the indication is cardiac arrest usually or tamponade which is not giving us time enough to shift the patient back to theater. but when exactly should we say lets re-open the patient and stop defibrillating etc any more.?
A sudden massive increase of output from the chest tubes in the range of 600 cc and more in conjunction with hemodynamic instability should lead to quick reopening. If there is massive blood loss clamp the tubes! Otherwise there will be no blood in the patient to maintain some kind of circulation.
As Dr. Durr pointed out already acute tamponade can be a reason for reopening in the ICU.
Regarding ongoing defibrillation you have to make up your mind if there is anything to lose from opening the patient in the ICU.
In my opinion, no. If the patient continues to have VF despite pharmacologic and electrical endeavours you have absolutely nothing to lose but the patient. On the other hand, if the operating surgeon has told you that there is nothing else to do for a patient and the patient was transfered to the ICU in order to avoid death in the OR there is no point to reopen such a patient due to lack of consequences.
So this comes down to proper communication between surgeon and ICU in order to differentiate between truly desperate cases and patients who have a good chance to survive the procedure.
Psysiologic (not simply ECHO) cardiac tamponade is the best reason.
A post-cardiac surgery ICU should be reasonably close to an OR (but one must have a room, surgeon, and hopefully, an anesthesiologist) and elevators are for medical patients.
I omitted "bleeding", as measured by chest tube output for the simple reason that tubes become clotted and tube output doesn't increase as the patient dies. Absence of respiratory movement in the air-fluid interface of the tube system is excellent indication that the tube output is unreliable.
The only time we open patients who have had cardiac surgery in our ICU is massive bleeding (400ml/hour or 200ml/hour for 2 consecutive hours or more) with haemodynamic compromise or severe cardiac tamponade with no very little time to get to theatre. Our ICU and the theatre are on the same floor and just 1 minute away , So as much as possible we do most of the reopening in the theatre. It is easier to get the patient to the theatre in our setting than to bring the theatre insturments to the ICU
Our usual tactics in rapidly developing tamponade - immediately evacuate blood to the cell-saver through small subxyphoideal approach and then, if hemodynamics rises to normal - shift the patient to the operating room, if there are signs of hypotension and ongoing bleeding - reopen it in the ICU.
Sir Alexey Evtushenko,, thank you for your valuable comment. what is your strategy for reopening in a case of persistent VF arrest?
In a case of persistent ventricular fibrillation we usually use a sequence of actions as follows:
external cardiac massage with the simultaneous reopening of the sternum;
then direct cardiac massage with simultaneous connection of cardiopulmonary bypass.
After the start of perfusion, we make diagnosis of the causes of recurrent ventricular fibrillation (TEE, flowmetry etc) and make a decision about how to proceed.
In our institution the loss of domain has prompted re-opening in the ICU with success. This is not always a bleeding event but perhaps also a general tissue swelling from volume resuscitation which then results in tamponade physiology similar to the operating room event where a patient may not be closed due to poor cardiac output with loss of domain. After time and diuresis the patient may later be closed and a favorable outcome results.
Massive bleeding 300 ml or more/h,3 or 4 consecutive hours is reason for reopen patients after cardiac surgery. Second reason is clinical signs of cardiac tamponade with hemodynamic unstabile patients.To reduce te risk of infection surgeon reopen patients in operating room. Some times ,very poor LVEDP end EF requires a reopen patients.
There may be a more recent one but this may help
http://www.csu-als.com/documents/cgi-bin/EJCTS%20Resuscitation%20guidelines%20March%202009.pdf
To reopen in ICU rather than move to OR is a judgement call that varies with patient, distance (and complexity) of moving to OR, qualifications of team in ICU, actual presence of OR staff, etc. Generally, gross, life-threatening hemorrhage and cardiac tamponade not responding to tube drainage may be best treated in ICU, especially in such cases as evenings when OR "first team" is home.
There are two scenarios to discuss here.
1) Arrest - it is widely recognised that the CALS protocol should be implemented in this setting. If there is no response to DCCV, pacing or in the instance if PEA - reopening should occur.
USA - https://www.sts.org/sites/default/files/documents/ExpertConsensus_ResuscitationAfterCardiacSurgery.pdf
Europe - https://academic.oup.com/ejcts/article/36/1/3/393715
Australasia - Guidelines in draft.
The importance of this cannot be overstated in promoting good team interaction and coordinated team action. It is taught internationally in this course series - https://www.csu-als.org/page/CSU-ALSCALS.
2) Cardiovascular instability / bleeding. In the setting or preserved output - it really is determined by the patient situation and organisational logistics (ie location of theatre relative to ICU). It is fair to say that such situations should be considered in advance of the clinical emergency and protocols/understandings established.
- Badges
- Science topic
- Similar topics
- Instrumentation Engineering
- Instruments