Case

[mtu620]

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What are your thoughts?
-induction plan/goals? Pros/cons of mask induction?
-what are your pearls for anesthetic management of adult congenital heart disease?
-fistula management?
-Difficult weaning from cardiopulmonary bypass - thought process and differential and response?

33 year old female ASA 4 with fistula between aortic root and pulmonary artery, s/p bioprosthetic aortic and pulmonary conduit replacement -undergoing 4th time redo sternotomy, redo aortic root replacement with HCA, Pulmonic valve replacement
PMH:
DiGeorge Syndrome (high functioning) and truncus arteriosus type 1A s/p repair, endocarditis (culture-negative) in 2015 and enterococcus endocarditis of bioprosthetic aortic valve and ascending aortic graft in 2017
BMI: 21
PSgHx:
-DOL #4: 12mm Hancock conduit, closure of VSD (1986)
-7 yo: conduit stenosis and severe truncal regurgitation s/p RV-PA conduit replacement with 20mm pulmonary allograft, truncal root replacement with 20mm aortic allograft w/ coronary reimplantation (1993)
-26 yo: aortic valve replacement 27 mm freestyle valve, aortic root replacement with 26 mm vascular graft, RV-PA conduit replacement 26 mm homograft (2012) with residual truncal sinus aneurysm
Medications
Penicillin V indefinitely due to endocarditis
CT aorta/abd/pelvis: chronically stenosed or congenitally absent right external iliac artery. The right common femoral artery is supplied by the right inferior epigastric artery and right pelvic collaterals
Congenital TTE: Aneurysm from the posterior aspect of the left coronary sinus, extends
posterior and rightward from the aortic root, unchanged from prior. Additional separate
outpouching from the same sinus; just superior and leftward of this; which communicates with the
distal MPA just proximal to the bifurcation, likely representing a ruptured sinus of Valsalva
aneurysm. There is continuous flow into the PA from this communication (cannot estimate gradient
due to poor Doppler angle). Normal LV size/fxn 7. Normal size and mildly hypertrophied RV, with mildly depressed function. 9. Large right pleural effusion and
moderate left pleural effusion

 

[T-burglar]

Prop roc tube.
Arterial line on side least likely to be involved in axillary CPB if needed or placed with SACP in mind if that’s planned.
Left femoral CPB or fem- ax CPB
Double stick neck for rapid infuser and PAC (don’t float to PA)

This procedure has a high chance of killing the patient. Prior root abscess will make it difficult to have a hemostatic root anastomosis. Anticipate bleeding to death despite best effort

 

[Ronin786]

Biggest goal of induction is going to be minimizing shunting across the fistula. Induce with as little FiO2 as possible, don't hyperventilate and avoid increasing afterload/sympathetic stimulation.

 

[Noyac]

Biggest goal of induction is going to be minimizing shunting across the fistula. Induce with as little FiO2 as possible, don't hyperventilate and avoid increasing afterload/sympathetic stimulation.

You want to minimize R to L shunting.

 

[AdmiralChz]

Refer to university academic center given high likelihood of prolonged mechanical circulatory support and blood bank requirements.

iPhone, chair, donut.

 

[mtu620]

You want to minimize R to L shunting.

minimize R->L or L->R shunting? isn't aorta to pulmonary artery = L-> R shunt?

 

[AdmiralChz]

To be more serious, though: Another question to ponder - do you think this case is best done at a pediatric cardiac center or an adult cardiac center? There’s a lot of inconclusive research / expert opinions for both sides, but I wonder what people’s experiences are in this.

Personally to me it seems surgeon-dependent and their comfort level at a given institution.

 

[AdmiralChz]

minimize R->L or L->R shunting? isn't aorta to pulmonary artery = L-> R shunt?

Probably, unless the fistula has been there for a very long time causing remodeling of the pulmonary circuit - the resulting pulmonary HTN may reverse the shunt (Eisenmenger-esque), especially on induction when the system pressure drops. Just spit-ballin’ though.

 

[vector2]

I dont know if I'm quite understanding the history...you said at age 26 she had an AVR/root replacement/ascending aorta grafting (i.e. bentall) but there was still a residual truncal sinus aneurysm., then later she had a redo bio AVR conduit for endocarditis... The only organic tissue she should have left at this point on the aortic circulation side are the coronary buttons since presumably her native sinuses of valsalva were resected long ago...

 

[Noyac]

minimize R->L or L->R shunting? isn't aorta to pulmonary artery = L-> R shunt?

My way of thinking with two martini’s on board as a disclaimer.
Where is the shunt?
If it’s the PA to systemic circulation then you want L to R shunt in order to continue to oxygenate the blood. Rather than R to L which will allow deoxygenated blood to enter the systemic circulation.
If it is post pulmonary circulation then R to L shunt is desired.

Someone help me, my head is spinning.

 

[Robotic Wis-Hipple]

I dont know if I'm quite understanding the history...you said at age 26 she had an AVR/root replacement/ascending aorta grafting (i.e. bentall) but there was still a residual truncal sinus aneurysm., then later she had a redo bio AVR conduit for endocarditis... The only organic tissue she should have left at this point on the aortic circulation side are the coronary buttons since presumably her native sinuses of valsalva were resected long ago...

Age 26 AVR was a Freestyle. So perhaps a bioprosthetic valve was placed within for the later IE surgery seeing as how it was a 27mm and I can’t imagine the Pt needed anything more than a 23mm.

Edit: I agree seems odd, the endo case mentions ascending graft replacement so who knows....... regardless, 4th time sternotomy, multiple arch surgeries, fistula...... yuck

 

[mtu620]

Can you explain what exactly doesnt make sense from the history?

Also what are the potential challenges in this case? I'll start. Feel free to add or expand:
1. Surgical - getting into the chest given multiple re-does.
2. Anesthetic - access: which side for central line and which side for art line?
3. Potential for pulmonary edema and pulmonary hypertension given l > r shunt
4. Need for circ arrest?
5. Bleeding/hemorrhage

 

[Robotic Wis-Hipple]

Can you explain what exactly doesnt make sense from the history?

Also what are the potential challenges in this case? I'll start. Feel free to add or expand:
1. Surgical - getting into the chest given multiple re-does.
2. Anesthetic - access: which side for central line and which side for art line?
3. Potential for pulmonary edema and pulmonary hypertension given l > r shunt
4. Need for circ arrest?
5. Bleeding/hemorrhage

Caveat; I don’t really do adult congenital.

In response to what’s confusing about history is we don’t know the exact interventions done on the AV/root and what is or isn’t graft at this point.

1. Getting into the chest is gonna be an issue. You are going to bleed. A lot. Worse if plan is to go on peripherally (heparinized) while dissection debridement of chest is ongoing. Alternative (might just be crazy) in peripheral CPB placeholding lines but no heparinization allowing for noncoagulopathic chest opening, possible central cannulation with plan to cannulate and go on peripherally if surgical catastrophe occurs in the chest.....that may help bleeding but risks forcing surgical team to divert from hemostatic attempts to cannulate if rupture occurs.

There is going to be tons of scar tissue and adhesions to graft material, this scar tissue is going to be encasing friable, aneurysmal tissue that will easily rupture. That is likely very bad, even with peripheral CPB.

2. Access to be decided after discussion with surgeon(s) and planned based on their expected access and salvage plans.

3. The shunt is obviously an issue. I’m of the mind to set my goal at minimizing perturbations from compensated? baseline. Try not to increase SVR,decrease PVR and increase L—>R shunt as this may worsen oxygenation status via pulm edema. Likewise increasing R—>L via raising PVR or tanking their systemic pressure shunts deoxygenated blood systemically. Aim to ride the razor blade in the middle but probably favor R—>L shunting temporarily so we don’t ruin the lungs (but maybe I’m missing something there).

4. If this is all root level, and shunt is sinus to MPA I’m not sure circ arrest is required. If they can get to ascending and get a clamp on why couldn’t we go on centrally and just replace the aortic root and PV? Maybe I’m missing something in the presentation.

5. I think I’ve already discussed bleeding enough.


I’m sure there’s some glaring thing I’m missing but that’s how I see it (until someone smarter shows us otherwise).

 

[T-burglar]

It sounds like the surgeon mentioned HCA. Most likely have to replace The entire ascending graft

 

[mtu620]

This patient expired in the OR - I will provide details if you are interested.

Below are two images of this patient's TEE of the aorto-pulmonary fistula. Note - this patient had a right sided aortic arch.

Can you label what each structure is for the short axis view (a-d) and in the long axis view (a-d)?

 

[deleted59964]

as much as I love a good case, this isn't one for me.

 

[AdmiralChz]

This patient expired in the OR

Great example of trying to do far too much on a exceptionally complicated patient. Unless this was done at a big academic center with adult congenital familiarity (ECMO backup, solid cardiology and intensivist support, experienced anesthesiologists with adult congenital experience [side note, this is RARE because most centers simply wont do these cases]), doing the case at all was somewhat of a disservice (clearly the benefit of hindsight applies). Don’t be a cowboy, and all those issuing caution in this thread were clearly spot-on.

@JobsFan is right - know your limits. It’s good to walk through some intraoperative considerations, but the first question to be addressed needs to be regarding the futility and risk of surgery itself.

 

[deleted171991]

Had this person not been born in the United States, she would have been allowed to die many years ago.

In the meanwhile, we spent millions on one person, millions that could have improved the lives/healthcare of many other people. Just food for thought.

 

[T-burglar]

So bled to death or surgeon just killed the pump when he/she determined that repair was impossible after resection?

 

[MoMoGesiologist]

Had this person not been born in the United States, she would have been allowed to die many years ago.

In the meanwhile, we spent millions on one person, millions that could have improved the lives/healthcare of many other people. Just food for thought.

I for one am proud to live in a country where we will spend millions to give someone even a minute more with their loved ones. We cannot put a price on life /s

 

[DrOwnage]

I for one am proud to live in a country where we will spend millions to give someone even a minute more with their loved ones. We cannot put a price on life /s

Life and quality of life are a different thing. Can't put a price on it, but there are objective ways of determining futility of care.

 

[MoMoGesiologist]

Life and quality of life are a different thing. Can't put a price on it, but there are objective ways of determining futility of care.

What are the objective criteria for futile care?

 

[mtu620]

This was at a large academic institution, with adult cardiac surgeon, congenital heart surgeon, adult cardiac anesthesiologist, cardiac fellow anesthesiologist (near finished with fellowship), CA3 (near finished with residency).

Pt was cannulated peripherally before sternotomy in femoral V, innominate artery. Went on bypass, circ arrest, then sternotomy to control bleeding.

Complications:
-- 2/2 lots of scar tissue during dissection > got into lung > massive air leaks b/l. Blowing bubbles into field.
--2/2 hypothermia lv distention causing pulm edema but surgeon unable to place vent b/c altered heart orientation
--BiV dysfxn - came off pump first time saw BiV dysfxn, needing to crash back on pump.
--Pump clotted off ‐ when needed to go back on pump, after giving protamine 1/3 , so needed to wait for new pump = crucial time delay
--after new pump arrived, bleeding + clot continued (found in desc. Aorta and lv apex) , cerebral sats extremely low(maybe 2/2 air), decision to give up CPR/resuscitation effort.

What could we have done differently? Not do case=aneurysm rupture, death. Life vs quality of life certainly an issue here.

Welcome any thoughts.

 

[T-burglar]

Did your resident give more protamine than he said he did? Did he/she push protamine instead of heparin to crash back? Give something that wasn’t heparin thinking it was heparin?

How long was DHCA? How cold was the brain before you killed the flow? How long was pump run number 1? What did you try to come off with? Where were you monitoring arterial pressure?

Bleeding from the LV apex and descending Aorta is a real head scratcher. Even with congenital anomalies.

As I posted earlier, not surprised if the patient bleeds to death (develops end stage MOSF and vasoplegia from constant hemorrhage) despite heroic effort

 

[MoMoGesiologist]

You could have come out of OR on VA ECMO and try to make it to 30 days so your surgeon’s and institution’s peri-op mortality numbers look good?

 

[mtu620]

This was not my case, I am just presenting it . Dont know if a medication error occurred but likely not.

DHCA 23m to 18c
SACP 23m
First Cpb 373m
Came off on NE and Vaso but was mostly resuscitating with epi pushes, open heart massage, transfusion.

Arterial pressure from r radial. Should've been L radial bc L innominate from R sided arch. This was a problem with communication but ended up no big deal bc they gave us a direct pressure measurement/cannula to measure cerebral perfusion.

I should've clarified. Bleeding from pulmonary injury and pseudoaneurysm rupture. Hypercoaguability ( clot in lv Alex and desc aorta after pump replaced + clotted first pump)

 

[pgg]

--BiV dysfxn - came off pump first time saw BiV dysfxn, needing to crash back on pump.
--Pump clotted off ‐ when needed to go back on pump, after giving protamine 1/3 , so needed to wait for new pump = crucial time delay

This is sort of 😱

What kind of evaluation or conversation was there before the decision to give protamine was made? Did things look OK, or did they look bad but the surgeon didn't think there was anything to be done ... so give it and hope for the best?

 

[T-burglar]

Probably should have anticipated needing inotrope to separate. Clotting the pump should be a never event. VA ECMO actually improves diffuse coagulopathic bleeding from cut surfaces by creating an abnormally negative CVP. But it doesn’t save the patient from major arterial hemorrhage. Especially if it’s proximal on the aorta.

Lots of reasons why the heart might be dead after 6 hours on pump with a superimposed deep hypothermia. Really insane attention to detail can make the difference between a death and a survival for cases that are going to be long. Was the coronary sinus catheter jammed in too far and not delivering cardioplrgia to the RV the entire pump run? Was the arrest fast and complete with Pleg dose number 1? Any activity on the ECG during the pump run? You said no vent could be placed, how was the LV decompressed while asystolic?

 

[deleted171991]

I for one am proud to live in a country where we will spend millions to give someone even a minute more with their loved ones. We cannot put a price on life /s

Another generous person... with other people's money.

Yes, we can put a price on every being (only air is free). The NHS in the UK has been doing it for decades for extraordinary treatments. Just try the exercise with your pet: how far would you go, out of pocket, in various survival situations (a week, a month, a year etc.)? Or with yourself, when taking your surviving family into consideration.

It's so easy to spend other people's money... That's why the more socialist a country the poorer usually (unless it has natural resources).

 

[rakotomazoto]

Interesting case, thanks for sharing. Not cardiac-trained, but I also thought of clotting off the bypass circuit as a "never" event. I understand that a partial dose of protamine was given, was this fact apparent at the time of "crashing" back on? Was it a calculated risk that "maybe they won't clot that bad if we just go for it" since there would obviously be some delay in setting up a new bypass machine/circuit? Or was it just in hindsight that it was realized that some protamine had been given? This sounds like a stressful, high-stakes case where things are going badly, no judgement for however it went down.

 

[vector2]

This was at a large academic institution, with adult cardiac surgeon, congenital heart surgeon, adult cardiac anesthesiologist, cardiac fellow anesthesiologist (near finished with fellowship), CA3 (near finished with residency).

Pt was cannulated peripherally before sternotomy in femoral V, innominate artery. Went on bypass, circ arrest, then sternotomy to control bleeding.

Complications:
-- 2/2 lots of scar tissue during dissection > got into lung > massive air leaks b/l. Blowing bubbles into field.
--2/2 hypothermia lv distention causing pulm edema but surgeon unable to place vent b/c altered heart orientation
--BiV dysfxn - came off pump first time saw BiV dysfxn, needing to crash back on pump.
--Pump clotted off ‐ when needed to go back on pump, after giving protamine 1/3 , so needed to wait for new pump = crucial time delay
--after new pump arrived, bleeding + clot continued (found in desc. Aorta and lv apex) , cerebral sats extremely low(maybe 2/2 air), decision to give up CPR/resuscitation effort.

What could we have done differently? Not do case=aneurysm rupture, death. Life vs quality of life certainly an issue here.

Welcome any thoughts.

Getting into the lung- surgeon needs to get help and start stapling. You'll never come off sans ECMO unless the big leaks are isolated and any pulmonary lacerations are fixed

LV distention- If surgeon can't find pulmonary veins, then he needs to vent the old fashioned way- i.e. jam the vent directly into the LA or LV apex. Other than hypothermia and complete arrest with cardioplegia, one of the mainstays of protection is decompression of the ventricles...

BiV dysfnx- you should've come off on high dose epi +- milrinone +- iNO for VQ mismatch with pulmonary edema. Norepi + vaso + intermittent epi pushes is not a real plan for DHCA + 370 min pump run

Pump clotting- don't give protamine unless the patient is really ready for protamine. Keep giving prbcs, fix all the surgical bleeding first, high dose inotropes, consider mechanical circulatory support, and then consider some protamine

By the time you have LV apex and desc Ao clot, the pt is already dead....

 

[sevoflurane]

This patient expired in the OR - I will provide details if you are interested.

Below are two images of this patient's TEE of the aorto-pulmonary fistula. Note - this patient had a right sided aortic arch.

Can you label what each structure is for the short axis view (a-d) and in the long axis view (a-d)?

View attachment 272113

Thanks for sharing the case. 👍

Tough one for sure and only academic places would likely take this type of case on. We certainly ship this type of case out to Stanford or Utah although we do plenty of complex cases/ECMO, etc. Just shipped out our first pediatric trauma case that we ECMO'd via carotid/IJ.... first in our state. That's a trauma case though... not scheduled.

A= R PA
B= Ascending aorta
C/D= High turbulence which represents fistula flow into MPA.

Obviously nobody here is pointing fingers, but Vector hit some good points in his post above. Poor myocardial/cerebral protection, coagulopathy and long pump run are poor predictors in a reasonable cardiac patient. This patient is very high risk. I'll agree with @FFP. When I was in Ireland doing anesthesia and ICU, this patient would have never made it to the OR due to underlying disease.
I'm guessing we are not getting the whole story in some way... but great learning case. You'll never forget it.

Thank you for taking the time to post this case. It makes the SDN anesthesia subforum a special place for us.

 

[AdmiralChz]

The protamine was a clean kill. Almost thoughtful to the patient who otherwise would have had a long, painful and nearly certain futile ICU stay.

 

[MoMoGesiologist]

Another generous person... with other people's money.

Yes, we can put a price on every being (only air is free). The NHS in the UK has been doing it for decades for extraordinary treatments. Just try the exercise with your pet: how far would you go, out of pocket, in various survival situations (a week, a month, a year etc.)? Or with yourself, when taking your surviving family into consideration.

It's so easy to spend other people's money... That's why the more socialist a country the poorer usually (unless it has natural resources).

The “slash s” at the end of my post meant it was made sarcastically! End of life care is hard, and the emotions make rationing healthcare quite difficult. Not only do we deal with patients who want everything at any cost, but also families, and also surgeons who (at least at my residency) who never say no to a surgery, no matter how likely it’ll ruin the life of a patient or their family.

As anesthesia, what is our role and how often do you tell a surgeon “this case is kinda pointless and this person’s gonna die regardless, let’s not do this”? I don’t personally want to be the end person rationing care. That should come from someone else: if not the government or insurance company, at least the surgeon. Not anesthesia. Hell even in the SICU we have a hard time asking surgeons to stop offering patients and their families false hope (my experience).

I’m wondering if bundled payments would be a good way to stop this tomfoolery. If you only get a set amount, maybe surgeons and ICUs and hospitals will stop offering endless ventilators, dialysis, ECMO care.

 

[DrZzZz]

The “slash s” at the end of my post meant it was made sarcastically! End of life care is hard, and the emotions make rationing healthcare quite difficult. Not only do we deal with patients who want everything at any cost, but also families, and also surgeons who (at least at my residency) who never say no to a surgery, no matter how likely it’ll ruin the life of a patient or their family.

As anesthesia, what is our role and how often do you tell a surgeon “this case is kinda pointless and this person’s gonna die regardless, let’s not do this”? I don’t personally want to be the end person rationing care. That should come from someone else: if not the government or insurance company, at least the surgeon. Not anesthesia. Hell even in the SICU we have a hard time asking surgeons to stop offering patients and their families false hope (my experience).

I’m wondering if bundled payments would be a good way to stop this tomfoolery. If you only get a set amount, maybe surgeons and ICUs and hospitals will stop offering endless ventilators, dialysis, ECMO care.

In my very limited time practicing, I've had this conversation with a surgeon twice. First one, surgeon agreed it seemed futile, but felt there was some potential benefit and since the family wanted it, we pressed on. The other time, the proceduralist (GI) agreed with me BEFORE I was even able to speak to them. I mentioned to a preop nurse how ridiculous the idea of proceeding was and that I needed to talk to the proceduralist before I'd even talk to the patient and family. When the RN called me back to speak to the proceduralist, I didn't say anything after introducing myself. He just said "Hi, yea, I agree with you. I'm canceling the case. Thanks for looking at the whole picture." Probably the best outcome I could have imagined with that.

 

[T-burglar]

im also curious if there was a CTA eval of the circle of willis before attempting unilateral SACP

 

[itwasalladream]

im also curious if there was a CTA eval of the circle of willis before attempting unilateral SACP

Is that routine in your practice? I think it makes sense to check, but I haven't seen it routinely checked before scheduled HCA w/ SACP cases, where I've been.

In my opinion the questions about minimizing shunt based on balancing PVR/SVR are relatively unimportant in this setting where it's not a massive mixing lesion like truncus arteriosus/single ventricle or something, and you're not talking about balancing circulations over the course of days, like in a peds CICU. Shunt sounds majority L->R anyway so there shouldn't be a hypoxia concern. For the relatively short time period between induction and getting on pump, I'd keep things simple and just maintain BP, sats (big pleural effusions so likely just stay on a lot of oxygen, it'll be fine), there are a lot of other things to worry about.

Agree w/ people saying strong inotropes would be plan A coming off pump here. Poor LV decompression, long pump time, circ arrest, redo, and heavy post-CPB transfusion plan are all factors alone that might lead me to start inotropes prophylactically. In combination I think it's a pretty straightforward decision, but you seem to have had a very experienced team, so maybe there were other issues at play.
There are a few confusing things - you said you went on ax/fem, then circ arrested, THEN sternotomy. Haven't seen that particular order (circ arrest before sternotomy). How did they arrest the heart? Even just cooling and letting it fibrillate seems like there would be a forseeable problem draining the heart due to the fistula. I think someone mentioned difficult arrest as another factor for needing inotropes coming off. If it was all retrograde, there are problems with that strategy too (RV protection).

There are places that routinely give 1/3 protamine before shutting of pump suckers and vents...haven't heard of it being an issue clotting the pump, but definitely a concern - did pt have a prior h/o hypercoagulability? If you came off with no inotropes and biV looks terrible and you're pushing epi, giving protamine may not be the right decision. The massive bleeding they were likely dealing with (assuming non-surgical) and urgency to reverse makes it a really tough scenario. Was enough reheparininzation given before crashing back on? No time to check ACT usually so I'd give a massive dose.

Really tough case, thanks for sharing. I can see why it might be done given her age, but yeesh.

 

[mtu620]

What kind of evaluation or conversation was there before the decision to give protamine was made? Did things look OK, or did they look bad but the surgeon didn't think there was anything to be done ... so give it and hope for the best?

things looked ok - granted we were still on pump so the circulation was still being supported. Thus we didn't see the consequences of the complications until after we separated. For example. We didn't see hemodynamic collapse a/w air embolism, there was no BiV dysfxn prior to separating, and oxygenation/ventilation were acceptable given the b/l air leaks. There was no clot - in fact, ROTEM showed e/o hypocoaguability - making us think we were battling bleeding rather than hypercoaguability/clot.

Thus, decision to give protamine –> waited until 1/3 -> Pump suckers off. It was minutes after pump suckers off before things started to get dicey. So we turned off protamine thinking we may have to crash back on. That's when things spiraled downward and we had to swap out the pump.

Probably should have anticipated needing inotrope to separate.

We separated with NE, V, Epi (apologies, failed to mention)

You said no vent could be placed, how was the LV decompressed while asystolic?

THey placed a vent via superior pulmonary veins after sternotomy

Interesting case, thanks for sharing. Not cardiac-trained, but I also thought of clotting off the bypass circuit as a "never" event. I understand that a partial dose of protamine was given, was this fact apparent at the time of "crashing" back on? Was it a calculated risk that "maybe they won't clot that bad if we just go for it" since there would obviously be some delay in setting up a new bypass machine/circuit? Or was it just in hindsight that it was realized that some protamine had been given? This sounds like a stressful, high-stakes case where things are going badly, no judgement for however it went down.

It's routine/protocol at our institution to turn pump suckers off @ 1/3 protamine. Hindsight 20/20 we should've stopped the suckers before protamine. However, while protamine certainly didn't help the clotted pump, the patient's hypercoaguability was multifactorial and not solely due to protamine. Again, she had a hypocoaguable ROTEM and, with that ROTEM, the pump never clots off. This suggests there was another process, perhaps air. Thus, protamine didn't help, but likely not the cause.

Getting into the lung- surgeon needs to get help and start stapling. You'll never come off sans ECMO unless the big leaks are isolated and any pulmonary lacerations are fixed

They couldn't identify the source of leak to repair. Also, from ABG standpont oxygenation/ventilation weren't terrible given were still on pump, not dependent on the lungs prior to separating.

LV distention- If surgeon can't find pulmonary veins, then he needs to vent the old fashioned way- i.e. jam the vent directly into the LA or LV apex. Other than hypothermia and complete arrest with cardioplegia, one of the mainstays of protection is decompression of the ventricles...

THey tried via mini thoracotomy to get to LV apex, but couldn't b/c of the anatomy/twistedness/orientation of the heart.

Pump clotting- don't give protamine unless the patient is really ready for protamine. Keep giving prbcs, fix all the surgical bleeding first, high dose inotropes, consider mechanical circulatory support, and then consider some protamine

Again, things looked not great but did not preclude separating. Else protamine wouldn't have been given.

A= R PA
B= Ascending aorta
C/D= High turbulence which represents fistula flow into MPA.

Correct!

There are a few confusing things - you said you went on ax/fem, then circ arrested, THEN sternotomy. Haven't seen that particular order (circ arrest before sternotomy).

purpose is to cool to circ arrest so can get into chest and when there's bleeding she wouldn't be jeorpardized as much b/c she'd be cold and they could secure the circulation and continue on.

did pt have a prior h/o hypercoagulability?

No. This pt deviated from the norm. Nothing predicted she would clot off the pump.

Was enough reheparininzation given before crashing back on?

Yes, there was about 5-10minute delay b/t new pump arrived. we checked an ACT after heparin which was appropriate to go back on.