them to the ICU.  There
was an old saying in Cleveland - "dark and warm".  We are VERY liberal with
blood, products, and these agents.  We also use a lot of rFVII.  I try to be
smart about it - like if they have anti-platelet agents on board, then give
them platelets (duh) - but I know a lot of people will order everything.  We
also have intra-operative TEGs which help.....and if all else fails, we let
them them bleed and bleed and bleed until they stop (which they usually do -
at some point), tamponade (fortunately less often), or we bite the bullet
and take them back.  It is all very expensive, but it sometimes beats the
alternatives.  Most of our patients are on something coming to the OR, so we
are a little use to post-op bleeding.  I some sure others have tricks that
work for them - but in some of these kinds of patients, I want them to just
get out of the OR alive and we can live to fight another day.  I had a lot
of experience in general surgery/trauma with packing the abdomen for 24hrs
to get them tuned up.  Warm and dark...... and anticipate the problem.

John - I do not disagree and we have discussed non-operative management,
however I am not sure there is any sound medical (or legal) grounds to
delaying surgery in a relatively healthy person just cuz they have poisons
on board.  Judging from how his aorta looked in the OR and how it was
falling apart in my hands as I was trying to fix it, I can not imaging
waiting.  Again it is a philosophy - with a lot of literature to back it up.

.... he is doing OK today, slowly waking up, no drips, keeping his pressure
down and gentle sedation so that hopefully we can make a soft landing.......


-michael

On 4/30/08, Edward Bender <ebender001 at charter.net> wrote:
>
> Michael:
> In a lot of your messages you beg indulgence due to your novice status.  I
> think that you must drop that now since you are doing a lot of "big-boy"
> cases successfully.
>
> Ed Bender, MD
>
>
> On 4/30/08 8:26 PM, "Michael Firstenberg" <msfirst at gmail.com> wrote:
>
> > 51 year/old.....presented with 4 day history of chest pain.
> > Tall, thin, long fingers....
> > ST changes on ECG.
> > Concern for AMI
> > Given:
> > ASA
> > High dose Plavix
> > Lovenox
> >
> > taken to cath lab
> >
> > found to have Type A dissection from valvue to iliacs........
> >
> >
> > oh, he also got reopro............
> >
> >
> > it has been a long day.
> >
> >
> > -michael
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