Clinical CT case that is a bit unusual.

[Lee123]

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Did the wound vac suck open the RV? .

I was close. RV... RA. same result.

 

[urge]

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-.

You lost me there.

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.

Why did you bring the subject of bis and/or oximetry into the discussion? What is your personal bias?

Did she still end up getting the wound vac?

 

[sevoflurane]

You lost me there.

Not clear was I.

1st time median sternotomy = cease ventilation before you power up the saw.
Redo median sternotomy = keep the lungs up.

I'm all for a Bis and Cerebral Oximetry in those rooms and I like cerebral oximetry in particular (air/plaque embolus, anemia, patients with cerebral autoregulation shifted to the right or concurrent bilateral carotid disease). I think they are both useful tools in the heart room... especially when you have something bad happen. You see your Cerebral Ox's go from 70 to 20 and then back up to 70 again = reassuring.

You use them Urge?

 

[sevoflurane]

Did she still end up getting the wound vac?

Not this time...packed and eventually came back for a flap.

 

[Bertelman]

SO HERE IS HOW IT WENT DOWN: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.

Great case. Sounds like all worked together to fix this cluster quite well.

I think the movement to the stretcher could have just as easily been the culprit in popping a hole in whatever chamber was punctured first. I would wonder how someone could be recovering for 2 days, sitting up in bed, coughing, walking, heart pumping away, then the placement of a wound vac on low-level suction somehow pops a hole in a chamber. Never underestimate the ability of a transfer to the stretcher destroying your evening plans for the next couple hours, or at least the cleanliness of your drawers.

Also hard to determine the true source of the sharpened sternum AFTER chest compressions were given. I would think that at some point during 2 sternal wire closures someone's index pad would have palpated a jagged edge large enough to cause this complication. Either way, clearly the hemorrhage began prior to the compressions.

 

[itwasalladream]

Sorry I still don't understand why you shouldn't drop the lungs on a redo

 

[btbam]

Sorry I still don't understand why you shouldn't drop the lungs on a redo

Me either, I would like to hear why though.

 

[proman]

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.

Really strong work on this case. I still think opening the chest was the right move. Goal is to open chest within 5 min of an arrest. If you think drugs and blood will work and the surgeons are going to be there quickly then I don't think it's wrong to wait.

 

[proman]

Sorry I still don't understand why you shouldn't drop the lungs on a redo

Different saw is used. Primary sternotomy uses a reciprocating saw that has a boot that fits under the sternum as a guide. It's that piece that can snag an inflated lobe and cause a lung injury

Resternotomy uses an oscillating saw much like a cast removal saw (can't cut skin). Adhesions that develop after primary sternotomy can put the RV, RA or PA directly under the posterior table of the sternum. Using a reciprocating saw will snag it and cut = bad day. Oscillating saws slowly separate the sternum anterior to posterior and usually protect the structures underneath. Many patients will have a CT of the chest showing how much space is under the sternum. Lungs aren't dropped during resternotomy because they typically won't be entrapped under the sternum, and redos take can take 10-45 minutes just to open the chest.

But, Urge knows all this. 😉

 

[itwasalladream]

Thanks for the reply

 

[drccw]

Nice case...

haven't done cardiac since I left residency...

some days I miss it.. most days I don't

drccw