How long is too long on the pump?

[VentdependenT]

73 y/o morbidly obese female with RCA dz and severe aortic stenosis has AVR and SINGLE VESSEL GABG with a pump time of FIVE HOURS.

Big surprise that she develops ATN with starting creatinine of 1.5. Surgical team wanted more and more fluids and a transfusion of blood for a hb of 8.5 (she got 2 units on top of a$$loads of fluid post op...dunno svo2 numbers. pt was NOT acidotic pre-transfusion) post op with 120mg lasix to try and correct an uncorrectable problem. End result------------->tubed at 11pm while my punkass is on call for hypercapnic respiratory failure from fluid overload.


My question: if they worked faster could this have been prevented? Is there a sort of "no-return of kidneys" pump time when you are this friggen old with CRI? There was no MAP issue from transition to, on, and off pump that lasted more than a couple of minutes.

This lady is gonna get a trach, a long term dialysis catheter, and a ONE WAY TRIP to a long term vent center.

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[UTSouthwestern]

Five hours?!?! Yes that's way too long. Anything over 2 is too long and my high volume valve surgeons will say anything more than one is ridiculous.

I'm assuming there was a problem with the annular sutures because I can't imagine even the worst surgeon taking that long. Have one guy that does Avr's unjust under 2 hours skin to skin with 30-45 min pump runs. Add 10-25 min if he has bypasses to do on top of the valve.

73 y/o morbidly obese female with RCA dz and severe aortic stenosis has AVR and SINGLE VESSEL GABG with a pump time of FIVE HOURS.

Big surprise that she develops ATN with starting creatinine of 1.5. Surgical team wanted more and more fluids and a transfusion of blood for a hb of 8.5 (she got 2 units on top of a$$loads of fluid post op...dunno svo2 numbers. pt was NOT acidotic pre-transfusion) post op with 120mg lasix to try and correct an uncorrectable problem. End result------------->tubed at 11pm while my punkass is on call for hypercapnic respiratory failure from fluid overload.


My question: if they worked faster could this have been prevented? Is there a sort of "no-return of kidneys" pump time when you are this friggen old with CRI? There was no MAP issue from transition to, on, and off pump that lasted more than a couple of minutes.

This lady is gonna get a trach, a long term dialysis catheter, and a ONE WAY TRIP to a long term vent center.

 

[coprolalia]

Yeah, we try to limit our pump runs under two hours too. As soon as we start going past 2 hours, I start saying VERY loudly in the OR, "TICK, TOCK, TICK, TOCK, TICK, TOCK..." until they tell me they are rewarming.

-copro

 

[urge]

How long is too long depends on what you are doing. For a single valve and a cabg seems really long. Complicated 3 valve or aortic surgery might take 5 hr on pump. There is no magic number. At least not that I'm aware of.

 

[bubalus]

My personal best (or worst depending on your frame of reference) is 8 hours. Done it a few times, mostly aortic roots with crappy surgeons. Not too good for the patient, but a great experience for the resident. I like doing those kind of cases because I learn a lot more, but I wouldn't want my mother being the patient.

 

[coprolalia]

My personal best (or worst depending on your frame of reference) is 8 hours. Done it a few times, mostly aortic roots with crappy surgeons. Not too good for the patient, but a great experience for the resident. I like doing those kind of cases because I learn a lot more, but I wouldn't want my mother being the patient.

You "learn a lot more" because you are sitting there doing absolutely nothing but reading.

I don't know why they make us even stay in the room when their on pump, especially if you have a good perfusionist.

Your incidence of pump head climbs exponentially if you do longer than two hour pump runs. Honestly, if someone's heart is so bad that they need three valves and a sh*load of vessels, then I consider elective CT surgery a form of physician-assisted Russian roulette. Problem is, most patients (and their families) don't know this going into it. They simply believe that granny is going to get her ticker fixed by the nice doctors and everything is going to be alright and she'll live another 100 years.

-copro

 

[VentdependenT]

I thought I'd read somewhere that after 3hours on CPB that morbidity and mortality starts to skyrocket.

Personally I think this woman would have been better off dying in 3 years because of her aortic stenosis.

We shoulda just put in a friggen Quinton in the OR before bringing her back to the unit.

On a somewhat related note: 7 foot austrian orthopod spine fellow spends 6 HOURS monkey-fuKKen around on a prone T-12 corpectomy in a 90 YEAR OLD DUDE WITH UNTREATED PROSTATE CA WHO COULD BARELY USE A FRIGGEN WALKER PRE-PATHOLOGIC FRACTURE. Dude's got hx of big ol' MI & A-FIB without any anticoagulation.

He got all frustrated that great-gramps couldn't follow commands IMMEDIATELY after surgery. THe due has conus-medullaris syndrome and its doubtful that neuro function will ever return. GREAT JOB GUYS! WHERE'S THE ANCEF?

Great-gramps followed commands POD 1 at about 1 am. I wrote the transfer orders to the floor at 1:01AM.

 

[coprolalia]

He got all frustrated that great-gramps couldn't follow commands IMMEDIATELY after surgery.

Physostigmine 2mg IV push. Repeat q10min until g-pops is reciting the Pledge of Allegience on cue.

-copro

 

[VentdependenT]

Physostigmine 2mg IV push. Repeat q10min until g-pops is reciting the Pledge of Allegience on cue.

-copro

Good idea, but not even worth it. This dude was beyond physostigmine.

 

[ZA_Gasman]

At our centre, pump times regularly go over 2 hours, and often approach 5 for anything more difficult than a simple valve or CABG... What worries me more is the long clamp times... We get very excited if a cross clamp is on less than 90minutes. For some strange reason our surgeons get very upset when we blame post op complications on long bypass times. I'm sure it has nothing at all to do with the God complex which gets issued to all CT surgeons when they become residents. You guys are just technicians... now get over it and get it done fast!

 

[jetproppilot]

73 y/o morbidly obese female with RCA dz and severe aortic stenosis has AVR and SINGLE VESSEL GABG with a pump time of FIVE HOURS.
.

Venty, thats really bad. I'm at a loss for words.

As you know (better than I probably since youre gonna be a CV stud soon), on pump time is one of the few times in surgery that M&M increase linearly with time.

We all want surgeries to go fast.

Open hearts are the ones that have to be fast.

Unfortunately not all heart surgeons can be like David Ott at Texas Heart.

Whadda frikkin stud.

Watching him sew in grafts/valves was like watching a sewing machine.

If you're using more than one anesthesia page, the heart surgeon picked the wrong specialty.

 

[VentdependenT]

Venty, thats really bad. I'm at a loss for words.

As you know (better than I probably since youre gonna be a CV stud soon), on pump time is one of the few times in surgery that M&M increase linearly with time.

We all want surgeries to go fast.

Open hearts are the ones that have to be fast.

Unfortunately not all heart surgeons can be like David Ott at Texas Heart.

Whadda frikkin stud.

Watching him sew in grafts/valves was like watching a sewing machine.

If you're using more than one anesthesia page, the heart surgeon picked the wrong specialty.

Well she started pissing POD 3 on just a wiff of lasix....thats a wiff of 40 mg an hour for 3 days. Who needs that pesky vestibulocochlear cranial nerve anyways. Who knows what the future will bring....besides a reintubation, a stroke, pneumonia, etc.

I pulled the tube this morning because she passed her SBT's, was totally coherent, and started pissen (0.5cc/kg/hr ideal body weight x 24hr). Pullen TV's 600 on pressure support of 7. God bless them 8.0ETT's in chicks...shoulda popped an 8.5 in there.

Anyhoots the cardiac team went KNUTS on me because I didn't run it by them first. F-em dude. If it was my grandma on the g@d damn vent and she met criteria then pull the g@d damn tube. Ugh...this critical care crap is for the birds dude.

I told the cardiac team to stop the GENTAMYCIN she's been getting since I saw her last. Je$us H man...

Gimme my sevo back damnit.

 

[Arch Guillotti]

My question: if they worked faster could this have been prevented? Is there a sort of "no-return of kidneys" pump time when you are this friggen old with CRI? There was no MAP issue from transition to, on, and off pump that lasted more than a couple of minutes.

I don't think that MAP issues for short discrete periods of time contribute to post op renal failure nearly as much as the prolonged period of laminar flow does. The pt. you describe is a set up for renal failure and there likely wasn't too much you could have done to prevent it.

 

[ZA_Gasman]

Agree with Arch here. The patient was a sitting duck to bump off the kidneys, and with preop CRI, even if she had a quick pump time, she was still ilkely to get postop renal dysfunction. She, of all patients however, didn't need 5 hours on pump. Funny how, no matter what we do on pump, the major determinant of outcome is good hands... good surgical hands (and damn, it is hard to say that )

 

[rodeoqueen]

V

Unfortunately not all heart surgeons can be like David Ott at Texas Heart.

Whadda frikkin stud.

Watching him sew in grafts/valves was like watching a sewing machine.

I must agree, I just rotated through THI, he did a CAB (3 vessel) and AVR with a pump time of <30 minutes....it's art.

Also, makes the anesthesia a bit more exciting...you're barely on pump before it's time to go off again

 

[SouthSideSteve]

Pacifico @ UAB routinely had 25 min pump runs.