Frustration!

Since this blog was made to inform and to educate I have been dealing with some frustration. Nothing at Washington Hospital Center. It has to do with anesthesia. There was a case that I pumped a few days ago that caused the frustration and today enforced this. The patient was small which means small blood volume and low Hgb. The case was a CABG and we were doing many grafts. We went on and the case was going exceptionally well. We maintained a steady volume and were approaching the end of the case. At WHC we use the CDI 500 (absolutely love it!!), as we are approaching the end of our case we had a resident anesthesiologist walked over and looked at our CDI and notice the Hgb was close to 7.5. He immediately walked over and began to check a unit of blood. WHAT!? We had been doing all that we could to increase the Hgb, (Hemoconcentrating, mannitol, etc.) He had already planned on giving this patient a unit of blood based only on 1 number. We also use the Sominetics Cerebral Monitoring (love it too!) the only thing that was a little off was the Hgb, all the other blood gases and monitors were good. It was really upsetting that someone on our cardiac team can destroy all of the efforts that were made for blood conservation, and give blood.

The educational part of this is there needs to be involvement of every member of the team, education is the foremost. This resident didn't look at "the big" picture but focused on only one thing. The perfusionist that I was with was livid. She couldn't believe what she was seeing. She truly was a "patient advocate". I learned that it is my job to stick up to anyone no matter who it is or what the issue is, the patient has a right to the best service. All of this so the anesthesia resident didn't have to work too hard.

Thus the issue today, another small patient, another small Hgb. Prebypass anesthesia gave over 2 liters. The estimated post dilutional hematocrit was 6.3, we ended up priming with one unit of blood. Turns out we had plenty of volume (it was a valve) and could have hemoconcentrated while on bypass to help with the Hgb. Patient did great ended with a Hgb of 9.8 and anesthesia gave over 3.5 liters is a bypass run of just over an hour.

My learning points. 1. Don't jump the gun when deciding to give blood, wait and see what the first gas comes back with before adding. 2. Be more aggressive when RAPing, and VAPing, even if I need anesthesia's help in getting pressure up so I can accomplish this task. 3. Use all of the tools to put together an action for each patient not just a single number. 4. Don't treat a number! Treat a patient.


Greg