CPB backup for sternotomy

[turnupthevapor]

I am at a community place with no OHS program. A surgeon wants to do sternotomy to address two lung issues (one on each side). I was a bit hesitant since there is no bypass back up available here. Wondering if I could take a poll to see if it is standard of care to have CPB backup when using a sternal saw for an elective case. TIA

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[vector2]

On a virgin chest with no hx of previous cardiothoracic surgery I would not be worried if perfusion were not present.

 

[sevoflurane]

Redo sternotomy would be a different story entirely, but if it’s a competent CT surgeon then a fresh sternum should be hard to mess up.

Only RV injuries I’ve had have been with redo sternotomies.

 

[btbam]

Even if they did saw through the ventricle what are the odds you’d make it on bypass before the pt exsanguinates?

 

[sevoflurane]

Quite good actually.

 

[sevoflurane]

Don’t necessarily have to go onto bypass if you hit the RV.

 

[PainDrain]

Don’t necessarily have to go onto bypass if you hit the RV.

Seen and heard of several RV injuries (trauma, surgical misadventures) that were fairly stable; it’s the high pressure side of the heart that doesn’t like to be messed with.

 

[btbam]

Don’t necessarily have to go onto bypass if you hit the RV.

Sure I agree with that. Any semi competent CT surgeon should be able to do a primary sternotomy without ventricular involvement but crazier things have happened I guess.

 

[T-burglar]

Even if they did saw through the ventricle what are the odds you’d make it on bypass before the pt exsanguinates?

Good if the surgeon doesn’t freeze up . I’ve seen good surgeons control the situation and a nervous surgeon flail around.

Push the sternum back together with two people. One on each side of the patient as a way of holding pressure. Then go on crotch bypass and Cool down. Let the sternum relax and figure things out on sucker bypass.

Exsanguination can happen but if you lacerate the RV malignant rhythms and acute coronary transection are usually the driver of sphincter tone

 

[sethco]

Out of curiosity, what surgical procedure was planned on both lungs that required a Sternotomy?

 

[nimbus]

One example would be a thymectomy. Nowadays they are all done as robotic VATS but we used to do them with partial or full sternotomy and without pump standby.

 

[chocomorsel]

Good if the surgeon doesn’t freeze up . I’ve seen good surgeons control the situation and a nervous surgeon flail around.

Push the sternum back together with two people. One on each side of the patient as a way of holding pressure. Then go on crotch bypass and Cool down. Let the sternum relax and figure things out on sucker bypass.

Exsanguination can happen but if you lacerate the RV malignant rhythms and acute coronary transection are usually the driver of sphincter tone

I am sorry, I don't do hearts. Was wondering what you meant by "crotch bypass" and "sucker bypass".

 

[Iso4ane]

I am sorry, I don't do hearts. Was wondering what you meant by "crotch bypass" and "sucker bypass".

Crotch Bypass - Femoral Artery and Vein cannulation

Sucker Bypass - Think Yankauer in pool of blood in chest as whats going towards the bypass circuit.

 

[chocomorsel]

Crotch Bypass - Femoral Artery and Vein cannulation

Sucker Bypass - Think Yankauer in pool of blood in chest as whats going towards the bypass circuit.

Wow. No interest in that at all. In an emergent situations anyway although I will be dealing with ECMO in my near future.

 

[anbuitachi]

One example would be a thymectomy. Nowadays they are all done as robotic VATS but we used to do them with partial or full sternotomy and without pump standby.

Never done a thymectomy but we do sternotomy still for substernal thyroids

 

[drmwvr]

[

Never done a thymectomy but we do sternotomy still for substernal thyroids

Full sternotomy?

 

[drmwvr]

Wow. No interest in that at all. In an emergent situations anyway although I will be dealing with ECMO in my near future.

Odds are, then, it will be groin access as you're aware.

 

[drmwvr]

Don’t necessarily have to go onto bypass if you hit the RV.

Big difference between a saw into the RV v. RA/innominate/ao etc. Assistant can push on a hole and have a reasonable perfusion pressure while the guy in charge cannulates the groins. This is where we come in, obviously....

 

[vector2]

Never done a thymectomy but we do sternotomy still for substernal thyroids

Does this happen routinely at your shop or only when surgeons don't think a thorascopic / mini thoracotomy approach is feasible?

 

[anbuitachi]

[


Full sternotomy?

Does this happen routinely at your shop or only when surgeons don't think a thorascopic / mini thoracotomy approach is feasible?

Honestly they aren't that commonly done here but I've only seen partial sternotomy for them

 

[sethco]

One example would be a thymectomy. Nowadays they are all done as robotic VATS but we used to do them with partial or full sternotomy and without pump standby.

I wouldn't classify a Thymectomy as a bilateral Lung procedure. I was assuming the OP meant bilateral Decortication or Pleurodesis or something else. However, I think a Sternotomy would be useless or complete overkill (vs b/l Thoracoscopy) for most true Lung procedures. That's why I wanted the OP to clarify

 

[sethco]

Crotch Bypass - Femoral Artery and Vein cannulation

Sucker Bypass - Think Yankauer in pool of blood in chest as whats going towards the bypass circuit.

Sucker bypass still requires Arterial cannulation. The Yankauer acts as the venous return/cannula. Has anyone ever personally seen this done?

 

[Robotic Wis-Hipple]

Sucker bypass still requires Arterial cannulation. The Yankauer acts as the venous return/cannula. Has anyone ever personally seen this done?

Yup. Couple times already. Works better than you’d think. Though my experience with it has been initiated by surgical complications in the heart room, so not exactly a crash requiring groin cannulation.

 

[dchz]

Sucker bypass still requires Arterial cannulation. The Yankauer acts as the venous return/cannula. Has anyone ever personally seen this done?

I've seen it in a 5 months old kid coming in for redo sternotomy when the aorta was entered accidentally on sternotomy. It's different than adults since the kid's entire blood volume was like 400-500 ccs. One could argue that the suctioned volume is semi not necessary compared to what the perfusionist can give... but the sucker was there so techinically it's sucker bypass.

But i believe (can't quite see everything from head of bed while pushing massive amounts of blood), the surgeon cannulated the aorta distal and clamped proximal and suctioned the chest cavity for "venous" drainage.

 

[Robotic Wis-Hipple]

I’ve seen some interesting injuries from sternotomy already, a couple I never thought I’d ever see.

 

[turnupthevapor]

Out of curiosity, what surgical procedure was planned on both lungs that required a Sternotomy?

It is a fella with lots of blebs on the rt, and a lesion to be BX on the left.