Awake open heart surgery

[GoodmanBrown]

In this case, a picture is worth a thousand words. From Wired UK:

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[sevoflurane]

Thoracic epidural? Been done before. Still.... a little crazy.

 

[GoodmanBrown]

Thoracic epidural? Been done before. Still.... a little crazy.

Oh, yeah. I wasn't really thinking it was totally brand new or anything. I think the thing that made it interesting for me was that when I first clicked on the link, the picture went off the bottom of my computer screen. So, I was just looking at the face with the drapes. So when I scrolled down, it came as a surprise. Thought it was interesting enough to post.

 

[sevoflurane]

Yeah man... I hear ya. Highlights the fact that there is a billion different ways to skin a cat.

 

[Noyac]

Something doesn't look right in that picture. THe head is straight but the body is twisted to the pt's left.

I'm skeptical.

 

[proman]

There's a video of a woman in Turkey having a CABG done under high thoracic epidural. Not sure about the validity of this picture, but it's been done elsewhere.

Why is a better question.

 

[sevoflurane]

There's a video of a woman in Turkey having a CABG done under high thoracic epidural. Not sure about the validity of this picture, but it's been done elsewhere.

Why is a better question.

Been done at UPitt many times.

 

[Licoricestick]

Something doesn't look right in that picture. THe head is straight but the body is twisted to the pt's left.

I'm skeptical.

I agree something isn't quite right about this picture. I hadn't noticed the body angle til Noyac point it out, but isn't that pump tubing coming left to right across the picture, just at the end of the sternotomy? Whilst I'm aware there are case reports of awake CABG, I don't think anyone has been crazy enough to extend this to ON pump CABG.

Of course it's a couple of years since I have been involved in any hearts... and I guess they could have the circuit hooked up just in case (although I don't recall seeing it done that way for off pump cases before - just a pump available and ready to go in the perfusion room if required).

 

[Planktonmd]

I don't know if the picture is legitimate but I have to say that I find the concept of putting a patient on bypass while they are awake very fascinating.
I have never seen it but I would love to know if any one has seen it or heard of it.
I wonder if the perfusion pressure would be adequate to maintain normal mentation and what would the patient's experience be like?

 

[rsgillmd]

Something doesn't look right in that picture. THe head is straight but the body is twisted to the pt's left.

I'm skeptical.

I noticed the same thing. But what I can say is I know it's been done many times for off-pump in India. When my uncle had a CABG, he asked about it, but was told there were too many vessels to do off-pump.

 

[proman]

I agree something isn't quite right about this picture. I hadn't noticed the body angle til Noyac point it out, but isn't that pump tubing coming left to right across the picture, just at the end of the sternotomy? Whilst I'm aware there are case reports of awake CABG, I don't think anyone has been crazy enough to extend this to ON pump CABG.

You can do these awake on pump. We'll have kids on ECMO awake and interactive, so I don't think it's that absurd.

But, I'm still waiting to hear for a good reason to do it this way. One reason to not do it awake is that you lose the benefit of pharmacologic (volatile and opioid) preconditioning that you would get asleep.

 

[somedumbDO]

so do they not do hypothermia?? cooling someone down to 30 minus awake seems pretty uncomfortable, also mentation?? interesting

 

[urge]

Anyone else wondering about respiratory mechanics?
What happens when the pleura is opened?

 

[cchoukal]

And what do you say them when they realize they just stroked out?

"Doc, is my face drooping? Why do I smell almonds?"

 

[Planktonmd]

ECMO and bypass + hypothermia are not the same.

You can do these awake on pump. We'll have kids on ECMO awake and interactive, so I don't think it's that absurd.

But, I'm still waiting to hear for a good reason to do it this way. One reason to not do it awake is that you lose the benefit of pharmacologic (volatile and opioid) preconditioning that you would get asleep.

 

[Bertelman]

I was suspicious that photo was shopped when I first saw it, but reading the article put my mind at ease...

Open-heart surgery in seven easy steps

1. Insert an epidural catheter into the patient the day before the operation.

2. Patient to theatre. Administer a test dose of the epidural below the nape of the neck.

3. Give the patient the full dose and wait 20 minutes for all sensation from the chest to be blocked. Test by prodding the patient’s skin with a needle.

4. Open breastbone using electric saw.

5. Main surgery.

6. Close the breastbone with steel wire and close skin.

7. Transfer patient to intensive care.

Clearly that's journalistic integrity over at Wired UK.

 

[proman]

ECMO and bypass + hypothermia are not the same.

CPB can be done without hypothermia.

 

[hoyden]

Something doesn't look right in that picture. THe head is straight but the body is twisted to the pt's left.

I'm skeptical.

agree and the proportions of the head and other parts do not match. Head is too big( as if it is a toddler by proportions)

 

[Planktonmd]

Have you ever heard of open heart surgery done with bypass and cardiac arrest without hypothermia?

CPB can be done without hypothermia.

 

[urge]

Have you ever heard of open heart surgery done with bypass and cardiac arrest without hypothermia?

You can do a cabg with warm bypass and a beating heart.

I think the picture was taken with a wide angle lens and cropped to show the relevant stuff.

 

[proman]

Have you ever heard of open heart surgery done with bypass and cardiac arrest without hypothermia?

I've done it.

 

[Planktonmd]

I've done it.

Ok,
I am a little rusty on cardiac anesthesia, I understand that it is possible to go on bypass with cardiac arrest with normothermia, but how long can you stay on bypass without cooling?
Do you have to use a higher than usual perfusion pressure?
What is the advantage of doing it without hypothermia?

 

[doctor712]

What makes me skeptical... where was that camera when the shot was taken? Imagine how difficult the logistics would be to get above the sterile, surgical field, mid-procedure, to grab that PERFECT shot...hmmm.
Without a ladder placed over the bed, that is.

 

[GoodmanBrown]

I was suspicious that photo was shopped when I first saw it, but reading the article put my mind at ease...

Open-heart surgery in seven easy steps

1. Insert an epidural catheter into the patient the day before the operation.

2. Patient to theatre. Administer a test dose of the epidural below the nape of the neck.

3. Give the patient the full dose and wait 20 minutes for all sensation from the chest to be blocked. Test by prodding the patient’s skin with a needle.

4. Open breastbone using electric saw.

5. Main surgery.

6. Close the breastbone with steel wire and close skin.

7. Transfer patient to intensive care.

Clearly that's journalistic integrity over at Wired UK.

Another point in favor of some shadiness is that you can order the DVD from the surgeon (anesthesiologist?) to get your step-by-step instructions. But it's only available if you're a surgeon or anesthesiologist, that way laypeople can't try it at home!

 

[Bertelman]

What makes me skeptical... where was that camera when the shot was taken? Imagine how difficult the logistics would be to get above the sterile, surgical field, mid-procedure, to grab that PERFECT shot...hmmm.
Without a ladder placed over the bed, that is.

I've already voiced my opinion regarding the legitimacy of the shot, but I could take a similar vantage point during every case in the OR. All it takes is a step up, and from our view that's exactly what the operation looks like, albeit upside-down.

 

[proman]

Ok,
I am a little rusty on cardiac anesthesia, I understand that it is possible to go on bypass with cardiac arrest with normothermia, but how long can you stay on bypass without cooling?
Do you have to use a higher than usual perfusion pressure?
What is the advantage of doing it without hypothermia?

Major benefit is avoiding comlications of hypothermia. We've done it for patients with cold hemaglutinin disease (+/- plasmapheresis) and for muscular dystrophies (softer call).

Most (90%) of your myocardial protection comes from asystole. Going from beating, full, perfused to asystole, empty and cross clamped reduces myocardial oxygen consumption from 10ml/100g/min to 1, at 37 degrees. So warm CPB can still be very protective. Going from 37 to 32 only give 20% reduction, 32 to 28 is another 20%.

Even without doing warm CPB, some times we'll passively cool (drift) and they normally get to 33 or so. But the main keys to cardiac protection is having an asystolic empty heart.

There are risks, flows (not pressure) tend to be higher and bubbles are more likely to form. Risk of stroke is also tripled, and you do lose the cerebral protective effects of hypothermia. The few I've done warm, the risk of hypothermia was felt greater.

Still waiting to hear a good reason to do a heart awake.

 

[proman]

The December 03 SCA newsletter has an article on awake heart surgery at http://www.scahq.org/sca3/newsletters/2003dec/drug5.shtml

FTA:
Awake heart surgery (AHS) has been concluded to be "feasible" and "safe".7-12 The conversion rate to general anesthesia with endotracheal intubation ranged from 0-10%.7,8,10,11 Reasons for conversion included inadequate analgesia, or respiratory difficulties relating to pneumothorax. As many as 28% of cases are complicated by a pneumothorax.7,8,10 Approximately 8% of cases need additional infiltration with local anesthesia in the xyphoid or suprasternal notch, and one patient had inadequate analgesia.8 Of the 208 patients included in these articles, perioperative analgesia was excellent in 207 patients.7-12 Duration of stay in the intensive care unit ranged from 0 to < 24 hours, while hospital stay ranged from 1 to 7 days.7,8,10,11 In one study, 8 patients were discharged home the same day of surgery after meeting the following criteria:8

Patient demand
Technically flawless operation
Postoperative blood loss < 150 cc/4 hours
No evidence of ischemia by electrocardiogram or echocardiography
Stable hemodynamics
No pain
Flawless assisted mobilizations in first hour
Flawless nonassisted mobilization at the fourth hour
Negative echocardiography at the 6th hour
Discharge at the 6th hour

Still sounds crazy to me.

 

[dhb]

Ok,
I am a little rusty on cardiac anesthesia, I understand that it is possible to go on bypass with cardiac arrest with normothermia, but how long can you stay on bypass without cooling?
Do you have to use a higher than usual perfusion pressure?
What is the advantage of doing it without hypothermia?

I don't think hypothermia has proved it's superiority over normothermia. At my program we do all our hearts in normothermia except for deep circulatory arrest of course.

 

[Antibiotix2006]

http://www.youtube.com/watch?v=zPBdSNMnXSc

Awake CABG's are common at this hospital in Bangalore, India. However the surgeon is being credited for it.

 

[bigdan]

Been done at UPitt many times.

Here's a link to cardiac surgery done at UPMC; it was a MIDCAB at the VA.

http://www.sciencedaily.com/releases/2000/07/000705055700.htm

dc

 

[Wife of awake]

In this case, a picture is worth a thousand words. From Wired UK:

My husband is the one many of you were talking about in early 2007. He was on Dateline, interviewed by Hoda Kolb

 

[Spinach Dip]

Mind = Blown

 

[Spinach Dip]

Anyone else wondering about respiratory mechanics?
What happens when the pleura is opened?

That was one of my first thoughts also. Breaching the chest wall => collapsed lung waiting to happen.

I suppose bag-mask ventilation would work if the patient can't maintain their own respiratory function (and is cooperative).

 

[drmwvr]

Anyone else wondering about respiratory mechanics?
What happens when the pleura is opened?

No need to open the pleura if it's just an aortic valve. As to the cooling question, it's routine to not actively cool anymore. Just allowing the temp to drift toward mid 35's is common.

 

[BobBarker]

I took care of a pt awake initially on bypass, for severe tracheal stenosis repair. No change in mental status when going over to bypass. The case was presented at last years SCA meeting.