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CATASTROPHIC SURGICAL EMERGENCIES: VASCULAR

CATASTROPHIC SURGICAL EMERGENCIES: VASCULAR. York N. Hsiang, MB ChB MHSc FRCSC Department of Surgery Vancouver General Hospital. CATASTROPHE…. Noun Sudden, extensive, or notable disaster or misfortune Reversal of what is expected Also called, cataclysm. NOT ALL CATASTROPHES ARE EQUAL….

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CATASTROPHIC SURGICAL EMERGENCIES: VASCULAR

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  1. CATASTROPHIC SURGICAL EMERGENCIES: VASCULAR York N. Hsiang, MB ChB MHSc FRCSC Department of Surgery Vancouver General Hospital

  2. CATASTROPHE… • Noun • Sudden, extensive, or notable disaster or misfortune • Reversal of what is expected • Also called, cataclysm

  3. NOT ALL CATASTROPHES ARE EQUAL… An Ohio nurse accidentally put a kidney in the trash, prompting the University of Toledo Medical Center to suspend its live donor program as it investigates the incident (Aug 26, 2012)

  4. NOT ALL CATASTROPHES ARE EQUAL…

  5. Bad Judgement Bad experience Good Judgement

  6. Lack of knowledge Unrecognized situation Catastrophe

  7. Preparation Opportunity Success

  8. Case 1 – Postop Bleeding • 0300 RN calls because of bleeding from surgical wound • 72 y/o M, 12 hours post axilloaxillary bypass • RN describes a spurt of blood hitting the ceiling • O/E HR 72, BP 140/90, patient calm, good pulses, no hematoma, wounds dry • What do you do?

  9. Case 1 – Postop BleedingDiscussion • What is going on? • Can you confirm this? • How is this situation managed?

  10. Case 1 – Postop BleedingWhat actually happened • Resident went back to sleep • Resident gets chewed out by Attending following day • On the next call night, the exact same thing happens • Resident notifies attending and graft is excised

  11. Case 2 – Post Op swelling • 87 y/o M, ward patient,12 hours post R carotid endarterectomy • Sudden coughing episode leads to swelling R neck • Has difficulty talking, trachea deviated • What do you do? • There is a skin stapler removal kit next to the bed. Should you use it?

  12. Case 2 – Post Op swellingDiscussion • How do you relieve airway obstruction? • What do you think would happen if the neck staples and s.c. sutures are taken down? • Can you stop massive bleeding?

  13. Case 2 – Post Op swellingWhat actually happened • Resident thought he was offering the best treatment by utilizing what he was told • Staples and sutures removed • Torrential hemorrhage ensues • Patient sent urgently to OR with Resident using his fist to slow the bleeding • Patient dies of hemorrhagic shock

  14. Case 3 - Sewing • You and your vascular attending have been getting along well. • While closing the calf wound on a below knee in situ fempop graft, your attending gets called away to help with another case • He asks you to close up, “but be careful not to injure the vein graft” • During your closure, you accidentally make a through and through pass with a 2-0 vicryl suture through the vein graft – blood is pouring out of the needle holes • What do you do? • What/when do you tell the staff surgeon what happened?

  15. Case 3 – SewingDiscussion • Stopping bleeding • How do you stop bleeding in this case • What type(s) of haemostatic suture(s) and/or sealants do you know of? • When to tell the Attending what just happened • Don’t tell if all works out • Call right away and deal with the fall out

  16. Case 3 – SewingWhat actually happened • Resident tried digital compression • When that failed, tried clamping the graft • Unable to place a haemostatic suture, Resident calls Attending • After being chewed out, Resident watches Attending close bleeding holes and learns how to place haemostatic sutures

  17. Case 4 - Plaque • During a radical neck dissection, your staff points out a heavily calcified carotid artery • He encourages you to palpate it, and appreciate the firmness of the plaque • You take his recommendation and palpate the plaque • Postop, the patients wakes up with an ipsilateral stroke • What do you do?

  18. Case 4 – PlaqueDiscussion • What do you do when you come across things that are not part of your original procedure? • Is it OK to pinch the ureter with forceps or slap the bowel to watch it contract? • What does that achieve? • Is it OK to massage an aneurysm?

  19. Case 4 – PlaqueWhat actually happened • Patient developed dense contra lateral hemiplegia • Resident observed Attending explain to relatives that a stroke had occurred • Resident learned to be more respectful of organs not related to the primary operation

  20. Case 5 - Access • You have successfully punctured the right internal jugular vein and threaded the guidewire into the right atrium • But, in your zeal, when advancing the catheter over the guidewire, you pushed the guidewire completely into the patient • What do you do now?

  21. Case 5 – AccessDiscussion • What do you do when you lose wire access? • Should you place another line while waiting for help to get this stray guidewire out? • Should you remove this operatively or percutaneously by snaring it out?

  22. Case 5 – AccessWhat actually happened • Resident got chewed out (again) • CXR performed to determine whether wire was still in subcutaneous tissue or entirely within the major veins • Half of the wire was still in the subcut. Tissues, so formal cutdown to remove wire • Resident learned the importance of never losing wire access

  23. Case 6 - Hypoxemia • 93y/o, M in PAR 2 hrs. following open AAA repair for ruptured AAA • pO2 60 on 100% O2, CXR shows min. change from preOp • Anesthetist suggests TEE; latter shows large PE in PA • What would you recommend?

  24. Case 6 – HypoxemiaDiscussion • What are the causes of postop hypoxemia? • What are the causes of postop hypoxemia with a normal CXR? • How do you diagnose PE? • Is TEE a recognized diagnostic modality for PE?

  25. Case 6 – HypoxemiaWhat actually happened • TEE image shown to Cardiology who agreed that it was likely a big PE • Convinced that the patient had a life threatening PE, Cardiac surgery consulted • Patient taken back to OR stat for emergency pulmonary embolectomy • At OR, no embolus found • This was a doctor’s relative • There are reasons for diagnostic algorithms; one should question why a clinical course that goes away from a recognized algorithm should be pursued • The TEE image of the “PE” is never seen again

  26. Case 7 – Postop swelling • 67 y/o M, 3 days following L fempop bypass • Has L thigh and calf swelling • Hb stable • What do you do ?

  27. Case 7 – Postop swellingDiscussion • What causes postop swelling? • Why is the most common reason for postop swelling in Vascular patients? • How common is DVT in Vascular patients? • What is the diagnostic test to determine DVT? • If an ultrasound is not immediately available, what options do you have?

  28. Case 7 – Postop swellingWhat actually happened • IV heparin started overnight while waiting for US • Following morning, patient has significant swelling and ecchymoses over bypass sites • Protamine given • Primum non nocere; If your diagnostic suspicion is low, wait for the results of the diagnostic test

  29. SUMMARY • Catastrophes occur because of lack of knowledge, lack of attention, or over thinking problems • Admit your ignorance • Ask for help when exposed to a new situation • In the OR, ask Attending to show how they want things done • Do not deviate from usual diagnostic and treatment pathways

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