[HSF] Thoracic Pseudoaneurym

Tea Acuff tacuff at swbell.net
Wed May 28 15:37:39 EDT 2008 

Sounds like a fairly "liberal group" of JHW, but who am I to complain about the theological details. 
What is so interesting about this group of patients is the "extreme" bias rationalized in the management of the cohort. I think this is actually what happens in a unformalized manner in the local practices of different surgeon particularly as we can see from different countries/ interests/ training as is obvious from the variety of options/ opinions we are exposed to in the forum.
Do you think circ arrest is required for the case? Would like to avoid CPB before sternal split? What is your assessment of the risk of inadvertant hemorrhage vs prolonged CPB?
tea



----- Original Message ----
From: "tdmartin2000 at aol.com" <tdmartin2000 at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, May 28, 2008 1:57:02 PM
Subject: Re: [HSF] Thoracic Pseudoaneurym

OK here is our JHW and soon to be "blood conservation" group protocol

1. Pt seen as outpt in clinic with all studies including a pre clinic cbc, inr, pt/ptt, plt count
2. If all are not normal- do everything possible to correct them, Usually epo will do
3. Try to get hct to 40 to 45 if at all possible. (my anecdotal experience is that the hct will drop by 1/3 for a pump of 2 to 3 hrs. Hct is just a number that will allow you to take 2-3 usnits of blood off at the beginning of your case
4. Ask the pt (if JHW) what they will take. Many will now take "fractions of blood" including albumin and cryo. All will take recombinant factor7.
5. Make sure that all blood drawn on admission is done in pediatric tubes and make sure they do not get typed or cross matched (may be on standard admit orders)
6. Make sure all team personel are well aware of the JHW status to avoid any mistakes preoo or on admission
7. In the OR take 2 to 4 units of blood off prior to heparinization. This is done in CPD bags from the?blood bank. the key is to make sure that blood does not come in contact with the pump thereby salvaging all factors and plts which are actually more important that the red?cells. You have to have an anesthesiologist that is comfortable doing this and can do it safely. 
8. Surgical technique has to be meticulous and not even the capillaries are allowed to bleed on entry. Everything is done with the electrocautery. 
9. Use a low volume pump set up and possibly retrograde prime, along with a hemoconcentrator on the pump.
10. Do everything possible to limit pump time and amount of cooling. For aortic archs, consider axillary cannulation or antegrade perfusion of the arch vessels at a higher temp than normal (28 instead of 20 to 18).
11. for non JHWs do not transfuse on pump unless the hct goes below 18.
12. For JHWs do not check hct unless done with istat and try to do all labs w istat to limit blood use.
14. Give at least 40u/kilo of heparin to limit the possiblity of under anticoagulation which may lead to consumption of factors and plts
15. If aprotinin is available and it is more that a first time operation then I would use it.
16. Come off pump warm- at least 37c
17. Limit cell saver use if possible during pump run
18. Give back all blood taken off at the beginnng after the protamine is in
19. Use bioglue on all aortic grafts ( i forgot to put this in earlier)
20. Do not close until it is the Sahara
21. Do not hesitate to use whatever the pt will allow for products- including factor 7.
22. Make sure the ICU team is on board and doesn't "lab" the pt to death and uses care in volume replacement.

I am sure I have forgotten something but these are the basics.

Tom Martin
U of Florida
Gainesville


-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 27 May 2008 10:07 pm
Subject: Re: [HSF] Thoracic Pseudoaneurym



i also have associated bloodless complex heart surgery as an oxymoron.
maybe those who practice it routiely can shed some light on their
system - obvously more than just being good surgeons.

On 5/27/08, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> Michael
>
> At 74 and with two prior, and gracious, gifts of bloodless cardiac surgery,
> I think this patient needs a compelling reason, and a compelling surgeon, to
> earn himself a third.
>
> I wonder given that he is asymptomatic how this was diagnosed: 7.8 cm might
> sound dreadful but if we had another CT from 18 months ago, or one 12 months
> from now, that also showed 7.8 we might be a bit more relaxed. As surgeons
> we always feel a need to fix things but it is not clear in my humble opinion
> that his life expectancy with surgery is necessarily better than his life
> expectancy without surgery. Certainly his surest way of being alive in three
> or six, or even likely twelve, months is not to have surgery, and his surest
> way to be dead in a month is to have surgery today. Although Dr Martin's
> group does have phenomenal success in these patients, I suspect that in most
> hands, embarking on such a surgery will transform to physician assisted
> death. Many groups have not even been able to perform routine hypothermic
> arrest cases without blood products.
>
> I think some things are mutually exclusive - in the same way a cardiologist
> would not place a drug eluting stent in someone who will not take
> antiplatelet agents, we should not embark on such major reoperative surgery
> in a (relatively) anemic elderly patient who will not have a blood
> transfusion. Blood transfusion is as integral a part of therapy for his
> disease as is antiplatelet therapy for coronary stenting.
>
> Ani
>
>
>
>
>> From: cardsurg at bellsouth.net> To: OpenHeart-L at lists.hsforum.com> Date:
>> Tue, 27 May 2008 16:10:03 -0400> CC: > Subject: [HSF] Thoracic
>> Pseudoaneurym> > I have a 74 yo Jehovah witness two years out from a redo
>> AVR with a 7.8 cm> pseudoaneurysm adjacent to the ascending aorta. The CTA
>> suggest a small> communication, at the level of the aortic suture line.
>> The Pseudoaneurysm> abuts the sternum. His hemoglobin is 12.6. He is
>> presently asymptomatic> with no fever or chills but occasionally gets
>> "pressure in his chest". He> is the sole care giver for his bedridden
>> wife.> > I have proposed extracorporeal circulation, hypothermic
>> circulatory arrest> and repair with a conduit if his hemoglobin were
>> higher. With the current> limitations regarding erythropoietin use I would
>> welcome input on management> suggestions.> > Michael Vincent Smith, MD> >
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