andersenpa Posted November 12, 2010 Author Share Posted November 12, 2010 Surgeon walks in the ICU. You wheel the pt (quickly!) back to the OR for a salvage look in the chest......... Link to comment Share on other sites More sharing options...
kargiver Posted November 12, 2010 Share Posted November 12, 2010 M, Clear your PMs - I tried writing you :) G Link to comment Share on other sites More sharing options...
merseur Posted November 12, 2010 Share Posted November 12, 2010 Last thoughts? Get her stable. Drain the effusion. Insert a CT or US guidedthoracentesis. Link to comment Share on other sites More sharing options...
andersenpa Posted November 12, 2010 Author Share Posted November 12, 2010 Get her stable. Drain the effusion. Insert a CT or US guidedthoracentesis. US guided thoracentesis- not in an unstable pt (bite your tongue!) j/k treat it like a trauma put in a 36 fr tube! too late though pt is rolling into OR, splashing betadine on the chest.... Link to comment Share on other sites More sharing options...
merseur Posted November 12, 2010 Share Posted November 12, 2010 Oouch 36 Fr tube. Isn't that too big? I had this patient with similar presentation. 65 yo female. SP CABG x3, inserted IABP. Low EF. POD#2, stable, IABP removed. Saturday(POD 3), I was rounding in unit. She started to code. She coded 5 times in an hour. Able to bring her back each time. End up taking her back to the OR. LIMA closed. Put a new vein graft to the LAD and she did fine. Experience post op renal and respiratory failures. POD 6 coded for the last time. Link to comment Share on other sites More sharing options...
andersenpa Posted November 12, 2010 Author Share Posted November 12, 2010 Oouch 36 Fr tube. Isn't that too big? I had this patient with similar presentation. 65 yo female. SP CABG x3, inserted IABP. Low EF. POD#2, stable, IABP removed. Saturday(POD 3), I was rounding in unit. She started to code. She coded 5 times in an hour. Able to bring her back each time. End up taking her back to the OR. LIMA closed. Put a new vein graft to the LAD and she did fine. Experience post op renal and respiratory failures. POD 6 coded for the last time. No such thing as a chest tube that's too big (j/k) For blood and possibly clot I'd want the biggest tube possible. 32-36 is good. Smaller tubes for air or free flowing transudative effusions. So..... We got back to the OR post-haste and opened the chest. Nothing impressive in the way of pericadial fluid- I had drained most of the it in the ICU. Stuck a sucker in the left pleural space- 1600 cc frank blood, which blurted out under tension. Quick improvement in hemodynamics. Did some other tidying up and brought her back to the ICU with an open chest. Closed her the next day. I thought this was an interesting case b/c this pt carried several of the possible dx for PEA: hypovolemia (recently dialyzed + perioperative blood loss) ? hyper/hypoK- ruled out but an immediate thought in a renal pt Acidosis- also possibility in renal failure Hypoxia- potential postop complication from fluid overload, secretions (mucous plug), PE Ischemia/Infarct- recent CABG, CAD Tamponade Pneumothorax- chest tubes removed one day prior The final thoughts were: relatively hypovolemic from her first postop dialysis combined with pericardial fluid and, most importantly, tension hemothorax. This was a little lady and 1600 of blood in the left chest probably had a significant tension effect. After the OR I was thinking that I got faked out by the CXR. The film did not have a huge white-out from a bloodt effusion but the echo showed fluid in the pleural space. in retrospect I should have but the chest tube in at the bedside- it may have avoided a trip to the OR. The only upsides to exploring her chest was 1) washed out some mediastinal clot, 2) put new, functional pacing wires on (old ones were not working). I don't think there was one clear cause of PEA arrest in this lady but a combination of several different factors. Link to comment Share on other sites More sharing options...
jmj11 Posted November 12, 2010 Share Posted November 12, 2010 No such thing as a chest tube that's too big (j/k)For blood and possibly clot I'd want the biggest tube possible. 32-36 is good. Smaller tubes for air or free flowing transudative effusions. So..... We got back to the OR post-haste and opened the chest. Nothing impressive in the way of pericadial fluid- I had drained most of the it in the ICU. Stuck a sucker in the left pleural space- 1600 cc frank blood, which blurted out under tension. Quick improvement in hemodynamics. Did some other tidying up and brought her back to the ICU with an open chest. Closed her the next day. I thought this was an interesting case b/c this pt carried several of the possible dx for PEA: hypovolemia (recently dialyzed + perioperative blood loss) ? hyper/hypoK- ruled out but an immediate thought in a renal pt Acidosis- also possibility in renal failure Hypoxia- potential postop complication from fluid overload, secretions (mucous plug), PE Ischemia/Infarct- recent CABG, CAD Tamponade Pneumothorax- chest tubes removed one day prior The final thoughts were: relatively hypovolemic from her first postop dialysis combined with pericardial fluid and, most importantly, tension hemothorax. This was a little lady and 1600 of blood in the left chest probably had a significant tension effect. After the OR I was thinking that I got faked out by the CXR. The film did not have a huge white-out from a bloodt effusion but the echo showed fluid in the pleural space. in retrospect I should have but the chest tube in at the bedside- it may have avoided a trip to the OR. The only upsides to exploring her chest was 1) washed out some mediastinal clot, 2) put new, functional pacing wires on (old ones were not working). I don't think there was one clear cause of PEA arrest in this lady but a combination of several different factors. Interesting case, thanks for sharing it. However, thanks to you, I tore up my PA Cert and started delivering mail for the first time today. :>) Link to comment Share on other sites More sharing options...
meaux Posted November 12, 2010 Share Posted November 12, 2010 Thanks for the case, can you give me any CME for it? j/k Link to comment Share on other sites More sharing options...
merseur Posted November 13, 2010 Share Posted November 13, 2010 No such thing as a chest tube that's too big (j/k)For blood and possibly clot I'd want the biggest tube possible. 32-36 is good. Smaller tubes for air or free flowing transudative effusions. So..... We got back to the OR post-haste and opened the chest. Nothing impressive in the way of pericadial fluid- I had drained most of the it in the ICU. Stuck a sucker in the left pleural space- 1600 cc frank blood, which blurted out under tension. Quick improvement in hemodynamics. Did some other tidying up and brought her back to the ICU with an open chest. Closed her the next day. I thought this was an interesting case b/c this pt carried several of the possible dx for PEA: hypovolemia (recently dialyzed + perioperative blood loss) ? hyper/hypoK- ruled out but an immediate thought in a renal pt Acidosis- also possibility in renal failure Hypoxia- potential postop complication from fluid overload, secretions (mucous plug), PE Ischemia/Infarct- recent CABG, CAD Tamponade Pneumothorax- chest tubes removed one day prior The final thoughts were: relatively hypovolemic from her first postop dialysis combined with pericardial fluid and, most importantly, tension hemothorax. This was a little lady and 1600 of blood in the left chest probably had a significant tension effect. After the OR I was thinking that I got faked out by the CXR. The film did not have a huge white-out from a bloodt effusion but the echo showed fluid in the pleural space. in retrospect I should have but the chest tube in at the bedside- it may have avoided a trip to the OR. The only upsides to exploring her chest was 1) washed out some mediastinal clot, 2) put new, functional pacing wires on (old ones were not working). I don't think there was one clear cause of PEA arrest in this lady but a combination of several different factors. Good. Interesting case. When do you remove the CTs? Link to comment Share on other sites More sharing options...
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