Ruptured AAA: What are the odds... really?

[johankriek]

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I agree with going straight to the OR, but I wouldn't let him put metal to the skin until I had all my crap ready.

when did you get back from your hiatus?

you must be nice and fresh for hurling more insults and put downs for anyone who doesnt see it YOUR WAY.

 

[gasnewby]

So take those outcome studies concerning an emergent surgery like ruptured AAA repair with a grain of salt.

not sure why one would discount so many studies over 20+ years, multiple centers vs single center, international centers vs US centers, that in a remarkably consistent fashion, demonstrate 50% operative mortality.

 

[jetproppilot]

We were gonna get Jesus on staff at Rush but he gave up on medicine. He now runs a club in Ibiza.

HAHAHAHAHAHAHAHAHAHAHAHAHHHAHAHAHAHAHA

I think I just pee peed on myself.

 

[jetproppilot]

not sure why one would discount so many studies over 20+ years, multiple centers vs single center, international centers vs US centers, that in a remarkably consistent fashion, demonstrate 50% operative mortality.

I'm just suggesting that after you see many of these, and you witness the difference that can be made depending on which surgeon is doing the operation, that you consider refining your personal conclusions after reading a study which does not control for surgeon morbidity/mortality.

There is a growing trend of publisizing surgeons outcomes, that prospective patients can look at, and make a better decision concerning their own care based on numbers.

Especially in heart surgery.

Have you ever seen a study in our literature, or anybody elses literature for that matter, that controls for surgeon's outcomes that did the surgery that was included in the study?

 

[Lonestar]

i have only come across 3 if these ruptured suckers as a resident, and i have to say i agree with jet and plank. The dude that i was not able to get the line in quickly was the one who made it, because the surgeon got proximal control quickly. Once i didn't get the cordis after one try, me and my attending decided to just go with the two 16 gauges and the a-line without holding up the surgeon. It tooks us maybe 10 min total to get ready for incision. The dude was hemodynamically stable before. we ended up putting another 16G PIV and that was it. Didn't waste time fiddling around with central line. The other two pts. i had lines in, but it took the surgeon a few min to find proximal control.

 

[VentdependenT]

when did you get back from your hiatus?

you must be nice and fresh for hurling more insults and put downs for anyone who doesnt see it YOUR WAY.

You just have to start in eh?

 

[jetproppilot]

when did you get back from your hiatus?

you must be nice and fresh for hurling more insults and put downs for anyone who doesnt see it YOUR WAY.

Going on record telling the public I sent Slim an email that he'll be banned if he keeps this unprovoked s hit up.

Next time.

Thirty ought six locked and loaded........sighting in, Lieutenant....

 

[zippy2u]

Jetman is absolutely,positively spot on about this case. I'll relate a case I had several years ago that is similar to this case. Community 150 bed hospital. no heads, hearts or sick peedies. Get a call about 1AM, emergent case. Early 70s lady with a "leaky" infrarenal AAA. Come on down and let's play. Quickly fire up the expresso machine and gulp a double shot to clear the cobwebs. 2 cigs in the Jappo car and bang, I'm at the hospital's front door. Stroll in the OR and the pt. is already on the OR table! Machine's not on, no meds drawn up, WTF! I introduce myself to the pt. and place the monitors on her. Surgeon says she's hemodynamically stable and says not much blood in the belly. ER-> CT scanner-> OR within an hour. Lady's only got a 20G peripheral line. No blood in the OR( pt. was T and Xed and blood should be ready in about 1/2 hr.) Surgeon wants to cut "NOW BEFORE SHE DIES". Dammit, I want that blood like yesterday, I think to myself. I kick it in slow mo gear to buy time. Told cut man to start a central line while I get the a line. The 2 lines buy me 5 minutes only. Cut man looked me straight in the eyes without blinking and said this pt won't even need blood. In fact, 100mls will be the EBL. So we go, with no blood... skin to skin 50 minutes with a dacron graft, the whole shebang. EBL--100ccs. This surgeon just saved my ass BIGTIME. The 4 units of PRBCs arrive in the OR as I'm wheelin her to PACU. Extubated in OR. Holy Shazamm, I just tangled with an IDIOT SAVANT OF VASCULAR SURGERY. AAA repair and no blood given in OR or PACU. Lady only required 1 unit of blood during her 3 day hospital stay. I left the hospital at 3:30AM, smoked 1/2 pack of cigs and thought I just had an encounter with the new Messiah. Regards, ----Zippy

 

[bubalus]

Damn, Zip. That dude definately sounds like the Rainman of vascular surgery. Wish we had him at our institution.

UT, who makes RSAS and RIS? We've got a Belmont and I think it's way better than the Level 1. It will do 750 ml/min at 37 degrees. It's got a 2 liter bucket with multiple ports to hang up fluid. We actually hook our cell saver outflow tubing directly to one of the lines. As cool as it is, 2.2 lpm kicks ass, and I'd love to try those.

 

[UTSouthwestern]

Damn, Zip. That dude definately sounds like the Rainman of vascular surgery. Wish we had him at our institution.

UT, who makes RSAS and RIS? We've got a Belmont and I think it's way better than the Level 1. It will do 750 ml/min at 37 degrees. It's got a 2 liter bucket with multiple ports to hang up fluid. We actually hook our cell saver outflow tubing directly to one of the lines. As cool as it is, 2.2 lpm kicks ass, and I'd love to try those.

Have to look it up for the RSAS or drop by downtown to see. I tried to find one on line to request the Heart Hospital to buy but couldn't find it on line. MedCon makes the RIS but they were acquired by McKesson so don't know if they still make the RIS.

I like it because even with a surgeon of questionable skills, you can essentially maintain the patient's preload with a gaping hole in the aorta. The key is to have a cellsaver and have it hooked up to one of the loading ports so that you can simulate a bypass reservoir and not have to keep pumping in fresh products.

 

[coprolalia]

I'm getting the impression that we'd be wise to invest in better rapid infusion equipment at home base.

-copro

 

[gasnewby]

I'm just suggesting that after you see many of these, and you witness the difference that can be made depending on which surgeon is doing the operation, that you consider refining your personal conclusions after reading a study which does not control for surgeon morbidity/mortality.

Have you ever seen a study in our literature, or anybody elses literature for that matter, that controls for surgeon's outcomes that did the surgery that was included in the study?

i don't know...i remember one that showed better outcomes in higher volume centers (surprise)

i'm not saying a good surgeon couldn't have saved this guy. i'm saying your average surgeon will lose 50%. and for some reason i'm getting defensive, and probably shouldn't be, that the anesthesiology resident is stating that a certain surgeon is "notorious" for losing ruptured AAA patients.

and that he's comparing a suprarenal AAA vs this one. sure, the suprarenal AAA is a little more complicated in terms of repair. you have about 1 hour of warm ischemia time for the kidneys, you have to bypass or reconstruct the renal arteries, and sometimes you have to divide and then reconstruct the left renal vein to get to the neck. but i'm betting this one didn't crash when the belly was opened.

anyhoo...sounds like a ****ty case. he should keep his chin up.

 

[UTSouthwestern]

I'm getting the impression that we'd be wise to invest in better rapid infusion equipment at home base.

-copro

Most definitely. Don't fret about this case. Sometimes it is just not going to go the way you want it to go and those are days you learn the most in residency.

Your concern and desire to break down this situation to learn and understand shows you are conscientious, willing to learn, and someone I would trust with my and my family's lives.

 

[Tenesma]

dude -- i did vascular training with one of the best vascular surgeons in the country - and for these cases do you know what he would do...

a mini left-thoracotomy - with soft-clamp ready to x-clamp proximal --- while he does this we would make sure our cordis/ric lines were in... - he then would make a cut-down for the femoral artery and insert a catheter with balloon for distal control

the issue is distal control and in some of these vasculopaths they back bleed from the pelvis when it ruptures and that is where it can bleed like stink

he then opens belly - while vascular fellow slowly x-clamps proximally and gen surgery resident inflates balloon -

this technique which takes him (literally) less than five minutes has worked pretty well.... it still bleeds like stink but at least you have some after-load...

the reality with the tamponade is that these guys usually don't crump until 1) you induce them (in which case it is an uphill epinephrine-dosing battle or 2) they open the belly...

 

[ruthlessferengi]

just curious, any data on routine use of ER thoracotomy in ruptured AAA? would you do ERT on someone who lost pulse in ER with suspected AAA? also, putting those balloons up is difficult in the best of times under controlled conditions, what was his technique?