Salt Lake Regional Medical Center, Cardiology. Terron Arbon, Stacy Tukuafu, Dean Porcelli, Paul Allred

Transcription

1 Salt Lake Regional Medical Center, Cardiology Terron Arbon, Stacy Tukuafu, Dean Porcelli, Paul Allred

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5 Superior Vena Cava (SVC) Inferior Vena Cava (IVC) Right Atrium (RA) Atrial Appendage Crista Terminalis (CT) Ismus line Sino-atrial node - SA node Atrio-ventricular node - AV Node Tricuspid valve HIS Right bundle branch RBB Left bundle branch LBB Purkinjie Fibers Coronary Sinus (CS) Coronary Sinus Ostium (CSos) Right Ventricle (RV) Right Ventricular Outflow track (RVOT) Pulmonary Artery (PA) Pulmonary Vein (PV) Left Superior pulmonary vein (LSPV) Right Superior pulmonary vein (RSPV) Left Inferior pulmonary vein (LIPV) Right Inferior pulmonary vein (RIPV) Left Atrium (LA) Mitral line Mitral annulas Transeptal Foramen Ovale

6 We re Pacing During pacing the heart is being stimulated to induce arrhythmia. Palpitations Chest Pain Decreased Blood pressure Rhythm requiring external (sync) cardioversion

7 Pacing the V During Right Ventricular-stim pacing the heart is being stimulated to induce Ventricular tachycardia. Sustained Ventricular tachycardia requiring (not synced) cardioversion Decreased Blood pressure Palpitations Chest pain Anxiety

8 Start Isuprel at Isuprel is used to stimulate the heart and aid in induction of arrhythmia. Palpitations Chest Pain Headache Dizziness Light headedness Insomnia Tremor, Nervousness and Anxiety Sweating Nausea, Vomiting, Diarrhea Dry Mouth

9 Phrenic Nerve pacing Phretic nerve pacing is used to detect if the ablation catheter is on or near the Nephritic nerve. Ablation on the phrenic nerve could possibly cause diaphragm immobility. Airway, Breathing O2 Saturations Chest rise and fall

10 Ablating in the RSPV (Right Superior Pulmonary Vein) Vagus response has been caused by the stimulation of the vagal c-fibers. Reflexible asystole is reproducible when burning near a unmyelinated vagal c-fibers or ganglionated plexis, (GP). Asystole

11 Ablating the Posterior wall Heat transferred from the Posterior left atrium to the esophagus is known to cause esophageal fistula. Esophageal temperature rise. Late signs: Chest pain Frothy white bubbles from the mouth Coughing or choking when eating Vomiting Difficulty breathing Death

12 Adenosine Adenosine commonly used for antiarrhythmic medication is also used post PVI ablation in determining Pulmonary vein electrical isolation. Asystole Chest Pain Shortness of Breath Tingling of senses Dysrhythmia Hypotension

13 60 Year old Mother of 2 boys who owns a bowling alley with her husband Has been complaining of symptomatic palpitations (PVC s) since the 1970s Recent Holter shows just shy of 31,000 PVCs with episodes of bigeminy and trigeminy. Failed treatment with beta blocker and antiarrhythmic drug

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15 Inducible Tachycardia with V stim pacing

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20 Operative Phase To the 1540 Sternotomy access to repair right ventricle perforation, 3 to 4 mm in length below the pulmonary valve along the right ventricle outflow tract cc of clotted blood evacuated from the pericardial sack. There was a 4-5 mm laceration to the right lobe of the liver adjacent to the area where pericardiocentesis was attempted. Bleeding was controlled with sutures and hemostatic agents

21 Vital Signs Pt arrived in the OR with BP 105/59mm on 0.02mcg/min and 5mcg/kg/min Initially BP ranged from 90/45mm to 113/48mm. At 1645 BP rose to 127/62mm and vasopressors were decreased to 0.01 mcg/min and 3mcg/kg/min respectively At 1730 BP reached 130/80mm at this point both vasopressors were DC d.

22 CVP remained cm throughout the surgery HR bpm remained NSR no noted ectopy SPO % on fio2 40% rate 12

23 Meds From pt was on: Ancef 2gm IV ( CaCL 1gm IV ( Blood & IV fluids Received 3 units PRBC s intraoperative 900cc of crystalloids given intraoperatively Chest tubes Single mediastinal Left and Right Pleural

24 Venous and arterial Access Right IJ 8 Fr sheath (placed in OR) Right femoral 8 Fr venous sheath (Cath lab) Left femoral 8 Fr venous sheath (Cath lab) Right femoral 6 Fr atrial line (Cath lab)

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26 Immediate Post OP Pt was taken to the 1815 intubated and stable condition. Decision was made to sedate (propofol) and rest Pt over night. Pt received 1 PRBC and 2 FFP post op Pt remained stable off an vasoactive medication through the night.

27 Post OP day 1 Sedation was DC 0845 for weaning parameters. Pt tolerated well and was 1000 on 3/28/14 on 4L N/C Left and Right Femoral sheaths and arterial line where DC d 1400 on 3/28/14. Supplemental O2 Dc d & PT on RA by Pt required 1L O2 periodically through remainder of stay Pt was out of bed and ambulating by 1650 Pain controlled with IV Tylenol (Ofirmev 2 doses) and Hydrocodone-acetaminophen 5/325, 1-2 tablets every 4 hrs. PRN (total 7 doses) Pt also received Vancomycin 1gm IV Q12hrs for total of 3 doses

28 Post OP day 2 On 3/29/14 Foley catheter and left pleural chest tube DC d. Increased frequency of ambulation Promoted (4 walks per day) Advanced to regular diet, initial poor intake

29 Post OP day 3 Remained hemodynamically stable. Right pleural chest tube and mediastinal chest tube removed Ambulating in hall ways, increased total (x6), tolerating well

30 Post op day 4 Pt remained in stable condition, labs WNL, hemodynamically stable chest x-ray clear RA SPO2 87% on 3/31/17, plan to DC home today with home O2 and no additional needs. To follow up with surgery within 10 days post DC.

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