(link to the original post from forever ago for anyone just seeing this reply:
Let's do some echo:)
Unfortunately I can't get the post-op clips cause it was so long ago it's archived in PACS, and the archive retrieval isn't working.
Anyway, the folks who suggested peripheral VA-ECMO cannulation had the same thinking as I did. Problem is, the senior CT surgeons here at the time wanted nothing to do with our fledgling low-volume ECMO program, in part due to not wanting to deal with access complications in non-CT patients if they were consulted and in part due to lack of familiarity, hence they were not willing to go along with that plan. They wanted to get some sheaths in the groin and then try to go on pump peripherally if he crashed out.
Anyway, since ECMO was out I had to come up with an alternative plan for sternotomy. Spent about half an hour liberally topicalizing the guy's airway in the ICU with 4% lido nebs, 4% viscous atomization, and 5% paste smeared on some pharyngeal structures. Dead numb to oral stimulation at that point.
A-line done in ICU. Roll to OR, and of course he's still SOB so he's 30 degrees head up at this point. Low dose norepi and vaso are running to support a MAP of 60-65. Start low dose precedex and give him a tiny dose of versed and ketamine. Surgeons start working on the groin sheaths while we do a MAC line in the neck. Have to increase the precedex a bit given groin discomfort. Also start with low dose epi knowing full well inotropes and vasopressors are not fixing the underlying problem.
Lines are in and now it's time for sternotomy. Even with low-dose sedation and no opioids, the guy is now at the point where he has maxed out his psychological and physical reserves. That is to say, he's becoming pretty obtunded and vasopressor support is going up. I put the mask on and close the popoff and do a "test breath." Hemodynamics don't change much with a 10-15 cm H2O positive pressure breath and I needed to confirm this because I'm thinking that even if you could magically unsedate the guy he's not going to have the reserve to breathe adequately in about 10-15 minutes.
Even though he's getting obtunded, he's not to the point of being a floppy fish where anyone could slip a blade in. I've used etomidate about 5 times in the last 8 years in the heart room, and this was one of 'em. Small dose of etomidate and a few more milligrams of ketamine along with an epi push and we're able to put the McGrath in. No reaction from him and we intubate easily. Turned a tiny bit of iso on, put him on PSV with no PEEP and gradually increased the inspiratory support. Hemodynamics remained rock stable.
I think we're good to paralyze so roc goes in, pt goes on positive pressure ventilation without crashing (norepi now at 20 mcg/min, epi at 2, vaso at 0.04).
Surgeons does sternotomy and of course whatever this mass is has totally frozen itself between the pericardium and epicardium. Super dense. Surgeons dissect as much as they can but it becomes clear they're not going to be able to establish an adequate tissue plane without going on pump. So, we heparinize and go on peripherally.
Long story short, we get to the "mass" totally obliterating the right heart and it is what appears to be.....a massive old blood clot. Turns out, the history of PCI was relevant in that this was likely a months-old coronary perforation from his RCA PCI that just kept accumulating blood without causing symptoms until it reached critical mass. Surgeons were able to remove it and then went through the long task of performing a pericardiectomy d/t the inflammation of having all that old-ass blood and fibrin sitting there for so long.
Pt comes off pump like a champ on minimal support now that he actually has an RV again. Extubated POD 1. D/c'ed POD 6 with no issues at all.
