Okay, here's what we did:
18g peripheral plus left-radial a-line in the pre-op area. Just a scosh of midazolam. Took her to the OR, and tried to put in a right IJ introducer, but couldn't get it (got the damn flash from the finder, but couldn't get the big needle to hit the spot, ended-up with a hematoma, and the surgeons put a right subclavian in). All of this was done awake. We floated the Swan pre-induction (just a RBBB) and were getting pressures early. Then, off to sleep with about 500mcg total of fentanyl, etomidate, and breathing her down with iso. Tube went in easy with no hemodynamic changes.
We didn't use Aprotinin because of her kidneys. We used Amicar instead, bolused 80mg/kg then 30mg/kg/hr infusion for the whole case. They cut down the sternum with minimal pressors and dissected off the LIMA. I had to touch her up with a little phenylephrine here and there, but her PAS/PAD never got above 40's/20's. The TEE went in without a problem, and cards came to do the read.
I gave her 21,000 units of heparin, they cannulated, and we went on pump without much problem. Total pump time was a little over 3 hours, with cross-clamp time about 2hrs, 10mins.
Coming off-pump was a bitch.
I checked a sugar and it was in the 290's (baseline was 90-something), so I bolused her with insulin and started a drip. As they started weaning her, I couldn't maintain good pressures. The perfusionist had given her 4 units PRBCs before hemoconcentration, and we ended-up giving her another three before they closed. She also got platelets, FFP, and 500 of albumin. Still crap pressures with the PA pressures now climbing into the 50's, although she was putting out a lot of clear urine. My attending wanted to give some Lasix, so we did. We ran Levophed, dopa, and nitro during the coming-off period. They A/V paced her. By the end of the case, she was maintaing good UOP with SBP in the 120's and PA pressures in the low 40's again. Problem was, she was dumping too much blood out of the mediastinal tube. We took her tubed to the cardiac ICU. So, I got her through it, but it looks like she's going to be a bring-back later tonight.
I like the vaso/milrinone combo. That might have helped with squeezing her beans as well as inotropy. Didn't try that, although we had it there. I don't have enough experience yet with these cases to "step up" and recommend anything different than what my attending wanted to do. Her main problem, I think was volume and a slow bleed from somewhere in her heart. This particular CT surgeon is known to have a higher bring-back rate than some of the others. I'll post-op her tomorrow and figure out things turned out.
I felt bad for this lady. She told me in the pre-op area that she felt she was too old to be having this surgery. I guess this is one of those damned if you do, damned if you don't cases and she was convinced to proceed. I just hope now she actually makes it out of the hospital. She was a total sweetheart.
Great case. Thanks for the discussion!
copro
