Morbidity & Mortality

1. Morbidity & Mortality November 18, 2011 Jud Mehl, DO & Nicole Weiss, MD

2. 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 done • Severe anteriolateralhypokinesis, EF 25-30

3. Cath LAB • Patient brought emergently to cardiac cath • 95% stenosis LAD • 80% stenosisLCx • 50 % stenosis RCA • Fick output 2.6 L/min • CI 1.7 L/m/m2 • CCO Swann placed in R IJ • IABP Placed • Primacor infusion

4. Hospital COURSE • Placed in ICU on Wednesday evening – hemodynamics stable • Scheduled for 3-V CABG on Monday • Patient seen Saturday – looks like a million bucks • Swann and IABP out, PICC placed; A few LGF • Procedure and risks explained to patient with daughter at bedside

5. 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 stable • On Primacorgtts • Decision to continue with CABG

6. Anesthetic Management • GETA • Left Internal Jugular Cordis placed • Ultrasound utilized • Placed without difficulty, single stick • Swan-Ganz floated with difficulty • Required multiple attempts • CPB initiated • No initial complications

7. Introducer / SWANN

8. 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 Primacorenroute to ICU

9. 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

10. 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-ruptured • Anastamosis of CABG ripped off • PICC line found in chest • Likely most of the damage was secondary to vigorous cardiac massage • Which came first? • Connective Tissue Abnormality? Vessel friability from PICC?

11. 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?

12. 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)

13. 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

14. The FUTURE OF THE SWAN