Tag Archives: cardiopulmonary bypass

Red up, blue up, volume in

Such is the chatter I pick up going on between the cardiac surgeons and the perfusionists.  The simplicity and efficiency of the lingo belie the complexity of the cardiopulmonary bypass machine.

My first month in cardiac anesthesiology nearly a year ago was rather stressful, with often difficult arterial and central venous lines, intense and dynamic physiological perturbations, and a general haze of confusion when it came to knowing exactly what was happening when.  One would think that that a major surgical event like, say, unclamping the aorta, would be heralded with a clear pronouncement, if not a chime, a blast from the trumpeter in the corner of the operating room, the unfurling of a scarlet “Aorta Unclamped” banner, and a few turns of the disco ball above.

Not quite.  In the midst of the rocky course of coaxing an octogenarian’s heart off bypass, dealing with hypothermia, metabolic derangement, coagulopathies, and blood volume shifts, I must pick up on quickly uttered words like, “Pressure down, off.”

As a whole, however, I’m enjoying this month much more than before.  Knowing the basics already of how to do straightforward bypass graft and valve surgery, I feel like I’m able to pick up on more details, like nuances of induction of anesthesia, performing transesophageal echocardiography, how to better communicate with the surgeons and the perfusionists, and pearls and pitfalls when it comes to coming off cardiopulmonary bypass.  Transporting an intubated patient with multiple intravenous infusions in a large ICU bed can still be challenging, but at least now I don’t feel overwhelmed by just setting foot in the cardiothoracic ICU.  Having rotated through six months ago, many of the nurses are friendly faces.

Even medical situations that used to be daunting now seem fairly routine.  The patient’s on 6 mcg/min of norepinephrine and 4 units/hr of vasopressin?  A little nitroglycerin?  No big deal.  Pulmonary pressures a little high? Let’s start some nitric oxide.  And I know it’s bound to come to an end at some point, but my hands have been golden this month.  Bright red arterial blood flashes back in my catheter with no redirection; the catheter slides right into the artery.  Central lines slip into the neck like slipping my fingers between the sofa cushions.  Difficult view on intubation?  I’ll just ease a narrow bougie into the trachea and glide the endotracheal tube over that.  So that’s at least been rewarding.

My biggest difficulty has come consistently toward the end of a run on bypass, when the circulating blood must be reheated in order to bring the patient’s body temperature back closer to a physiologic temperature.  (The patient is cooled during bypass to help decrease the brain’s and heart’s metabolic demands.)  Around this time, I page my attending to announce, “We’re rewarming.”  That’s the hardest thing to say, with all those R’s and W’s.  I’ve even tried coalescing the two R’s into one (“Weereewarming”), but I’m thinking of just shortening the message to “Rewarming.”  Or maybe just “Warming,” since, unlike leftovers, this is only the first time I’ve brought the patient’s temperature up.  I’ll try some of these out, and let you know what works best.



Filed under Work

Random thoughts from the big house

Whenever the “Ouch” pager clipped on my belt this week goes off, I’ve found myself standing quickly and informing others in the room, “I’ve got to go. There is a child in pain.” I’m not sure they can always tell the comment is meant to be tongue-in-cheek. Often it’s the hyperattentive parent, not the child, that makes me most uncomfortable. Of course I want to help these kids (many of whom are post-surgical or have sickle-cell vaso-occlusive crises), but wow, some of these parents need to tone it down.

For instance: venipunture. If there were a magical way to draw blood without using a needle, of course we would do it that way. Or if we could make do without labs, we wouldn’t drawn them. Naturally, no toddler is going to relish the thought of a vaccine or a needle-stick. But I feel that when we make such a big deal about it, it makes the experience for the child that much more traumatic. Surely there’s a cultural component. I wonder if the African children I saw in Cameroon would be so upset by the mosquito-bite sensation of a blood draw?

On the pediatric pain service, we aim to use multimodal therapy. For one child recovering from a Chiari malformation surgery, today’s plan was opiates, adjuvant medications, physical therapy, and a visit by the clowns.

Many children treated with opiates develop constipation, leading to the necessity of routine and often aggressive bowel regimens. One of my favorite quotations of the day was instructions to the nurses from my attending, regarding a constipated child. “Cotinue the stool softeners and go ahead and try another suppository. If that doesn’t work, then try an enema. Those are more intrusive.”  “Intrusive” puts it mildly.

On a creepy note, one of my fellow residents, while reading a chapter in a basic textbook today, asked me, “Who said ‘Practicing anesthesia is practicing medicine of the autonomic nervous system.’?” My response, “I did. I coined that phrase in 1986 while giving a lecture in Chicago.” We both laughed, and then my colleague said, “The quotation has a 1 beside it.” I directed him to look at the endnote at the back of the chapter. Reference 1 was another book produced by publishers based in Chicago, copyrighted in 1986. What are the chances?

Another fellow resident related to me the story of his patient who caught on fire several months ago. The patient was crumping before his heart surgery, so the surgeons sloshed sterile prep on the patient, cracked the chest, and “crashed” onto cardiopulmonary bypass. It’s unclear how the fire started, but in the process of sawing through the sternum, perhaps a stray spark ignited the still-wet alcohol-based cleaning solution. The fire was quickly dowsed with saline, but the patient (already intubated and under general anesthesia) had a couple blisters on the neck and chest. Given the, uh, unusual circumstance in the operating room, an intra-operative dermatology consultation was requested.

The instructions were simple, as the burn was very mild. “Put some silvadine on the blisters….and oh yes, give some extra fluid.” We thought the last piece of advice, though generally appropriate, was cute . Here is a patient on cardiopulmonary bypass, during which we’re continuously draining the patient’s entire blood volume approximately once per minute and pumping the anticoagulated blood back in, carefully maintaining temperature, pressure, volume, anesthetic depth, and anticoagulation parameters. And we’re told to give a little extra fluid.

This is akin to getting a car’s engine replaced, and asking the mechanic to make sure there’s enough windshield wiper fluid.


Filed under Musings, Work