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[DrDre']

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It has been boring lately.

I am on cardiac now. Doing an ascending aortic aneurysm repair on Monday. Any pearls?

On a lighter note, ran 113 miles this week.

Time to celebrate with cherry pie and single malt!

 

[Planktonmd]

It has been boring lately.

I am on cardiac now. Doing an ascending aortic aneurysm repair on Monday. Any pearls?

On a lighter note, ran 113 miles this week.

Time to celebrate with cherry pie and single malt!

I haven't done cardiac anesthesia in a long time but why not, let's talk about ascending aortic aneurysm repair.
Are they replacing the aortic valve as well?
Maybe someone could tell us about deep hypothermic circulatory arrest, it's advantages and it's issues.
How about spinal cord protection?
Let's talk preop, intraop and post op.
This is a very juicy subject so let's do it.

 

[lfesiam]

It has been boring lately.

I am on cardiac now. Doing an ascending aortic aneurysm repair on Monday. Any pearls?

On a lighter note, ran 113 miles this week.

Time to celebrate with cherry pie and single malt!

113 miles! 😱

nice Dre. 👍

 

[Noyac]

I haven't done deep hypothermic circulatory arrest since New Years day 2002 when I did it twice in one day on two different pts.

 

[zack_morris]

Doing an ascending aortic aneurysm repair on Monday. Any pearls?

Bring something to read. Depending on extent of repair (ie AVR, arch/head vessel involvement/repair), these can involve a pretty long pump run.

 

[Planktonmd]

I haven't done deep hypothermic circulatory arrest since New Years day 2002 when I did it twice in one day on two different pts.

The russians are the world leaders in cardiac surgery under deep hypothermic arrest.

 

[coprolalia]

Even with deep hypothermic arrest, you'll still probably run low-flow (like 500mL/minute) to the brain. We drop 'em to about 18 degrees. Remember to take the ice off of the head when you're ready to re-warm. Somehow, people always forget to do that. And, the BIS (if you use it) will or should read close to "0". Pretty eerie.

-copro

 

[Planktonmd]

Even with deep hypothermic arrest, you'll still probably run low-flow (like 500mL/minute) to the brain. We drop 'em to about 18 degrees. Remember to take the ice off of the head when you're ready to re-warm. Somehow, people always forget to do that. And, the BIS (if you use it) will or should read close to "0". Pretty eerie.

-copro

The question though: Do we really need any brain perfusion under deep hypothermia?
The Russians do these cases with no perfusion at all and no perfusionist in the room, they use it for all kinds of cardiac procedures and their mortality rate is an impressive 0.8 %.

 

[proman]

The main issues as I see it:

Organ preservation: namely cerebral but also renal and gut. What is the longest safe circ arrest time? We don't really know. What about giving drugs for cerebral protection (ie barbs, propofol). Mannitol for both cerebral and renal (free radical scavenging). We don't know what's truly needed other than true hypothermic tissue. Some do retrograde flow through the SVC, others do selective arterial flow (probably what copra is referring to) with axillary cannulation.

Acid-base management: alpha stat vs pH stat, lots of studies done, issue isn't resolved. You end up balancing less ischemia but higher embolism risk with more ischemia but fewer embolism.

Coagulopathy: The colder the worse. Some places go down to 9C. Greatly extends the safe circ arrest time but much worse bleeding.

DHCA was the first case I saw as a med student shadowing. Very interesting, it's why I choose anesthesiology and why I'll do a cardiac fellowship.

 

[urge]

pent, sux, tube.

 

[Planktonmd]

pent, sux, tube.

😀
Is a 20 gauge IV good enough?

 

[Licoricestick]

😀
Is a 20 gauge IV good enough?

Why not? The surgeon's have the ultimate in central, large vessel access, and it'd improve the turnover times 😉

 

[bubalus]

Even with deep hypothermic arrest, you'll still probably run low-flow (like 500mL/minute) to the brain. We drop 'em to about 18 degrees. Remember to take the ice off of the head when you're ready to re-warm. Somehow, people always forget to do that. And, the BIS (if you use it) will or should read close to "0". Pretty eerie.

-copro

BIS is known to have artifact issues when you pack the head in ice. I've seen a BIS in the high 90s with the head in ice and a NP temp of 13.

I know the DHCA is the academic discussion here, but not all ascending aneurysms require DHCA.

In my mind, the biggest issue, one that is frequently overlooked in our discussions is a good, fast surgeon. DHCA is a protectant, not a panacea. Why do the Russians have such good results? Good surgeons.

 

[DrDre']

The case went well. 17 mins of circ arrest. Had two 22 ga IVs for access.

😀
Is a 20 gauge IV good enough?

 

[Planktonmd]

In my mind, the biggest issue, one that is frequently overlooked in our discussions is a good, fast surgeon. DHCA is a protectant, not a panacea. Why do the Russians have such good results? Good surgeons.

Correct!
They are good surgeons, you know why?
Because they have to be, they have to do these surgeries without bypass and as a result they have to learn how to do them as fast as possible.
We don't have studies on the neurological outcome of the Russian no perfusionist method but it would be interesting to know if their method produced more neurological deterioration than the conventional method.

 

[Planktonmd]

The case went well. 17 mins of circ arrest. Had two 22 ga IVs for access.

I think Urge might argue that 2 IV's are overkill for such a straight forward procedure.

 

[doctor712]

Correct!
They are good surgeons, you know why?
Because they have to be, they have to do these surgeries without bypass and as a result they have to learn how to do them as fast as possible.
We don't have studies on the neurological outcome of the Russian no perfusionist method but it would be interesting to know if their method produced more neurological deterioration than the conventional method.

Maybe it's an obvious answer, but why? Hospital infrastructure? Money?
Both? No CPB machines in all of Russia? All of the above?

btw, I'm working on this PCI Aortic valve replacement trial, went to grand rounds tuesday that's talking about the next phase of it all (even though PCI Aortic replacements are really cutting edge and cool as it is)...and that is Percutaneous MV Repairs. More complex than AV because of anatomy but it's really fascinating stuff! It'll be fun to be resident-ing in CV Anesthesia in 5 years. (oh man, im gonna hear it for that!)

D712

Edit: I think this explanation might be my answer.

http://query.nytimes.com/gst/fullpage.html?sec=health&res=9E07E4D6113DF937A1575AC0A960958260

Pretty awful.

 

[proman]

The Russians do have CPB capability, it's just not very common.