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Discussion in 'Anesthesiology' started by nutmegs, Dec 10, 2008.
and it has to do with a massive vascular injury during a hip revision.
and me handing off the resuscitation 4 hours later. and me not placing a central line before the case. and the lateral position with no neck. and something dumb like 22 liters through the belmont.
holy cow. what kind of access did you have? maybe they should have called the trauma service for damage control.
Well that is a nightmare. I can think of very few reasons to place central access during a hip case unless your access is absolutely terrible to begin with so nobody can fault you for that. I have done double redos a few times and haven't used any special access for them. WHat is concerning as well is possible conversion to GA. Did you start out w/ a spinal?
vascular was in there pretty fast. in the end we used much more volume than was needed, but without central access we were limited to pushing epi and phenylephrine through those "two large-bore PIVs". his pressures just sucked unless the fluid rate was holding them up, though, even when they had relative control of the injury (it was hard because they didn't know what the injury WAS- it wasn't like they saw the artery and nicked it. they think the retractor "tore" something...). I think his heart sucked more than we knew and may have been infarcting. in retrospect, more pressors and less fluid but damn....
thank god, no. we placed an epidural for POP but due to his size and the fact that the case was posted for like 6 hours we tubed him right off.
The good news is that this type of complications only happens in academia and you almost never see it in private practice.
2 good peripheral IV's is a reasonable access for hip revision, and as Arch said, unless the patient had terrible veins I would not place a central line.
agree - I haven't placed any central lines in my 5 months or so of private practice. Hopefully I can find a case to put one in, but usually a 14 g or 16 g piv or two will do fine if I need some access. One of the senior partners has a line "every case is a one iv case until proven otherwise"
according to the vascular note, they ended up repairing/bypassing the common femoral. he got a swan overnight and his heart is still sucking...
Another example of academia providing "skewed reality" to a resident.
Dude, that s hit doesnt even come close to happening in private practice.
You said this was for a hip?
Twenty two liters?
I've seen better animal studies.
The surgeon you've been given the "opportunity" to work with needs to consider psychiatry.
I said it was a hip where they shredded the common femoral with a retractor. and no, I don't think he had 22 liters of loss- it was hard to tell because only a fraction of it was going to the canister. he needed volume and got volume, then needed pressors and got volume. in retrospect.
private practice wouldn't do the case. sent him up to be a statistic on our books instead.
Thanks for proving my point.
More commonly in academics, my friend.
More commonly in academics.
Did they repair the common femoral artery or was it actually the femoral vein. I'd put my money on the vein. You don't tear an artery as easily as a vein. And I've seen it happen b/4. It ain't pretty.
Posting the case for 6 HOURS? That's long.
I don't doubt private practice ortho does revisions. I'm not sure what made this one especially difficult, just that it was discussed as being more technically challenging and posted for longer than our standard revisions.
The vascular note said artery, and they angio and repaired it. The pressure went from 106/70 to 40/20 literally in the space of seconds, so...
His insurance or lack there of.
Damn!!! I am at a loss. I have done a number of trauma ortho cases and the surgeon never came close to hitting a femoral artery in the lateral position. Even with a deep Charling Retractor, that is close to impossible. The surgeons incision must have been severely inferior. Most of that blood loss must have been in Lap sponges and on the floor since it wasn't in the suction canister. What was the surgeon doing, taking out half the sacrum as well?