Description of Event or Problem · 1
PATIENT EXPERIENCED A HEMOPNEUMOTHORAX WHICH DR. BELIEVES IS DUE TO THE J WIRE GETTING CAUGHT IN THE PATIENT PRIOR TO INSERTING THE CATHETER. OPERATIVE NOTE: AFTER INFORMED CONSENT WAS OBTAINED, THE PATIENT WAS TAKEN TO THE OPERATING ROOM, PLACED SUPINE ON THE OR TABLE, GENERAL ENDOTRACHEAL ANESTHESIA WAS INDUCED, BILATERAL CHEST AND NECK WERE PREPPED AND DRAPED IN STANDARD SURGICAL FASHION. THE PATIENT RECEIVED PREOPERATIVE ANTIBIOTICS AND THE SCDS WERE PLACED. AFTER A TIMEOUT WAS PERFORMED, THE PATIENT WAS PLACED IN REVERSE TRENDELENBURG POSITION. USING A SELDINGER TECHNIQUE, THE RIGHT SUBCLAVIAN VEIN WAS ENTERED AT THE FIRST ATTEMPT. ULTRASOUND WAS USED TO SEE THE VEIN INITIALLY THOUGH NOT AT TIME OF ENTRY, THERE WAS VENOUS BLOOD RETURNED AND A GUIDEWIRE WAS PLACED THROUGH THE NEEDLE AND THE NEEDLE WAS REMOVED. FLUORO WAS INSTITUTED AND THE GUIDEWIRE ACTUALLY TRAVERSED ACROSS TO THE SUBCLAVIAN VEIN ON THE CONTRALATERAL SIDE. THE GUIDEWIRE WAS ATTEMPTED TO BE REMOVED UNDER DIRECT FLUOROSCOPIC GUIDANCE, BUT WAS PULLED BACK TOO FAR INTO THE SUBCUTANEOUS TISSUE AND THEREFORE WAS REMOVED AND PRESSURE HELD IN THE SUBCLAVIAN REGION. AFTER A COUPLE MINUTES, ANOTHER ATTEMPT WAS MADE AT THE SUBCLAVIAN VEIN, TWO OR 3 ATTEMPTS WERE MADE WITH NO RETURN OF AIR BUT NO ENTRY TO THE SUBCLAVIAN VEIN. AT THIS JUNCTURE, IT WAS FELT THAT IT WOULD BE BETTER TO PROCEED WITH RIGHT U. ATTENTION WAS THEN TURNED TO THE RIGHT JUGULAR. USING ULTRASOUND GUIDANCE, THE RIGHT INTERNAL JUGULAR VEIN WAS LOCATED AND ENTERED VIA SELDINGER TECHNIQUE. THE NEEDLE WAS SEEN ENTERING THE VEIN AND THE GUIDEWIRE WAS PLACED THROUGH THE NEEDLE. ONCE AGAIN, THE GUIDEWIRE LOCATION INSIDE THE RIGHT INTERNAL JUGULAR VEIN WAS NOTED BY ULTRASOUND. FLUOROSCOPY WAS ONCE AGAIN DONE AND THIS SHOWED THE GUIDEWIRE TO BE IN THE SUPERIOR VENA CAVA IN THE APPROPRIATE LOCATION. THE GUIDEWIRE WAS SECURED TO THE DRAPES WITH A CLAMP. AND A POCKET WAS CREATED IN THE RIGHT ANTERIOR CHEST. AN INCISION WAS MADE IN THE SKIN AND DISSECTION WAS CARRIED DOWN TO CREATE THE POCKET. ONCE THE POCKET WAS DONE, ATTENTION WAS THEN TURNED TO PLACING THE DILATOR OVER THE GUIDEWIRE. A SMALLER INCISION WAS MADE AT THE SKIN WHERE THE GUIDEWIRE ENTERED THE SKIN. A PEEL-AWAY SHEATH CATHETER AND DILATOR WERE THEN INTRODUCED INTO THE RIGHT INTERNAL JUGULAR VEIN. WHEN ATTEMPT WAS MADE TO REMOVE THE GUIDEWIRE, THE GUIDEWIRE WAS STUCK AND WOULD NOT READILY BE REMOVED. FLUOROSCOPY WAS ONCE AGAIN DONE AND THIS SHOWED THE PEEL-AWAY SHEATH AND CATHETER TO BE IN THE SVC ALONG WITH THE GUIDEWIRE, BUT THERE WAS A KINK AT THE DISTAL PORTION OF THE GUIDEWIRE THAT HAD NOT BEEN PRESENT PREVIOUSLY. IT WAS A HOCKEY STICK KINK AND THE GUIDEWIRE WAS NOT COMING UP THE DILATOR. IT WAS FELT THE SAFEST THING TO DO WOULD BE TO REMOVE THE DILATOR AND THIS WAS DONE AND THE GUIDEWIRE WAS THEN REMOVED SEPARATELY AND-ONCE AGAIN COME WITHOUT ANY NOTED COMPLICATIONS. PRESSURE WAS HELD IN THE INTERNAL JUGULAR VEIN. THE RIGHT SUBCLAVIAN VEIN WAS AGAIN EXAMINED WITH ULTRASOUND BUT AT THIS POINT, THE VEIN WAS NOT READILY VISIBLE AND THEREFORE NO FURTHER ATTEMPT WAS MADE AT THIS. IT WAS FELT THAT A SECOND ATTEMPT AT THE RIGHT INTERNAL JUGULAR WOULD BE MORE PRUDENT. USING ULTRASOUND ONCE AGAIN THE RIGHT INTERNAL JUGULAR VEIN WAS ENTERED VIA SELDINGER TECHNIQUE AND THE GUIDEWIRE WAS INTRODUCED AND THE NEEDLE REMOVED. WHEN FLUOROSCOPY WAS DONE, THE GUIDEWIRE ACTUALLY WENT DOWN THE JUGULAR AND ACROSS THE MIDLINE AND IT WAS THEN NOTED THAT THE CARDIAC SILHOUETTE SEEMED TO BE SHIFTED. AT THE SAME TIME WHEN THIS SECOND ATTEMPT WAS MADE THE ANESTHESIOLOGIST NOTED THAT THE PATIENT BECAME MORE TACHYCARDIC AND HYPOTENSIVE. SHE STARTED TO DEVELOP HEART RATES IN THE 130S AND 140S AND BLOOD PRESSURE DROPPED. THE WIRE WAS THEN REMOVED AND AN ANGIOCATH WAS INSERTED IN THE CAVITY CREATED FOR THE PORT. NEEDLE DECOMPRESSION WAS DONE OF THE CHEST WHICH SEEMED TO RELIEVE SOME OF THE ISSUES. A CHEST TUBE SET UP WAS BROUGHT INTO THE ROOM AND A HEIMLICH VALVE WAS ALSO BROUGHT TO THE ROOM. THE HEIMLICH VALVE CAME FIRST AND A SEPARATE INCISION WAS MADE INFERIOR TO THE PORT SITE AND THE HEIMLICH WAS INTRODUCED OVER A RIB INTO THE CHEST. IT WAS THEN PLACED TO SUCTION AND THERE WAS BLOOD NOTED WHICH WAS FARM MORE THAN WOULD HAVE BEEN EXPECTED. AT THIS TIME, A DECISION WAS MADE TO PLACE A CHEST TUBE AND A 26FR CHEST TUBE WAS PLACED BY DR. (B)(6) IN THE RIGHT CHEST AT THE MID AXILLARY LINE AT ABOUT THE S'" TO 6'" INTERCOSTAL SPACE. THE CHEST WAS ENTERED AND A 28FR CHEST TUBE WAS PLACED INTO THE CHEST CAVITY. THERE WAS AN IMMEDIATE RETURN OF DARK VENOUS BLOOD. THE CHEST TUBE WAS SECURED AT ABOUT 20 CM AND CONNECTED TO THE PLEUR-EVAC. THERE WAS IMMEDIATE RETURN OF 800 ML OF BLOOD. ABOUT THIS TIME, THE PATIENT BECAME EXTREMELY TACHYCARDIC AND HYPOTENSIVE AND THERE WAS CONCERN THAT THERE WAS NOT A PULSE. A THREAD CAROTID PULSE WAS FOUND AND THE PREP AND DRAPING WERE STRIPPED DOWN. DR. (B)(6) , SECOND ANESTHESIOLOGIST, ENTERED AND PLACED AN 18 GAUGE IV IN THE PATIENT'S RIGHT LOWER EXTREMITY. ATTEMPTS WERE MADE TO FIND MORE IVS AND FLUID RESUSCITATION WAS UNDERTAKEN. BEFORE THIS TIME EMS HAD ALREADY BEEN CALLED DURING THIS PROCESS AND WAS ON THEIR WAY. DR. (B)(6) , ANESTHESIOLOGIST, CONVERTED THE LMA TO AN ENDOTRACHEAL TUBE INTUBATION. AT NO TIME DID THIS PROCESS REQUIRE CPR, BUT THE PATIENT WAS HYPOTENSIVE AND TACHYCARDIC DURING THIS PROCESS. AT THIS POINT, DR. (B)(6) BRIEFLY LEFT THE ROOM TO GO EXPLAIN TO THE HUSBAND WHAT WAS GOING ON AND CAME BACK TO THE ROOM TO CONTINUE TO ASSIST WITH RESUSCITATION. EMS ARRIVED AND THE PATIENT HAD 2 IV ACCESS AND BLOOD PRESSURE IN ABOUT THE SO'S WITH TACHYCARDIA IN THE 120'S TO 130'S. PATIENT WAS TRANSFERRED TO A STRETCHED AND TAKEN TO (B)(6) HOSPITAL. DURING THIS TIME, (B)(6) ED WAS NOTIFIED AND A MASSIVE TRANSFUSION PROTOCOL WAS UNDERWAY AND THE ED PHYSICIAN WAS AWARE. HE WAS ALSO ATTEMPTING TO LOCATE A CARDIOTHORACIC SURGEON ON CALL. THE PATIENT WAS TRANSPORTED BY EMS TO (B)(6) HOSPITAL ED WITH DR. (B)(6) RIDING WITH THE AMBULANCE AND WITH PRIMARY SURGEON IMMEDIATELY FOLLOWING. THE PORT SITE AND THE HEIMLICH SITE WERE CLOSED WITH STAPLES. DRESSING WAS PLACED AROUND THE CHEST TUBE BEFORE THE PATIENT WAS MOVED. THE PATIENT WAS TRANSPORTED IN CRITICAL CONDITION TO ST. MARY'S HOSPITAL.