The Most Badass Thing I’ve ever seen a Surgeon do!
A case of Cardiac Tampanode in the OR
I never wanted to be a surgeon but I think it’s a damn cool job. Matter of fact, I think it’s cooler than my own job – even if I wouldn’t trade the two for a million years or a million bucks (lifestyle, lifestyle, lifestyle).
Getting to work with surgeons day in and day out, as an anesthesiologist, I have a lot of respect for surgeons. Yes even the one’s with the classic “surgeon’s personality.” Here is a one example of an awe-inspiring moment in the OR.
Note: This is a dramatized scenario intended to educate and entertain, and is not based on any one particular event or person. Any resemblance to real person or event, is purely coincidental.
The Setting: I’m on my cardiac anesthesia rotation, and due to a cancellation, we are going to start the day with emergent case being moved into our room. The case is a 60ish diabetic male with history of recent CABG, transfered to our care center from another ER due to severe post-op sternal wound dehiscence. His initial presentation revolved mainly around the worsening appearance of this poorly healed sternotomy incision and concerns for infection.
However, in the 48 hours since he had been admitted, his clinical picture was suddenly worsening. The patient was becoming increasingly short of breath at rest and blood pressures were starting to slowly trend down. An urgent bedside echocardiagram in the middle of the night revealed the likely cause of his deterioration, a large pericardial effusion! The patient was scheduled for emergent sternal exploration and debridement to relieve the growing effusion.
Prior to the OR, the patient continued to do clinically worsen. The patient had been started on Levophed (norepinephrine) in an attempt to raise his blood pressure, which was now struggling to stay above 90s systolic. Upon our pre-operative examination on the way to the OR, the patient was awake and oriented, but clearly a bit sluggish to respond. He also had started to have a “dusky” appearance. A worrisome “look” that despite the pressor being used to elevate blood pressure, he was likely poorly perfusing his extremities and organs. His pericardial effusion had certainly evolved into full blown cardiac tamponade! This is a condition where the fluid around the pericardium is now large enough that it is compressing the heart and limiting the ability to pump blood.
Once in the OR, inducing a patient into anesthesia can be a particularly dangerous with cardiac tamponade. The common induction drugs (propofol especially), can lead to further hypotension on their own. Typical airway securement in an emergent case is via “Rapid Sequence Induction” – involving rapid paralysis during intubation and use of positive pressure ventilation. In tamponade, the initiation of positive pressure (and the resulting decrease in preload) can lead to catastrophic hypotension, loss of cardiac output, ischemia, and quickly death. The risk of an induction/airway without paralytics is a higher likelyhood of aspiration of gastric contents, particularly concerning if the emergent patient is not correctly NPO (fasting).
In this case, there were a few other considerations. The patient course had progressed rapidly and such had very little IV access. Once in the OR, additional large bore (16ga x2) peripheral IVs were added as well as an arterial line prior to induction for continous blood pressure monitoring. With our lines in place, the decision to induce was made using a spontaneous technique. The drug chosen was Ketamine – known for its potent analgesic and amnestic characteristics with minimal respiratory depression. Additionally, the inhalational agent Sevoflourene was also used to add further depth to anesthesia while again maintaining spontaneous ventilation. No paralytics were given and the patient was quickly and easily intubated using a direct laryngoscopy while maintaining spontaneous ventilation. IV fluids also had been ran “wide open” to increase preload during induction.
Then, figuratively, the “shit hit the fan.” Despite the spontaneous anesthetic induction, the patient crashed anyway. Systolic pressures dropped to the 70s, then 60s, and despite quick boluses of epinephrine – continued to drop. The surgeon, “just outside” the OR, was summoned by the nursing. “This guy is about to code!” A tense and frantic atmosphere began to over-come the OR.
Yet, cool and calm as can be, the surgeon walked in – “A glove and a scalpel, now please.” The nurse, less calm, was fumbling through the large pile of sterile gloves typical of a major cardiac case. The patients blood pressure was now in 50s, despite near code doses of epinephrine. More forcefully the surgeon repeated, “Any glove, and any scalpel, now, and please someone run a chloraprep over his sternum.”
With just a single sterile glove on and a scalpel in the corresponding hand, the surgeon approached the quickly prepped patient and delivered just one long, deliberate incision to the sternum. In that single cut, the scalpel passed through the soft tissue of the chest and mush-like dehisced bone where the prior sternotomy had been. In a phenomenal eruption, several liters of blood came pouring out from the patients chest and the surgeon stepped away. “That will do it, let’s get him prepped and draped for real now.” He then quietly headed out to formally scrub as the patients blood pressure returned to normal.
The patient would need several units of packed red blood cells and some FFP during the formal operation, but left the OR in stable condition. He would spend some time in the ICU and received a wound vac for his poorly healed chest, though ultimately did well long-term.
Despite the good outcome, this case isn’t without teaching points. The spontaneous ventilation induction technique for anesthesia is fairly classic teaching for tamponade. BUT many would have strongly advocated for waiting until the patient had been prepped, drapes up, and the surgeon was already fully gowned with scalpel in hand at bedside prior to induction. Communication between surgeons and anesthesiologists can be of upmost importance in a case like this, and certainly the decision exactly when to put the patient to sleep can often necessitate the input of both physicians.
The calmness and single deliberate life saving incision by this surgeon, however, has put it at #1 on my all time badass surgeon moves!
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JAMIE K. FLEISCHNER, CLU, CHFC, LUTCF, PRESIDENT