Heart Surgery in America: Friday 3.2

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Friday 3.2

Getting it Together

You know how we all have our personal perfusion comfort zones?

Cell saver in one spot, heater cooler with drug box on it, a nook for your clip board, drugs loaded a certain way?  It’s a way for us to condition ourselves in times of stress.  Developing a reflex memory of sorts to help us get from point A to point B in as short of a time as possible, with as little re-routing as possible, to allow us to multi-task while dealing with  the next whatever mean spirited twist of fate  life has to offer.

A dark confluence of compounding factors that have somehow crawled up out of the woodwork- to decide that “now” is a great opportunity to come together on the periphery…

Our personal organization is a safety net of repetition.  Doing it over and over the same way- to help minimize oversights or mistakes and mitigate the above stated ill-begotten storm.

A New Comfort Zone… Not !

Well all of that was out the window.  No soft warm comfort blanket to nest myself in, just the harsh reality that I would have to duck if I stood up and moved backward, because my cell saver power cord is strung up  to a floating ceiling plug- turning it into a potential guillotine.  There are cords in front of the pump where they shouldn’t be, making it a sure thing to catch on the wheels if trying to get closer to the field to pass off lines.

Somebody hands me a 1000 ml bag of ACD for my prime- which I automatically reject, but the milliseconds keep adding up.  We just have NOTHING in this room.

No trash can (so needle caps, peel packs, and all that stuff- has no place to live), no sharps box, everything is on the opposite side of where I’m used to having it, and I’m getting intimate with the back  wall and the surgical field at the same time.

Now I know what a red cell feels like when it’s punched out of the raceway from a roller head pump.  I felt totally used and definitely over-occluded.

Under circumstances like this, when there is no help (of perfusion caliber), you have to select the most qualified individuals and talk them through the task of getting set up.

So as I am connecting my oxygenator up to the circuit, I have one person dropping crystalloid prime, another getting water lines and O2 lines ready to hook up, someone getting syringes, drugs, blood filters (yeah we aren’t going to RAP today), getting the cell saver to work, zeroing my arterial pressure line, and starting to prime the circuit.

Gasp.

Out of breath and feel like I’m going to hyperventilate.  So I slow it down.

It’s not the drama, just the sheer pace and barking out so many different commands to put it all together.

ECC is primed, and ready to hook up.  Will deal with the cardioplegia (MPS Quest system) once I am on bypass.

Of course I had a liter too much of prime in my reservoir, and taking into account that the hemoglobin was 6 ish, that amount of volume was not an acceptable option.  I had no way to get blood in the prime- as there was nothing available (in the immediate short term) for me to chase out the crystalloid.  So my plan was to get on as quickly as possible, but dump as much prime before I did so, and start transfusing immediately when on bypass as more blood becomes available.

There was no efficient way to take off the prime.  No IV bag or even a pail to dump it in, so I threw a towel down and opened a side-port off of my recirc line, and basically sprayed the excess prime onto the floor and blanket.

LESS than elegant, probably looked savagely inept and low tech, but it got the job done.  Neanderthal perfusion if there ever was such a thing (I cringed while doing it- figured it just HAD to look bad).

We now have a patent arterial line to the Aorta- bubble free.

BSA is somewhere around 1.8. M2, dialed in @ 100% FiO2 with a sweep of 2 LPM on an uncalibrated Sechrist blender.

Venous line attached… CDI and venous sat probe still recalibrating.

On bypass it is…

The Bypass Run

Was actually a cakewalk.  Cool immediately, and hovering at 31 C.  Resecting a mass of ventricular wall roughly  equal to the circumference of a coke can, Dacron buttress patches to the newly exposed surfaces of the remaining viable heart muscle, and then a primary closure of the resected LV.

A lot of blood and bicarb, the cavalry arrived (a swarm of CCP’s), and we came off with a balloon pump.

Made it upstairs to the ICU.