MORBIDITY & MORTALITY

November 18, 2011

Jud Mehl, DO & Nicole Weiss, MD

THE CASE 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

doneSevere anteriolateral hypokinesis, EF 25-30

CATH LAB Patient brought emergently to cardiac

cath95% stenosis LAD80% stenosis LCx50 % stenosis RCA

Fick output 2.6 L/min CI 1.7 L/m/m2

CCO Swann placed in R IJ IABP Placed Primacor infusion

HOSPITAL COURSE Placed in ICU on Wednesday evening –

hemodynamics stable Scheduled for 3-V CABG on Monday Patient seen Saturday – looks like a

million bucksSwann and IABP out, PICC placed; A few

LGF

Procedure and risks explained to patient with daughter at bedside

HOSPITAL COURSE 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 stableOn Primacor gttsDecision to continue with CABG

ANESTHETIC MANAGEMENT GETA Left Internal Jugular Cordis placed

Ultrasound utilizedPlaced without difficulty, single stick

Swan-Ganz floated with difficulty Required multiple attempts

CPB initiated No initial complications

INTRODUCER / SWANN

FIRST COMPLICATION 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

FURTHER COMPLICATIONS 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

UNCLEAR ETIOLOGY OF THE CODE IN THE ICU Multiple vessels damaged between

leaving the OR the first time and returning to the OR the second time Initial Innominate Vein Tear Re-rupturedAnastamosis of CABG ripped offPICC line found in chestLikely most of the damage was secondary

to vigorous cardiac massageWhich came first?

Connective Tissue Abnormality? Vessel friability from PICC?

TRAUMATIC LINE PLACEMENT?

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?

RISK FACTORS ASSOCIATED WITH HIGHER COMPLICATION RATES 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)

HOW CAN THIS BE PREVENTED IN FUTURE PATIENTS? 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

THE FUTURE OF THE SWAN