[HSF] Bleeding

[Prasanna Simha M]

I saw Dr Mohr applying it(Tachosil) in Leipzig for a case. I did not know it
is that expensive .
Prasanna

On Sun, Aug 2, 2009 at 12:56 PM, Giuseppe Rescigno <grescigno at mac.com>wrote:

> Prasanna,
>
> in case of postop massive hemothorax I prefer to approach it through a
> thoracotomy, like you did. I have noted that the patients tolorate a small
> thoracic cut very well. In Europe we use a product called Tachosyl that is
> effective in controlling parenchimal oozing (about 200 euros each)
>
>
> Giuseppe
> Il giorno 01/ago/09, alle ore 18:16, Prasanna Simha M ha scritto:
>
>  I had an unusual case  which I would like  to be commented on by the
>> forum.
>>
>> Pateint was a 50 year old male who had a closed and then an open mitral
>> valvotomy follwoed by a balloon mitral valvotomy. patient now had severe
>> calcific MS and severe TR , siginificant RV dysfunction , hepatic
>> dysfunction (Childs A) and was O negative.
>> He under went a redo mitral valve replacement. I had fem fem cannulation
>> and
>> a suprahepatic  perfusion (NTG) catheter.. I did the sternotomy under RAP
>> (retrograde priming) induced  elective hypotension that allows the RV adn
>> RA
>> to fall back and I did not have to go on CPB at sternotomy. I did a
>> limited
>> dissection and entered the right pleura. I actually was able to open the
>> left pleura despite an old CMV and noted some adhesions inferiorly and did
>> not have to do any dissection per se ther (monor release of a couple of
>> adhesions to allow me to deair the heart.
>> I went trans RA transeptal without taping the cavae and repaired the
>> tricuspid wtih my inidgenous rng and did the mitral replacemnt with a 25
>> mm
>> Medtronic easy fit valve. Things looked uneventful and when I came off CPB
>> statretd doing modified ultrafiltration when I noticed a lot of blood
>> collecting in the left pleural cavity which I could not see. Ithought
>> initally it may be collected blood but it kept reaccumulating and I could
>> not really see any bleeder per se. I packed and thought things would
>> settle
>> with protamine. It did not and I tried seeing with a dental mrror and
>> finally thought I will pass a rigid bronchoscope through  the lateral
>> chest
>> wall but later ended up doing a small thoracotomy and inspecting the
>> pleural cavity where I saw a significant spurter from what looked like an
>> avulsed adhesion  and a lot of ooze from the lung surface in that area (I
>> had not ventured into that area.) and it  was in a cul de sac which was
>> impossible to see from the front.I underran the spurter in the lung and
>> ball
>> cauterised the oozing but there was still some oozing so took a long
>> vaginal
>> pack role and packed the area and brought it out through a small opening
>> in
>> the small thoracotomy. It has stopped the bleeding.
>> Patient was shifted on multiple intropes which was rapidly reduced  after
>> shifting to the ICU (needed more of volume supplementation in my opinion
>> than inotropes). patient had Sats of  around 75 % and some bleeding from
>> the
>> ET tube. I insisted on using a lung protective strategy of ventilation and
>> did not allow the FiO2 to be accelerated above 40 %but used  low tidal
>> volume high PEEP open lung strategywith open lung maneuvers to be done
>> whenever the ET tube is discinnected for suctioning.. Currently the
>> patient
>> is hemodynamically stable. Sats are creeping up and Sats are now 94 % and
>> slowly rizing. lactates decreasing and currently on 3 mics dopamine + 0.35
>> mics of Milrinone /Kg/min as inotropic support and 3 mics/Kg/min of NTG
>> through the suprahepatic intraaortic perfusion catheter. X Ray shows some
>> whitening locally of the lung and the pack . There is no bleeding from the
>> ET tube currently. He is getting awake but I have told the registrars to
>> extubate him only after the pO2's pick up above 90 mm Hg and  with PEEP
>> decreased to 10mm Hg.
>>
>> What could be the causes of avulsion of this adhesion - sternal spreading
>> ?
>> (it was way below and out of site.How would you manage it ? I hope this
>> patient doesnt  have additional complications. I hope I can remove the
>> pack
>> after 72 hours with local anesthesia and a bit of Ketamine/Propofol.I am
>> particularly worried as he ahd a significant period of hypotension and
>> hope
>> this does not adversely  affect his borderline hepatic function. He also
>> has
>> received  donated (non autologous blood) which I always worried about
>> giving
>> in patients with hepatic dysfunction.
>>
>> --
>> Prasanna Simha M
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-- 
Prasanna Simha M