Presentation on theme: "November 18, 2011 Jud Mehl, DO & Nicole Weiss, MD."— Presentation transcript:
November 18, 2011 Jud Mehl, DO & Nicole Weiss, MD
69 yo female PMHx: HTN, Pulm HTN, NIDDM, RA, Osteoporosis PSHx: Cataracts, Hysterectomy, Abdominoplasty MVA 5 days before presentation; “bruised ribs” but with progressive SOB over next 4 days, prompting call to 911 In ER troponins = 8.8 Possible cardiac contusion, bedside echo done Severe anteriolateral hypokinesis, EF 25-30
Patient brought emergently to cardiac cath 95% stenosis LAD 80% stenosis LCx 50 % stenosis RCA Fick output 2.6 L/min CI 1.7 L/m/m 2 CCO Swann placed in R IJ IABP Placed Primacor infusion
Placed in ICU on Wednesday evening – hemodynamics stable Scheduled for 3-V CABG on Monday Patient seen Saturday – looks like a million bucks Swann and IABP out, PICC placed; A few LGF Procedure and risks explained to patient with daughter at bedside
Monday morning – CABG canceled for continued and worsening fevers. Patient on Vanc + Zosyn Rescheduled for Wednesday Wednesday AM – Fevers lower, patient looks unwell, hemodynamics remain stable On Primacor gtts Decision to continue with CABG
GETA Left Internal Jugular Cordis placed Ultrasound utilized Placed without difficulty, single stick Swan-Ganz floated with difficulty Required multiple attempts CPB initiated No initial complications
Surgeons note a substantial amount of bleeding at termination of CPB Laceration of the Left Innominate Vein found Likely secondary to line placement Surgically repaired prior to chest closure Patient transferred to ICU Low-dose Primacor enroute to ICU
Code called in ICU Patient unresponsive to initial resuscitation Patient’s chest opened at bedside Decreased cardiac blood volume noted Cardiac massage performed Rapid transfuser set up Emergently brought back to the OR Per surgeons Innominate Vein Laceration & Torn CABG Anastamosis PICC line found to be floating through the laceration Despite repair, patient coded and passed away the following day
Multiple vessels damaged between leaving the OR the first time and returning to the OR the second time Initial Innominate Vein Tear Re-ruptured Anastamosis of CABG ripped off PICC line found in chest Likely most of the damage was secondary to vigorous cardiac massage Which came first? Connective Tissue Abnormality? Vessel friability from PICC?
Well known complication documented in the literature More frequent on R side because the acute angle between the R IJ and the Innominate Vein puts the vessels at risk Multiple ways to puncture the vein Wire- The J-tip aims to prevent this complication. The straight end has a higher rate of perforation Dilator- If the dilator is advanced too far, it can cause perforation. This can also happen when the wire threads laterally into the subclavian artery Swan?
Consistent relationship between experience of the operator and risk of complications Number of needle passes Six fold increase in number of complications after three or more venopunctures History of previous catheterizations Dehydration BMI >30 or <20 Large catheter size Unsuccessful insertion attempts Coagulopathies do not increase the risk if the proper precautions are taken (transfusing platelets or FFP)
Weighing the risk:benefit ratio before placing a large central line with or without a swan Utilizing U/S in patients who are at a higher risk for complications Changing sites or starting over if resistance is met when threading the wire Ensuring that the dilator is not advanced too far