Hello Everyone! I hope that your rotations are going well. Yesterday I helped with a minimally invasive procedure known as a Heart-Port Case. In this type of procedure there is no median sternotomy made. Instead a para-sternal incision is made and the arterial cannula and antegrade cardioplegia cannula are inserted. The venous cannula is inserted femorally and the retrograde cardioplegia is inserted into the neck line by anesthesia. There is also no traditional cross clamp applied. A balloon serves as a cross clamp and is located on the inside of the arterial cannula. The balloon is inflated to a pressure of 450 mmHg (which we have to monitor during the case).
These are very time consuming cases to do. According to my preceptors, these cases were more commonly done about 10 years ago but are now making a "come back" because the company has made some changes to the cannulas. If you guys would like anymore information about this type of case, just let me know. The Edwards Life Science Representative said he would be more than happy to send information to anyone in the Midwestern Program!
Bethany
Friday, July 16, 2010
Tuesday, July 13, 2010
Malignant Hyperthermia Case
I have an interesting case to report, now that I actually figured out how to use this blog. About two weeks ago, I got to pump a case with a patient that had malignant hyperthermia. It seems to be a rare condition, so I thought I would share the perfusion aspects of the case.
Malignant Hyperthermia patients react poorly to anesthesia, so we had to remove all of our gas line tubing from our pump, as it was contamined with Forane. We established all new tubing from the gas blender to the connection of the O2 gas line we use in our circuit. We wye'd the tubing around the Forane, so none of the circuit could get contaminated. It is also important to avoid cold fluids with these patients, so we used warm cardioplegia and avoided adding any cold fluids (warm prime, blood). Thats all I can recall at this time, but it was a cool case. Hope everyone is enjoying their rotations.
Marcus
Malignant Hyperthermia patients react poorly to anesthesia, so we had to remove all of our gas line tubing from our pump, as it was contamined with Forane. We established all new tubing from the gas blender to the connection of the O2 gas line we use in our circuit. We wye'd the tubing around the Forane, so none of the circuit could get contaminated. It is also important to avoid cold fluids with these patients, so we used warm cardioplegia and avoided adding any cold fluids (warm prime, blood). Thats all I can recall at this time, but it was a cool case. Hope everyone is enjoying their rotations.
Marcus
Tuesday, July 6, 2010
Abscess at Washington Hospital Center
I had the opportunity to pump a case on Friday and it was a little different than most. We were doing an MVR. The patient had an abscess that was inside the left ventricle. It was just an ordinary case nothing out of the ordinary. He was a retired doctor, so we take extra good care of those guys. He was laughing and joking when he entered the OR and even giving us a little history lesson.
While on bypass the surgeon began to extract the abscess and realized how large it was. It had grown to engulf most of the anterior interior left ventricle. When the extraction was done there wasn't much tissue for the surgeon to work with. He decided to go with a patch on the interior and exterior of the ventricle. The surgeon was a little worried about coming off bypass and the patch holding. The patient came off bypass with no issues. It was a good case.
Today when we were getting ready to transport an ECMO patient I found out that the patient had expired. He was extubated without issue. He was talking, eating, and enjoying his family. The patch had given way and he went straight to asystole. The surgeon had never seen anyone go that fast. There was NOTHING anyone could do for him. While we did everything we could there are still somethings that are beyond our control.
--Gregory Kitchen
While on bypass the surgeon began to extract the abscess and realized how large it was. It had grown to engulf most of the anterior interior left ventricle. When the extraction was done there wasn't much tissue for the surgeon to work with. He decided to go with a patch on the interior and exterior of the ventricle. The surgeon was a little worried about coming off bypass and the patch holding. The patient came off bypass with no issues. It was a good case.
Today when we were getting ready to transport an ECMO patient I found out that the patient had expired. He was extubated without issue. He was talking, eating, and enjoying his family. The patch had given way and he went straight to asystole. The surgeon had never seen anyone go that fast. There was NOTHING anyone could do for him. While we did everything we could there are still somethings that are beyond our control.
--Gregory Kitchen
Washington Hospital Center ECMO
Well on Friday we placed a man on ECMO he had some really big issues. This morning he looked fantastic. So the Dr. decided that he was ready to come off of ECMO. We started out by weaning him down first to 3.0L/Min, then 2.0 then 1.5 then 1.0 then off of ECMO. He looked great he had great pressure and his sats were all good. THEN....... He crashed. Fortunately we were ready with a pump primed and ready to go. So on bypass we went.
We started out by putting in an RVAD (centrimag) which was a cool experience to be a part of. It is a little different. We run bypass like every other case except for a couple of important points. We don't use Cardioplegia, you don't want to arrest the heart when you are trying to assist. We came of off CPB and he looked good. THEN......you guessed it crashed on the left side. We hadn't de-primed our circuit yet (which you never do until the chest is closed) so we were ready to go right back on.
We ended up putting in an LVAD (centrimag also). It was really interesting to watch this part of the case because the RVAD was still running which made our gasses go all over the place. One second it was perfect then it was all messed up, then it went right back to being great. Last I checked at 4pm he wasn't able to oxygenate himself. Unfortunately it looks like he will be getting a Heartmate II for destination therapy.
All the time during school we talk about death so casually but today it really hit me that this man that I transported downstairs and his wife touched his hand and said, "I'll see you in a couple of hours" may not be able to talk to his wife again. It reinforced to me how serious this profession is and I must to everything that I can to be "a patient advocate" and make sure my skill set is where it needs to be to help these patients.
--Gregory Kitchen
We started out by putting in an RVAD (centrimag) which was a cool experience to be a part of. It is a little different. We run bypass like every other case except for a couple of important points. We don't use Cardioplegia, you don't want to arrest the heart when you are trying to assist. We came of off CPB and he looked good. THEN......you guessed it crashed on the left side. We hadn't de-primed our circuit yet (which you never do until the chest is closed) so we were ready to go right back on.
We ended up putting in an LVAD (centrimag also). It was really interesting to watch this part of the case because the RVAD was still running which made our gasses go all over the place. One second it was perfect then it was all messed up, then it went right back to being great. Last I checked at 4pm he wasn't able to oxygenate himself. Unfortunately it looks like he will be getting a Heartmate II for destination therapy.
All the time during school we talk about death so casually but today it really hit me that this man that I transported downstairs and his wife touched his hand and said, "I'll see you in a couple of hours" may not be able to talk to his wife again. It reinforced to me how serious this profession is and I must to everything that I can to be "a patient advocate" and make sure my skill set is where it needs to be to help these patients.
--Gregory Kitchen
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