Clinical CT case that is a bit unusual.

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sevoflurane

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So we all like the clinical cases... This isn’t my case... but it was a case of one of my partners that my wife ended up helping out with... I think it is a useful case to go over.

45 y/o lady found to have 4V disease. Morbid obesity, DM, HTN, Hyperlipids, etc, etc... Off to the CVOR, gets 4 bypasses... + some pledgets, thrombin-fibrin gel, hematoma at cannulation site. Comes off bypass without any issues...

Makes it to the CVICU and appears to be doing well post-op. However, POD 2, hot and ugly looking erythema around sternal sutures... getting bigger. CT shows probable infx above the sternum... so the plan is to go back to OR to do an I & D.

She gets opened up, cleaned up + abx irrigation... Surgeon places wound vac, scrubs out and says thank you as he leaves the room.... Access wise she has a double lumen picc for long term abx.

ICU bed gets wheeled in... patient gets moved over... next thing you know... pressure is going down, down... down... down... it’s 75/45 right now...

What are your thoughts and differential?
 
sevoflurane said:
So we all like the clinical cases... This isn't my case... but it was a case of one of my partners that my wife ended up helping out with... I think it is a useful case to go over.

45 y/o lady found to have 4V disease. Morbid obesity, DM, HTN, Hyperlipids, etc, etc... Off to the CVOR, gets 4 bypasses... + some pledgets, thrombin-fibrin gel, hematoma at cannulation site. Comes off bypass without any issues...

Makes it to the CVICU and appears to be doing well post-op. However, POD 2, hot and ugly looking erythema around sternal sutures... getting bigger. CT shows probable infx above the sternum... so the plan is to go back to OR to do an I & D.

She gets opened up, cleaned up + abx irrigation... Surgeon places wound vac, scrubs out and says thank you as he leaves the room.... Access wise she has a double lumen picc for long term abx.

ICU bed gets wheeled in... patient gets moved over... next thing you know... pressure is going down, down... down... down... it's 75/45 right now...

What are your thoughts and differential?
Click to expand...

Thoughts:

POD 2 heart comes to CVOR, goes to sleep, arms tucked and the anesthesiologist has only a double lumen PICC?. Bad decision. We have all seen **** hppen with supposedly ditzel cases in the CT room. I would have insisted on atleast one good IV.

BP 75/45 upon moving, Simultaneously I would be moving the patient back to the OR table,paging the surgeon and asking the OR nurses to prepare for something ugly. Calling for a TEE probe while having help work on more access and give pressors.
what are the ST segments doing?
 
Did the I+D involve re opening the sternum or just the skin?
So far all we know is sudden hypotension at the end of surgery.
Tamponade? Ischemia? Anaphylaxis?
Start by treating the BP with some pressors + fluids, stick the TEE in to see what the heart is doing and to see if there is a pericardial effusion, if no tamponade and no ischemia then treat as anaphylaxis.

sevoflurane said:
So we all like the clinical cases... This isn't my case... but it was a case of one of my partners that my wife ended up helping out with... I think it is a useful case to go over.

45 y/o lady found to have 4V disease. Morbid obesity, DM, HTN, Hyperlipids, etc, etc... Off to the CVOR, gets 4 bypasses... + some pledgets, thrombin-fibrin gel, hematoma at cannulation site. Comes off bypass without any issues...

Makes it to the CVICU and appears to be doing well post-op. However, POD 2, hot and ugly looking erythema around sternal sutures... getting bigger. CT shows probable infx above the sternum... so the plan is to go back to OR to do an I & D.

She gets opened up, cleaned up + abx irrigation... Surgeon places wound vac, scrubs out and says thank you as he leaves the room.... Access wise she has a double lumen picc for long term abx.

ICU bed gets wheeled in... patient gets moved over... next thing you know... pressure is going down, down... down... down... it's 75/45 right now...

What are your thoughts and differential?
Click to expand...
 
My thoughts are
1. Tamponade, pt may have a bleeding dyscrasia. Remember the pledgers and hematoma in the initial case.
2. Hypovolemia
3. Dysrythmia
4. PE ( dislodged with moving to bed)
5. Seeding of infection (very unlikely)

What's her HR and ECG trace look like? My approach would be to correct any dysrythmia, bolus ( remember, fast full forward for tamponade), and add pressor as needed while placing TEE.
 
agree with all the above although a component of anaphylaxis has to be high on the differential, especially with abx irrigation (vanc?). i never plan on doing a case with a picc, agree with at least someting for better access. definitely cant leave the OR, stabilize with pressors and fluids, call for echo, check ABG, consider asking the surgeon back in

whats the wound vac doing? where was the cannulation site hematoma? definitely could see gram negative sepsis show up quickly, although i think its unlikely.

or "hematoma" could turn into "dissection"...
 
Idiopathic said:
whats the wound vac doing?
Click to expand...

Nice... 👍

Anesthesiologists notices the wound vac. It's filled up, and now blood is coming from underneath the vac.... suddenly there is loss of suction and blood is going everywhere.

About 1/2-1 liter in a matter of a minute. Blood manages to have gotten into the hemopod and now there is no EKG tracing on the monitor cuz it shorted out/became nonfunctional.
Before then... no ST changes that could be seen. Sinus tachy... that got worse as the BP dropped.

@ Plank. The sternum was opened.

@ Doze and Idio, I agree. I'm not a big fan of picc only cases post CABG. Mac catheter D/C'd earlier that day as the patient was doing very well (we keep our bread and butter hearts about 4-5 days on average). FWIW, the picc was a dual lumen 18G that had decent flow... but I understand the concern and this case is proving it... even for a simple "I&D".

So... now you have no EKG, have a dual lumen picc, and a patient who is loosing blood from somewhere....

What are you going to do next?
 
For the med student lurkers.... These guys are honing in on what the cause and all their questions will lead you one way or the other. Generally speaking, hypotension can be caused by 4 factors:

Hypovolemic/preload: bowel prep + bumex drip + no fluids + 200 of propofol on induction, hemorhage, etc.
Distributive: anaphylaxis/anaphylactoid, sepsis, neurogenic/spinal shock, vasodialators running wide open, etc.
Pump: arrhythmia, contractility, CHF, MI, LV/RV dysfxn, air in your grafts or kinked graft, etc.
Obstructive: Temponade, tension pneumo, massive PE, asthma/autopeep/dynamic hyperinflation, etc.
 
A-line came out with the MAC catheter btw... 😡
 
An MS-III's thoughts...

Well then, it seems to be a hypovolemia problem. First order of business is to get the pt back on the table and get the surgeon back in there. Next would be to get a couple of large bore IVs going and start fluids (NS or LR?) ASAP. Is the pt still adequately sedated?

I suppose vasoconstricters are not really a good option at this point since the bleeding is uncontrolled. Seems like hypotension, to a certain point, is a good thing with this kind of bleed. What is the required MAP to maintain adequate cerebral perfusion?

Seems like it is not really the volume of fluid that is the problem, but the rate at which that fluid is being lost, and the pt's system is just lagging. Is blood transfusion necessary at this point? How much volume needs to be lost before you hang blood?

How's the O2 sat?
 
so back to the OR for redo sternotomy (i know technically no wires) but no art line? thats such a low risk high reward gadget here and something that you definitely wont be getting in the middle of the case.
 
scudrunner said:
An MS-III's thoughts...

Well then, it seems to be a hypovolemia problem. First order of business is to get the pt back on the table and get the surgeon back in there. Next would be to get a couple of large bore IVs going and start fluids (NS or LR?) ASAP. Is the pt still adequately sedated?

I suppose vasoconstricters are not really a good option at this point since the bleeding is uncontrolled. Seems like hypotension, to a certain point, is a good thing with this kind of bleed. What is the required MAP to maintain adequate cerebral perfusion?

Seems like it is not really the volume of fluid that is the problem, but the rate at which that fluid is being lost, and the pt's system is just lagging. Is blood transfusion necessary at this point? How much volume needs to be lost before you hang blood?

How's the O2 sat?
Click to expand...

so on the surface, what you say makes perfect sense. however, these things rarely fit nicely into one box. acute hypovolemia, definitely, although probably somewhat fluid up, when you consider the events of the past two days, and that fluid settles in the interstitial tissue, making other things harder. also, the heart, while revascularized, may still be recovering from manipulation/sutures/cardioplegia, and so there may be a significant component of depressed pump function causing this hypotension as well as preload deficiency. still cant rule out vasoplegia, although its less likely.

agree with expeditious art line and big IV, is this pure volume loss versus tamponade physiology...fill the tank with colloid of choice regardless, cut your tidal volumes, d/c peep, put your chest tubes/mediastinal tubes to suction, cut the wires if you go asystolic. send coags

oh yeah and the surgeon should definitely be back in the room by this point 😉
 
Seems like if the blood is exiting the sternum, tamponade is not really an issue even if there is blood within the pericardium, since you essentially have an open relief valve.
 
its not necessarily an open cavity with one exit point, you can have retrocardiac tamponade or imagine that if the pressure required to force blood out of the sternum high enough that you still cardiac compression (your "popoff" may still be high). there are cases of localized tamponade in patients with open chests due to clot, it needs to be in the differential.
 
Idiopathic said:
so on the surface, what you say makes perfect sense. however, these things rarely fit nicely into one box. acute hypovolemia, definitely, although probably somewhat fluid up, when you consider the events of the past two days, and that fluid settles in the interstitial tissue, making other things harder. also, the heart, while revascularized, may still be recovering from manipulation/sutures/cardioplegia, and so there may be a significant component of depressed pump function causing this hypotension as well as preload deficiency. still cant rule out vasoplegia, although its less likely.

agree with expeditious art line and big IV, is this pure volume loss versus tamponade physiology...fill the tank with colloid of choice regardless, cut your tidal volumes, d/c peep, put your chest tubes/mediastinal tubes to suction, cut the wires if you go asystolic. send coags

oh yeah and the surgeon should definitely be back in the room by this point 😉
Click to expand...
Why colloid?
 
Did the wound vac suck open the RV? In any case, call for help, start big volume line, fem aline. call CV surgeon.

Most likely you are going to attempt crash/sucker bypass until you can figure out what is hemorrhaging.
 
Did the wound vac suck open the RV? In any case, call for help, start big volume line, fem aline. call CV surgeon.

Most likely you are going to attempt crash/sucker bypass until you can figure out what is hemorrhaging.
 
My money is in aortic rupture/tear. The prior hematoma doesn't give me a good feeling.
 
What is up with the pledgers, thrombin gel and hematoma at the cannula ton site? Something doesn't add up here. I've done a lot of hearts and the only ones (which are very few) that had any of these measures were not your typical hearts. This pt has **** for tissue and we are most likely dealing with this. That is assuming that the coats are normal.

Plan: get some real access ( before an Aline because this is a waste of time) and push the fluids fast. Crystal or colloid, it doesn't matter. Get CV guy back now.
 
sevoflurane said:
She gets opened up, cleaned up + abx irrigation... Surgeon places wound vac, scrubs out and says thank you as he leaves the room.... Access wise she has a double lumen picc for long term abx.
Click to expand...

I'm not smart enough to think about various locations/tissue planes/etc that bleeding can happen in the world of CT surgery.

But when some crazy $hit happens in the OR, the first thing I think is "What did I or the surgeon JUST do or give to the patient?"

So when I hear "the surgeon places wound vac and then the patient tanks" I wanna disconnect that woundvac right. freakin'. now, I don't know what kind of crazy negative-pressure situation or tissue trauma it's making but it's probably not helping right now.
 
Noyac said:
What is up with the pledgers, thrombin gel and hematoma at the cannula ton site? Something doesn't add up here. I've done a lot of hearts and the only ones (which are very few) that had any of these measures were not your typical hearts. This pt has **** for tissue and we are most likely dealing with this. That is assuming that the coats are normal.

Plan: get some real access ( before an Aline because this is a waste of time) and push the fluids fast. Crystal or colloid, it doesn't matter. Get CV guy back now.
Click to expand...

You are definitely on to something here... let's just say the patient is protoplasm type F-

Tissue paper... tissue paper.
 
pgg said:
Ballsy!
Click to expand...

All depends on your comfort level.

Need for an a-line in these cases?

Meh...

Depends on how your patient is doing and your comfort level. A-line is not an absolute necessity.... although it did become a necessity.
Over the years, I've done tons of these I&D's and sternal flaps w/o a-lines in the post CABG patient. Idio is right in saying there may be some stunning of the myocardium however. Either way, it's comfort level. At least that is my opinion.
This patient is in the mid 40's, was extubated 30 minutes after getting to the ICU, had been hemodynamically perfect and would have been D/C'd the next couple of days if her sternum hadn't hosted some bugs for dinner.

Did my partner wish he had an a-line once shait hit the fan..? yeah... pretty sure of that.

The only balsy thing here is a MORBIDLY OBESE patient with a picc line and not a second IV... The picc's ran beautifully... 18g's running like 18g's... problem is with the length of a picc... once you want to push blood under pressure, you are gonna meet some good resistance to flow. Size matters here... smaller length = better for resuscitation... (but you already know that, this is more for the younglings out there 😉).
 
OK... back to the case.

What is the first thing you want to do here?

CALL FOR HELP!

I don't care if you wield the force- Yoda style. You are going to need many pairs of hand to direct.

Next....

Remain CALM- remember, when we get into these situations, the tone of the OR is being set by your actions at the head of the bed!

CT SURGEON gets a ring and is on his way...


So we have a patient who has now been moved back over to the OR table and re-intubated and paralyzed.

Help... arrives in the form of my better half and a 3rd partner... She gets an 18G stat on the dorsum of the arm just below the elbow 🙂love🙂....blood is hanging.

Now we have better access, blood is flowing via 3 18g's.

B.P. cuff is now not registering and the hemopod is not picking up electrical activity cuz it's fried....

What next?
 
Feel for a pulse. Radial then carotid.

No pulse = get the chest open stat. Closed compressions would not be advised.
 
Or do you open the chest yourself....?

This is real life case y'all.
 
Delicately...very delicately remove the wound vac. Have scrub pour a bottle of Betadine on the chest, retractors in and start squeezing.
 
Gooood call!

Yep. The defibrillator goes on as she becomes pulseless.

and guess what.... the defibrillator gives us an EKG!

PEA.
 
Bertelman said:
Delicately...very delicately remove the wound vac. Have scrub pour a bottle of Betadine on the chest, retractors in and start squeezing.
Click to expand...

So with a potential aortic cannulation site wide open... you want to open the chest?
 
GasMan2012 said:
What about the defibrillator?
Click to expand...

I'm guessing with no rhythm readout available they're not shocking in case it's asystole/PEA. Were there any pressors/epi on board at this point? Blood still pouring out from under the vac?
 
Last edited:
sevoflurane said:
So with a potential aortic cannulation site wide open... you want to open the chest?
Click to expand...

Of course not. Don't want her to die, either. To be honest, I never wanted to do the case. You're the one that called me in to help. 🙂

I'm not sure I understand what this Hemopod is.

Either way, whatever that cannulation site is doing, it ain't about to fix itself. I am presuming this case is occurring in a cardiac OR, with cardiac instruments on standby and still sterile. Which means someone can open that chest, put a finger in that hole and get some forward flow.
 
Last edited:
vector2 said:
I'm guessing with no rhythm readout available they're not shocking in case it's asystole/PEA.
Click to expand...
You can get a rhythm from the defib.

Are there pacer wires in? If so turn it off and check the rhythm again.... I'm thinking of everything before opening up a chest, lol but as a student this is way over my head
 
so PEA equals closed chest CPR or open chest CPR depending in your comfort level. me, i leave the chest closed as long as I know someone is coming soon. volume ASAP, you will need vasopressors too, put the probe back down and look for septal or free wall rupture or retrocardiac clot, although im hearing hoofbeats with this case so those are way down the list, if you have to do CPR this can obviously wait.

it sounds like ultimately the aorta will need a clamp, the question is just where and by whom
 
At some point that chest needs to be opened to determine the etiology. You've got no pulse, no pressure. This actually sounds like a perfect time to open it up. Otherwise, you'll encounter a blood bath and severe hemorrhage
 
Bertelman said:
I'm not sure I understand what this Hemopod is.
Click to expand...

That is our lingo for:

hires2.jpg


hires1.jpg
 
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My guess at where the bleeding is coming from is a cannulation site. The patient isn't fibrillating, so the grafts are likely ok. Maybe it's the aorta, but the RA cannulation sites as well as RV are also possible culprits.

Chest compressions with an open sternum aren't going to cut it. There's no way to generate intrathoracic pressure with external massage and open sternum. Internal massage is your only option. Like others have said, turn the vac off, remove the dressing and take the packing out. That alone may be enough to get vitals back. If not, separate the ribs, stick your hand in the chest and squeeze the heart (trying not to tear the grafts). If you see something big bleeding (like aorta or RA) put a finger on it. That's usually enough to stop the deluge until the surgeon makes it back. Anyone taking care of fresh cardiac surgery patients needs to know Cardiac ALS, and read the paper "Guidelines for resuscitation in cardiac arrest after cardiac surgery" European Journal of Cardio-thoracic Surgery 2009.
 
I'm thinkin it's time to cool the room and pack around the head with ice...this person ain't gonna have CO and/or MAP for a while.
 
fakin' the funk said:
I'm thinkin it's time to cool the room and pack around the head with ice...this person ain't gonna have CO and/or MAP for a while.
Click to expand...

PEA will become asystole before you hit 35 degrees if you are counting on passive cooling.

They'll have a MAP in about 5 min. if there is a perfusionist and a pump on standby. Less if some brave soul gets their hands on that heart.
 
Did the surgeon rewire the sternum? If not I would be much more likely to think about open cardiac massage. If he did rewire, you gotta hope he gets there quick. Its strange that this lady is pod 2 and already back with a sternal infection. This and the fact that there was so much trouble makes me wonder if there was not already an infectious process going on. I have also seen friable aortas like this in patients with undiagnosed aortitis from one of the many vasculitides like giant cell arteritis or polymyalgia rheumatica.
 
proman said:
Chest compressions with an open sternum aren't going to cut it. There's no way to generate intrathoracic pressure with external massage and open sternum. Internal massage is your only option.
Click to expand...

Would this be a good situation for abdominal CPR?

Great case.
 
SO HERE IS HOW IT WENT DOWN:

Epi/Neo and one round of compressions brought her back... temporarily.

The whole OR team is woking in harmony like some master symphony. Anesthesia is on their game, perfusion is on their game, circulators and scrubs are on their game... getting delegated to do their respective jobs.... including prepping for FEM-FEM bypass.

Controlled chaos.

We have a b.p., so at this point, rockstar anesthesia buddy gets an a-line as you are going to need it to go onto bypass.

Now we have a continuous wave form. B.P. in the toilet... but we are out of PEA and have somewhat of a perfusing rhythm. Neck line, FLUIDS, BLOOD, PRESSORS, FLUIDS, BLOOD, PRESSORS... repeat, repeat.

Both CT surgeons storm into the OR.

Sternal wires get cut and senior CT guy (20+ yrs. of experience) opens the chest....

Now imagine taking 4 garden hoses from your back yard... tying them together, pointing them toward the sky and turning them on at full blast. This was the type of catastrophic exsaguination that was encountered once the chest was open. NO WAY TO FIND THE HOLE OR PUT A FINGER IN IT... especially with 4 fresh grafts in the way.

In this particular scenario, if one of us had opened the chest before our surgeon colleagues had arrived, the patient would have bled out. No doubt.

WHAT IS THE NEXT MOVE....?

PACK the chest while surgeon #2 finishes getting access form below the diaphragm... A coupla minutes later and we crash onto FEM-FEM BYPASS (which was option #2).

16 units of blood + FFP + platelets, cryo, etc....

FINALLY.... some stability. Bypass.

WHAT DID WE FIND AND WHAT HAPPENED?

As we all know... the atrium is a thin piece of tissue which is why it is purplish in color... you can pretty much see blood through it vs. the ventricles. We also know that once the pericardium is removed, the RA and RV sit directly behind the sternum, which is why you don't stop ventilations on redo sternotomies. Her right atrium was particularly thin. Protoplasm type F-.

THE CULPRIT:

The previous sternotomy had somehow left part of the posterior sternum sharp when wired back together. When applied, the wound vac had pulled the right atrium into the sternum. Suction had caused a tear in the right atrium which caused the initial blood loss.
We also found a hole in the RV. We are not sure if it was the wound vac or the brief compressions that caused that hole.

Either way... 2 holes. One in the RA and the other in the RV.

On bypass they both get fixed.

SO WHAT HAPPENED?

The patient comes off w/o much in the way of pressors. ABGs are looking not too bad. Anesthesia guy decides not to put on a bis or cerebral oximetry. It wouldn't have changed his management.

Makes it to the CVICU...

THEN THE MIRACLE:

Patient is extubated the next morning. Completely neurologically intact. 👍



Learning point for me:

I have never heard of a wound vac causing this complication. Now I know. If I was in academics, I'd write up a case report....
 
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BTW, there are no single hero's with this case.

I love our CT team. Every person in that OR knew what to do and how to do it quickly. It was synergism at it’s best.

THIS WAS A TEAM EFFORT.
 
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