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Wed Jan 4 04:50:59 GMT 2006

In a message dated 03-Jan-06 21:17:29 Central Standard Time,  
SeppelI at wahs.nsw.gov.au writes:

So from  an intensivist as requested:

- I expect the anaesthetist is working  hard at basic resuscitation. This 
includes: warm the room until the surgeon  sweats, warm fluids (nothing clear - 
blood products only at this point),  clotting factors (platelets, FFP, 
cryprecipitate, prothrombinex), and rVIIa  before her ever got this bad. There is 
nothing an intensivist can add to what  a good anaesthetist is already doing. 
I will definitely agree with making the surgeon sweat, but  there are other 
ways to help raise the temperature, including careful warming of  fully 
humidified gases. As far as the fluid replacement, I'd be a bit more  reserved here, 
Ian...I'm thinking that with his major base deficit, unknown  renal status, 
and suspected iatrogenic hyperkalemia and relative hypocalcemia,  If that is not 
corrected, then even throwing enough blood products to 'fill his  tank' might 
not get his pressure over 100 systolic because of the further insult  to the 
already contused and hypoxic heart.

and I'm rather more anxious about his urine output right now.  I'd hate to 
salvage the patient only to condemn him to three dialysis sessions a  week.

- Please control his pulmonary bleeding promptly and get out of  his chest. 
No clever dissections, just a tractotomy or stapled resection
-  Please do as little as possible to the oesophagus - drain the proximal  
oesophagus and put in some medistinal drains. Come back tomorrow to do  
something a bit more clever such as a primary repair if feasible /  sensible.
- Close his chest quickly and get OUT of the operating  room
all good points...and consistent with the principles of  Meatball surgery as 
expounded by Drs Pierce and McIntyre during the late Korean  unpleasentness of 
some years ago.  My reading is that the cutting is done  and there is a long 
line of temporary staples or big sutures holding the edges  of the chest 
together by now.

When everything has settled down tomorrow by all means go back  to theatre 
for a second look see.

I'm suspecting that it will take more like 36 hours to get  things any better.

ck
Charles S. Krin, DO  FAAFP

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