List Archives

Fri Jan 6 02:02:36 GMT 2006

Summary to date.   In OR with patient with bilateral lung,  posterior LV, and 
distal esophageal injury who was trasfered from a distant  rural hospital.  
Now looking bad after damage control staple of both lungs,  drains to 
esophageal injury, leaving aorta alone and taking patient to ICU with  plastic drape 
over open clam shell incision with retractor left in  place.    

We have in the past tried and reported on the futility and non-benefit of  
IABP and CPB in similiar patients.   Their lungs turn to SOLID liver  like 
organs.    ECMO has similiar results.    He  is now in ICU.    One of the members 
of the surgical team  discovered at the end of the case that there was blood 
penetration from glove  tears in on both right and left gloves, two other 
members of OR team had  blood under one glove.     

Senior faculty and chief resident along with a social worker and  religious 
person talked to ALL of extended family from distant town:   

1.    Your relative had a near fatal injury in the  distant village and it 
was right to transfer him here with OR, laboratory, ICU,  nursing, etc. support. 
  Your doctors at your town are to be  commended.   You, his family are also 
obviously very supportive.  

2.    The good news is that he is still alive, although  in highly critical 
condition in the ICU, having had a lot of blood, lots of  drugs, and his heart 
stopped several times during surgery.   His  injuries include both chests, 
both lungs, back of heart and his esophagus  (swallowing tube).   

3.    After stopping the bleeding, we have chosen to  STAGE his many needed 
future operations, because he could not tolerate  being in the operating room 
any longer.   He is very critical and may  die any hour, tomorrow or even in 
several days

4.    When we get him warmed up, and with normal  clotting studies, we plan 
to take him back to the operating room and do  something to his injured 
esophagus and formally close his chest that we have had  to leave open, but have 
covered with a sterile plastic material.   

5.    You can go see him now in small  groups.   He is asleep from the drugs 
and from his  injury.    He has lots of tubes and cannot talk.   His  brain 
very well may be able to hear you, so tell him how much your care and of  your 
love and support.      

6.    You can really help with his care by going to the  Blood Center and 
donating blood.   We were able to give him blood  because others had given 
earlier in the week.    The gift of  blood is a gift of live.  

7.    Are there questions you may have and are there  things we should know 
about him. 

Answer:   Yes.   He has led a hard life and we think he  had some infections. 
  He has used drugs in the  past.     But he is now a good man with a good  
family.   Do what you must do, and you have our permission to operate  again 
whenever it is necessary.     

NOW,   I need your help again in the ICU.  

1.    He is very coagulopathic.   We have  available to us the following 
clotting studies.   What should we  order???:     PTT, Activated PTT, PT, INR, 
Activated  clotting time, platlet count, bleeding time.   Lee White Clotting  
time, Fibrinogen levels, specific clotting factor assays, TEG (regular), TEG  
(fast), D-Dimer, others.   Just which one or ones will be helpful in  influencing 
decision making?    HELP

2.    WHat sedation protocol should we use, if any?

3.    THere is some debate about antibiotic choices and  duration.   The 
chief resident has already written for TRIPLE  antibiotic coverage, including an 
aminoglycoside, cephalosporin, and  Flagyl.   The ICU resident wants to add an 
antifungal drug.  

4.    Is there need for DVT  prophylaxis?    

5.    Is there need for gastric acid  neutralizing?

6.    We have a whole list of imaging, and lab tests  available.   Which 
would you recommend to be ordered?

7.    We are warming all fluids he is  receiving.   We have brought in the 
BRAT autotransfusion device in  case we need to reinfuse any excess chest tube 
drainage.   Is this  principle - AUTOTRANSFUSION of chest drainage in the face 
of an open esophagus  really safe?  We have wrapped him in a Bair warmer.   
His  ventalatory system is heated.     Is there any other way we  should attempt 
to rewarm him.  

8.    His temperature is 92, oxygen saturation is 95%,  BP 95/60.  P 120.   
base deficit is 20.    

9.    The nurses are letting 2 family members come in  for short periods of 
time.   Should they be required to put on gowns,  shoe covers, masks, and caps?

10.    It is now not yet dawn, and we are discussing  just when we should 
take him back, and what the conditions should  be.   I have asked that the 
primary doctor write a progress note  committing himself to just when the patient 
should go back and under what  conditions he should NOT be taken back.     
Create a game  plan and plan to stay with the plan.    

Ok, now all the intensivists can give advice to the surgeons and take care  
of this patiennt.     Nurses on this list server can address  issues we have 
not yet identified or tabulated.    You will find  that you will maximally 
benefit from this progressively complex case if you will  write your views and 
recommendations.    What have we missed and  what would yoiu do?   What more do 
you want to know?

k

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