[HSF] Bloodless arch

Thu May 29 20:21:52 EDT 2008

I don't know what is wrong with you guys. If I can get out at 1500, I am all for it. Think what you want about me. I won't lose any sleep over it!
tea

----- Original Message ----
From: "Douville, Chuck" <ecdouville at orclinic.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, May 29, 2008 6:37:51 PM
Subject: RE: [HSF] Bloodless arch

Ani makes a great point here. I admire Tom and others who can do such a case without blood products. Dr. Martin has clearly shared how his JW program works and over time, he had demonstrated that his program is worthy of trust to be allowed to do a case such as this.
In my institution, the epo $ is a barrier to getting it and some will not pay for it. There have been concerns in the literature about using epo to push the hematocrit over 36, as I recall, though not in cardiac surgery patients. Regardless, neither I nor my associate would offer a redo arch aneurysm JW patient surgery, right now.  By the way, we do very good work, and we don't leave at 3 o'clock.
chuck

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Ani Anyanwu
Sent: Thu 5/29/2008 5:19 AM
To: openheart-l at lists.hsforum.com
Subject: RE: [HSF] Bloodless arch

Prasanna,

The question is not how many Ross, AAA, redos etc you have done without blood but how many such operations you have done in JW patients. The two are very different. Running a tight blood conservation program is very different from signing a contract of bloodless surgery with a patient beforehand. I presume you no more crossmatch blood for these cases given that you do them all bloodless or do you still have blood on reserve? The problem with case scenarios like this is that as the discussions go on, they become more and more academic and we lose track of the initial problem. We divert from the case at hand and talk more about theory, experience and scenarios which actually bear little relevance to the OP. Maybe if we want to recount anecdote or theory we should talk specifically about redo aortic surgery in an elderly JW patient done without blood - how many have even attempted this, talk less done this successfully?

My question to you directly - and to all others - is would you agree to undertake this operation without blood? I think that, more than any theory, will be more relevant to Michael who brought this up. So far only Dr Martin has said specifically that he has operated on similar problems in JW and he would consider operating on this patient if certain criteria are met. Lets cut to the chase - Prasanna and others - is there anybody else here that has seriously successfully operated on such a JW patient (74, two prior sternotomies, aneurysm abutting sternum, Hb 12.8, presumed requirement for DHCA), or would honestly consider doing so, without access to back-up of the blood bank? We must be very careful in seeming to advise a colleague to do an operation that we either have not done, or would not do, ourselves.

Ani

> Date: Thu, 29 May 2008 11:58:50 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Bloodless arch> CC: > > I agree. I have also done Ross, AAA and redos etc without blood. The> important thing is to treat each of these cases like a JW. I have a small> variation of your protocol which is essentially the same except for> returning the blood that is drawn after bleeding decreases if the field is> not wet. Thus the patient drains dilute blood and then is infused with the> fresh blood that has been kept on a Kahn agitator. The net HCt can thus be> increased. If wet I give one units that have been drawn and this allows for> hemostasis.I also make it a point to keep lines short, dry venous line> ,vacuum assist and retrograde prime routinely.I also return the whole pump> volume with forced diuresis and liberal SNp with antiTrendlenburg position> to allow the whole pump volume to be returned fully.On the next day I give
 a> slow diuretic infusion to dry out the patient slowly so that he is dry and> not having any failure fluid.> Prasanna> > On Thu, May 29, 2008 at 8:41 AM, <tdmartin2000 at aol.com> wrote:> > > Just a note concerning difficult cases without blood use.> > 71 yo 10yrs s/p AVR and 6 yrs s/p ascending replacement for acute> > dissection. Presented with 7 cm root and 6 cm pseudoaneurysm of the distal> > anastomosis between the aorta-SVC-rPA. Starting hct 39. Operated today- 3rd> > time sternotomy, redo complete root w valve conduit, ascending and total> > arch replacement. We followed the blood conservation protocol similar to> > what I outlined previously for JHWs. We took 3 u of blood off at the> > beginning and the hct on pump ran 22-24. Pump time 266 min, card ishemia 140> > min, circ arrest 26 min. After protamine the blood was reinfused and he> > dried up without problems. No intraop blood or products given. hct in> > icu-31, doing well.> > I wish they all
 did this well but I just wanted to point out that it is> > possible to do these cases without blood even in non JHWs.> >> > Tom Martin> > U of Florida> > Gainesville> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and >
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