Opening chests

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Sounds great. But no unfortunately not on site overnight so it's on us...
 
Does the patient want a dummy beginner opening his/her chest?

If you must practice at the top of your license and think you're doing more good than bad, the best way to learn to open the sternal closure is to watch plenty of sternal closures.

Then reverse the things they do in reverse order. *** The dunning-Krueger effect takes place here, you don't know enough to not know that there is many different ways to close the chest and each way of closure could result in different disasters if you don't open the chest the correct way.

If I could end world hunger and save the pt's life at the same time by opening a patients chest, I could probably open a sternal closure. However, I have never had a situation where I felt I need to open the chest and I do a fair number of cardiac surgeries. So I highly question the premise that an anesthesiologist who's never opened a sternal wound would be the best person to open the chest.
 
Guys please. Thank you for your opinions.

Now does anyone have any resources answering the question at hand?

Thank you
 
PpfSuxTube said:
Guys please. Thank you for your opinions.

Now does anyone have any resources answering the question at hand?

Thank you
Click to expand...

The Houston Methodist DeBakey center YouTube channel has a step by step instructional video for their fellows on median sternotomy. Just search for it
 
PpfSuxTube said:
Guys please. Thank you for your opinions.

Now does anyone have any resources answering the question at hand?

Thank you
Click to expand...
The short answer is no, we don’t. The long answer is that while we appreciate your patient commitment, none of us are willing to consider doing this so finding a resource seems like it’s of minimal utility.
 
Wait, are you on the hook as the anesthesiologist or the intensivist?

If you want to be proficient, then I would 1) familiarize yourself with the open chest cart and whether or not the surgeons are using wires, jace plates, or a combination. If you try to cut Jace plates with wire cutters… well, I’ve seen that go nowhere. 2) scrub into a few surgeries during the chest closure, or just scrub into an open chest code during the day while CTS is in-house.

If they are expecting you to do this as the Anesthesiologist… no way.
 
PpfSuxTube said:
Guys please. Thank you for your opinions.

Now does anyone have any resources answering the question at hand?

Thank you
Click to expand...
I’m not even anywhere close to your field, but IMO if this is an expected part of your job (which I guess it shouldn’t be based on every other response) then you should be asking the surgeons to train you how to do it.
 
Chill out guys, about 50% of my work is as a cardiac intensivist in a very high volume, high acuity, high complexity centre without fellows or residents...


Cardiac arrest following cardiac surgery

Cardiac arrest following cardiac surgery is surprisingly uncommon, considering the fact that the heart was already quite diseased (hence it needed the surgery) and then it has been cut, grafted, manually handled and perfused with perverse fluids. Apparently in America the rate is about 0.7-0.8%...
derangedphysiology.com derangedphysiology.com


  • After five minutes of unsuccessful resuscitation the chest should be re-opened. External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest.
  • Non-surgical staff are encouraged to re-open the chest in an emergency.


I'm glad none of you have to encounter this. It is very much my job.
About once per year unfortunately for the last few years
 
The closest experience I have with reopening a chest was one almost performed by a general surgeon. He was glad that by the time he scrubbed, CTS got there.

I guess I am saying if a surgeon hesitates to open sternal closure…. And they rotate through at least a few months in their residency. He’s probably closer to open that chest than any of us should ever be…. If it’s once a year event, there’s no way that anyone can be proficient for it. It’s one thing to “know” how to do it; it’s another when you actually have to do it. It’s like we all “know” how to obtain a surgical airway, I will be the first one to admit, I’ve never done it…. With all that said, if you as the intensivist is actually opening a chest, I am thinking it’s a last ditch effort, so go for it.
 
Definitely missing something here...very high volume, high acuity, high complexity center with the potential of requiring anesthesia surgical rescue? If that scenario is any kind of surprise (intra-operative course, comorbidities, risks, etc) somebody's got some 'splainin' to do. Pericardial effusion leading to tamponade doesn't happen in 30 seconds. Dude can jump in the Lexus and get to the hospital in the time it takes to avert catastrophe.
 
PpfSuxTube said:
What was it? 9:2 condescension to helpful ratio? That's pretty good for sdn professors. Thank you.

Listen I'm good with all the derision...
Click to expand...
Sorry, but really...not sorry...the issue is not 'how/should I open a fresh chest'...it just isn't...the one off, crazy grab the wire cutters (if anyone in the icu has any idea what those are, let alone where they are) OK fine...game winning hail Mary from the opposite free throw line...advice on how to get ready for that? I....
 
drmwvr said:
Sorry, but really...not sorry...the issue is not 'how/should I open a fresh chest'...it just isn't...the one off, crazy grab the wire cutters (if anyone in the icu has any idea what those are, let alone where they are) OK fine...game winning hail Mary from the opposite free throw line...advice on how to get ready for that? I....
Click to expand...
Listen guys, is anyone on here cardiac icu please chime in?

Pls read post cardiac surgery cardiac arrest algorithms and come back here... it's linked above

If you all want to unload your majestic skills and knowledge base upon me then great fine, I bow down you are all so much better than me..I get it. Thank you...

Those youtube Houston vids are very good. Thanks BTW... I'm out
 
PpfSuxTube said:
Listen guys, is anyone on here cardiac icu please chime in?

Pls read post cardiac surgery cardiac arrest algorithms and come back here... it's linked above

If you all want to unload your majestic skills and knowledge base upon me then great fine, I bow down you are all so much better than me..I get it. Thank you...

Those youtube Houston vids are very good. Thanks BTW... I'm out
Click to expand...

Happens a few times a year in our ICU, I've never had to do it though. Large tertiary academic center.
 
Theoretically it should be part of an ICU skillet but so should an emergent pericardiocentesis, trepanation, floating a temp venous pacer, cric, and other various niche emergent **** you have either low single digit (or 0) experience with. Watch a YouTube video if you feel like you want to have a framework of what to do but know that if the surgeon isn't around the patient is probably going to die no matter what you do.
 
OP -

I hear ya.
The ICU I began practice in had an active cardiac surgical program without any CT surgical team member in house. We used the STS Document on post-CT surgery arrest (attached) as our "protocol" and had some simulation stuff as way to "learn it" live. Never had to do it but the document (and CT surgeon-guided "practice" via simulation) took me from no understanding to at least a conceptual context.

This site has some steps to the process, and a couple vids at the bottom.

Hope this helps.
 

Attachments

dchz said:
Does the patient want a dummy beginner opening his/her chest?

If you must practice at the top of your license and think you're doing more good than bad, the best way to learn to open the sternal closure is to watch plenty of sternal closures.

Then reverse the things they do in reverse order. *** The dunning-Krueger effect takes place here, you don't know enough to not know that there is many different ways to close the chest and each way of closure could result in different disasters if you don't open the chest the correct way.

If I could end world hunger and save the pt's life at the same time by opening a patients chest, I could probably open a sternal closure. However, I have never had a situation where I felt I need to open the chest and I do a fair number of cardiac surgeries. So I highly question the premise that an anesthesiologist who's never opened a sternal wound would be the best person to open the chest.
Click to expand...
This is probably the best advice. If you want to know how to open a chest, you got to learn how they close it (and I can already think of 3-4 methods off the the of my head), and then be able to reverse it.
 
This thread has shown some people don’t understand the reality of being an intensivist at a large volume cardiac surgery center. Reopening a chest is something you have to be prepared to do if needed.

When I was an ICU fellow, I asked the cardiac surgery fellows how I should do it. They told me a few things: don’t pull the wires straight up when you’re pulling them out after you cut them (grab it with clamp and twist it out with its natural curve). Get plenty of suction set up. Make sure you have good lighting. Also, if you can identify bleeding plug it directly with your gloved finger - if you have a 4x4 in between your finger and the bleeding it’ll keep bleeding into the 4x4. Don’t try to fix anything, and wait for CT surgeon to get there.
 
lol at all the dismissive replies. Reopening a chest is very much a recognized part of post sternotomy resuscitation. Good luck doing effective CPR when there’s a big sac of blood sitting between the chest and heart

I unfortunately do not have good resources, but the actual reopening is not difficult. Cut through skin sutures with a scalpel the need someone to grab and lift wires with clamp while you cut through them. The hard part is coordinating the rest of the team while a couple people get scrubbed and try and maintain some semi sterile cpr. And then trying not to tear off the grafts while doing cardiac massage
 
Emergent resternotomy is in cardiac surgical ICU intensivist scope of practice . Being able to re enter without lacerating the heart / aorta / grafts with the wire removal requires getting a comfortable feel and familiarity with the tools and the anatomy so really you need to scrub in semi regularly - that’s the only way.
 
To the neysayers, someone getting into the chest within the first few minutes of a post-sternotomy arrest is a core part of the CALS algorithms. It has, though, been a little slow to catch on this side of the Atlantic. I remember being one of the first Americans to take the online CALS course as a fellow several years ago, and not a lot of places have really embraced the concepts.

This should be part of the onboarding process for new cardiac intensivists at your shop. Ask the surgeons there to give a presentation to your department (probably should do it at least yearly), with pictures and video of opening a chest in a controlled fashion. A place of your size likely has a couple of bringbacks a month, so they should have the opportunity to get the images/video. The decision to have the intensivists involved likely came from CTS, so they should have a hand in ensuring you are competent enough for this very rare occurrence.
 
psychbender said:
To the neysayers, someone getting into the chest within the first few minutes of a post-sternotomy arrest is a core part of the CALS algorithms. It has, though, been a little slow to catch on this side of the Atlantic. I remember being one of the first Americans to take the online CALS course as a fellow several years ago, and not a lot of places have really embraced the concepts.

This should be part of the onboarding process for new cardiac intensivists at your shop. Ask the surgeons there to give a presentation to your department (probably should do it at least yearly), with pictures and video of opening a chest in a controlled fashion. A place of your size likely has a couple of bringbacks a month, so they should have the opportunity to get the images/video. The decision to have the intensivists involved likely came from CTS, so they should have a hand in ensuring you are competent enough for this very rare occurrence.
Click to expand...
I don’t take issue with the fact that sometimes ICU needs to reopen the chest before CTS can get there.

The problem is that CTS expects this to happen with so little support, guidance, training, etc. that this intensivist feels the need to send out a desperate plea for resources to an online forum. It speaks to a lack of ownership and responsibility for the proper care of their patients on the part of the CTS dept. I would expect that from GI or IR but not a cardiac surgeon.

I agree 100% with your second paragraph. CTS needs to step up. They should do this unprompted because they want good care for their patients. If they don’t, then ICU needs to ask them to provide proper training.
 
PpfSuxTube said:
Listen guys, is anyone on here cardiac icu please chime in?

Pls read post cardiac surgery cardiac arrest algorithms and come back here... it's linked above

If you all want to unload your majestic skills and knowledge base upon me then great fine, I bow down you are all so much better than me..I get it. Thank you...

Those youtube Houston vids are very good. Thanks BTW... I'm out
Click to expand...
This is the same guy who was asking how to float a swan in another thread.
 
PpfSuxTube said:
Chill out guys, about 50% of my work is as a cardiac intensivist in a very high volume, high acuity, high complexity centre without fellows or residents...


Cardiac arrest following cardiac surgery

Cardiac arrest following cardiac surgery is surprisingly uncommon, considering the fact that the heart was already quite diseased (hence it needed the surgery) and then it has been cut, grafted, manually handled and perfused with perverse fluids. Apparently in America the rate is about 0.7-0.8%...
derangedphysiology.com derangedphysiology.com


  • After five minutes of unsuccessful resuscitation the chest should be re-opened. External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest.
  • Non-surgical staff are encouraged to re-open the chest in an emergency.


I'm glad none of you have to encounter this. It is very much my job.
About once per year unfortunately for the last few years
Click to expand...
Before I get more entrenched in my stance, I would like to understand your situation more:

-How many pump/cardiac cases do you provide anesthesia for per year?
-How many pump/cardiac cases are done at your center per year?
-What is your typical census in the cardiac ICU?
-Does your program report to the STS database? If so, how many stars?
-How many emergent re-entrant sternotomies are performed per year in the ICU?
-How many of those re-entrant sternotomies are done by CT surgeon vs intensivist?

To be fair, your OP gave no information on why you, the anesthesiologist, had to reopen a sternotomy. You mentioned nothing about being in an intensivist role.

I also feel like your unwillingness to explain your situation borders on egotistical and dismissive towards the people you're requesting help from.
 
Last edited:
bigdan said:
OP -

I hear ya.
The ICU I began practice in had an active cardiac surgical program without any CT surgical team member in house. We used the STS Document on post-CT surgery arrest (attached) as our "protocol" and had some simulation stuff as way to "learn it" live. Never had to do it but the document (and CT surgeon-guided "practice" via simulation) took me from no understanding to at least a conceptual context.

This site has some steps to the process, and a couple vids at the bottom.

Hope this helps.
Click to expand...

The article advocates that PAs or senior ICU nurses may be the optimal people to be trained for resternotomy. I cannot even begin to imagine how poorly that would go. Give me an anesthesiologist intensivist with no surgical training over that any day of the week.
 
mdo1738 said:
The article advocates that PAs or senior ICU nurses may be the optimal people to be trained for resternotomy. I cannot even begin to imagine how poorly that would go. Give me an anesthesiologist intensivist with no surgical training over that any day of the week.
Click to expand...
I know some damn good cardiac surgery PAs that are infinitely more capable of re-opening a fresh chest (that they’ve closed themselves 100s, if not 1000s of times) than anyone on this forum whose chosen to comment. I’d trust them over me or any other non-surgeon to open a post-op chest any day of the week.
 
mdo1738 said:
The article advocates that PAs or senior ICU nurses may be the optimal people to be trained for resternotomy. I cannot even begin to imagine how poorly that would go. Give me an anesthesiologist intensivist with no surgical training over that any day of the week.
Click to expand...
The article was promulgated by the STS, and I posted it as a reference. I think it is a useful resource. While there is almost certainly a hierarchy of whom I’d prefer to be reopening a chest in an emergency, I think the concept of suggesting non-physician involvement is much more a way to underscore that reopening the chest is an absolute emergency, and getting someone (trained to do so) into the chest matters as much as who enters the chest.
 
dchz said:
To be fair, your OP gave no information on why you, the anesthesiologist, had to reopen a sternotomy. You mentioned nothing about being in an intensivist role.

I also feel like your unwillingness to explain your situation borders on egotistical and dismissive towards the people you're requesting help from.
Click to expand...
yeah I did. It's right there. I post plenty on cardiac, echo, the bit of icu i know... Does everyone that asks a question have to preface it with their CV? Chill out
 
I find this interesting in that they asked me if I wanted to open the chest on my oral boards with a crashing post op cardiac case. My thinking was that only bad stuff would happen if I did that. I said no. I passed though. I wonder if it was standard of care back in 1997 when I took them.
 
psychbender said:
To the neysayers, someone getting into the chest within the first few minutes of a post-sternotomy arrest is a core part of the CALS algorithms. It has, though, been a little slow to catch on this side of the Atlantic. I remember being one of the first Americans to take the online CALS course as a fellow several years ago, and not a lot of places have really embraced the concepts.

This should be part of the onboarding process for new cardiac intensivists at your shop. Ask the surgeons there to give a presentation to your department (probably should do it at least yearly), with pictures and video of opening a chest in a controlled fashion. A place of your size likely has a couple of bringbacks a month, so they should have the opportunity to get the images/video. The decision to have the intensivists involved likely came from CTS, so they should have a hand in ensuring you are competent enough for this very rare occurrence.
Click to expand...
This.

If CTS expects in-house help to open chests acutely in the unit, they should be providing the training.
 
dchz said:
Before I get more entrenched in my stance, I would like to understand your situation more:

-How many pump/cardiac cases do you provide anesthesia for per year?
-How many pump/cardiac cases are done at your center per year?
-What is your typical census in the cardiac ICU?
-Does your program report to the STS database? If so, how many stars?
-How many emergent re-entrant sternotomies are performed per year in the ICU?
-How many of those re-entrant sternotomies are done by CT surgeon vs intensivist?

To be fair, your OP gave no information on why you, the anesthesiologist, had to reopen a sternotomy. You mentioned nothing about being in an intensivist role.

I also feel like your unwillingness to explain your situation borders on egotistical and dismissive towards the people you're requesting help from.
Click to expand...
You're definitely barking up the wrong tree here. CALS and re-sternotomy by non-cardiac surgery personnel is very much the standard at many, many centers. Unfortunately, standardized training is NOT routinely offered for something that is not in the realm of ordinary. The first post was exceedingly obvious to anybody who knows what CALS is.
 
Ronin786 said:
You're definitely barking up the wrong tree here. CALS and re-sternotomy by non-cardiac surgery personnel is very much the standard at many, many centers. Unfortunately, standardized training is NOT routinely offered for something that is not in the realm of ordinary. The first post was exceedingly obvious to anybody who knows what CALS is.
Click to expand...
But what do you think the risk:harm ratio is in low acuity center where nobody has ever done it? Like the janitor would have just as much knowledge as the personnel. CT surgeons love to blame everyone else for anything that happens to their patients because their metrics are so important to their compensation--having some poor sucker try to open the chest and cut/tear something vital mid code then get blamed for making the situation unsalvageable doesn't appeal to most people. I agree if they want to not be in house to deal with their own bull**** and want this to be done they need to create an in-service program and protocol for it.
 
chessknt said:
But what do you think the risk:harm ratio is in low acuity center where nobody has ever done it? Like the janitor would have just as much knowledge as the personnel. CT surgeons love to blame everyone else for anything that happens to their patients because their metrics are so important to their compensation--having some poor sucker try to open the chest and cut/tear something vital mid code then get blamed for making the situation unsalvageable doesn't appeal to most people. I agree if they want to not be in house to deal with their own bull**** and want this to be done they need to create an in-service program and protocol for it.
Click to expand...
Odds are, any non-CT surgeon opening the chest is going to be doing it for the first time. But given the statistics surrounding post-cardiac surgery arrests, they're almost always salvageable problems by simply opening the chest.

I'd argue the morbidity of pushing on a post-sternotomy chest is higher than the problems with opening the chest, it's just such a foreign concept that's hard to fathom. Kind of liking opening stitches in airway compromise after a thyroid.
 
Ronin786 said:
You're definitely barking up the wrong tree here. CALS and re-sternotomy by non-cardiac surgery personnel is very much the standard at many, many centers.
Click to expand...
I definitely am not. You're assuming my stance and arguing against an imaginary take that was not endorsed by me.

Also is it the standard that the non-cardiac surgery personnel go on SDN to get their training?
psychbender said:
To the neysayers, someone getting into the chest within the first few minutes of a post-sternotomy arrest is a core part of the CALS algorithms. It has, though, been a little slow to catch on this side of the Atlantic. I remember being one of the first Americans to take the online CALS course as a fellow several years ago, and not a lot of places have really embraced the concepts.

This should be part of the onboarding process for new cardiac intensivists at your shop. Ask the surgeons there to give a presentation to your department (probably should do it at least yearly), with pictures and video of opening a chest in a controlled fashion. A place of your size likely has a couple of bringbacks a month, so they should have the opportunity to get the images/video. The decision to have the intensivists involved likely came from CTS, so they should have a hand in ensuring you are competent enough for this very rare occurrence.
Click to expand...

Bertelman said:
This.

If CTS expects in-house help to open chests acutely in the unit, they should be providing the training.
Click to expand...
To clarify, my stance is very similar to the quoted comments:

If sternal re-opening is expected of the intensivists, the surgical team should be involved in the training. The sternal closure device/method are often institution specific and even surgeon specific.

Asking a group of people on the Internet who have not opened the chest regularly on where to find "dummy beginner" material is not a responsible way to obtain the training needed.

I have never said the intensivists with the right training should not open the chest in a cardiac emergency. Nor have I ever said that the chest shouldn't be opened during a post-sternotomy emergency.
 
Last edited:
dchz said:
I definitely am not. You're assuming my stance and arguing against an imaginary take that was not endorsed by me.
Click to expand...
Can you please just leave it so we can discuss this a bit? We're getting some good chat going now, don't derail it
 
dchz said:
I definitely am not. You're assuming my stance and arguing against an imaginary take that was not endorsed by me.

Also is it the standard that the non-cardiac surgery personnel go on SDN to get their training?



To clarify, my stance is very similar to the quoted comments:

If sternal re-opening is expected of the intensivists, the surgical team should be involved in the training. The sternal closure device/method are often institution specific and even surgeon specific.

Asking a group of people on the Internet who have not opened the chest regularly on where to find "dummy beginner" material is not a responsible way to obtain the training needed.

I have never said the intensivists with the right training should not open the chest in a cardiac emergency. Nor have I ever said that the chest shouldn't be opened during a post-sternotomy emergency.
Click to expand...
Of the four institutions I've worked at in a CTICU setting, surgeons have been involved in the training of chest re-sternotomy zero times. The one location that did have any form of training was by the ICU team.

You're clearly not quite grasping that "dummy beginners" with no OR experience are in fact expected to open chests in many centers around the country and the world. And the STS recommended training is in fact a bunch of "dummy beginner" material (see https://www.csu-als.org/page/CERTIFICATIONRECERTIFICATION)
 
Ronin786 said:
Of the four institutions I've worked at in a CTICU setting, surgeons have been involved in the training of chest re-sternotomy zero times. The one location that did have any form of training was by the ICU team.

You're clearly not quite grasping that "dummy beginners" with no OR experience are in fact expected to open chests in many centers around the country and the world. And the STS recommended training is in fact a bunch of "dummy beginner" material (see https://www.csu-als.org/page/CERTIFICATIONRECERTIFICATION)
Click to expand...
I think that's one reason why it has been slow to catch on in the states. It's a bunch of people talking about what you SHOULD do in theory, without any practical knowledge or experience. I spent a bunch of time with surgeons and my CCM attendings going through ECMO cannulation, and felt like I could get through it on my own, if I really needed (less so now, as I haven't scrubbed in since fellowship). If we spent nearly the same amount of time going through how to re-enter the chest with the surgeons, I'd feel less than completely lost, should the situation arise. As is, I direct the resuscitation, while standing over my surgeons shoulder going, "Are you going to open the chest now? Come on, open the chest now. The OR is taking forever, let's open the chest now."
 
People saying “but cardiac surgeons need to take responsibility for training the rest of us” are missing the point. Intensivists are not caretakers for cardiac surgeons. If they’re in my unit they’re my patients, and I don’t really care what expectations the surgeons have or don’t have.

I’m going to take responsibility for training myself to open a chest in the middle of the night when I’m there and the surgeon is half an hour away because that might be the difference between a successful and failed resuscitation.

So don’t pile on the OP for trying to do the same
 
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