The lowly Foley to the rescue
It was the 4th case .
A meticulous total arterial off pump bypass and and two hectic mitral and tricuspid valve repairs – the 2nd had required some extra time as it was a young lad and I wanted to avoid a valve replacement at all cost . Anyway they all went well. The 4th was the Associate consultant’s case – a young lady with myasthenia gravis and a thymoma . On CT it looked well encapsulated . The Associate was an experienced surgeon – a bit gung–ho at times (reminded me of myself !!).
I peeped in – he gave the thumbs up sign . I checked on the post op heart patients op and went into the changing room. The nurse barged in frantically – “Come fast” – was all she said . She is a veteran and not one to panic at small things . I raced in . There was 2 litres of blood on the floor and an ashen faced Associate. My anesthetist was rapidly pumping in fluid. A quick scrub and in I went . “ I just cranked open the chest and the tumour tore out the veins “ the Associate mumbled . He was shaken – but had the good sense to just put a few gauze pieces and his finger on the bleeders .
I saw that there were gaping holes in the veins ! . The sternal retractor on opening had torn the thymic tumour which was invading all structures around it (the CT was 6 weeks old – promised myself to always get a fresh CT before surgery ) . Packed again – hurriedly assembled an indigenous cell saver . On gently having a re-look with the cell saver salvaging all blood – saw an alarming site – totally torn off veins – + huge azygos bleeding like crazy .
I Put in 3 Foleys’ –
- Right brachiocephalic (R) ,
- Innominate (I),
- Azygos (A) and clamped upper end of SVC ,
- T = hard tumour .
- Repaired with autologous pericardium. Debulked to some extent .
The case highlights a few important points :
- Always get a fresh CT in a malignancy
- Spread the retractor slowly
- Do not panic
- Think on your feet – Quick thinking by team – Dr A Joseph, DrVivek Tewarson, Dr Viju Abraham, Cardiac Anesthetist Dr N Dua , Chief Perfusionist Mr William Prem who assembled the ‘cell saver’ (sucked into a cardiotomy reservoir and pumped it back in ) and OT incharge Mr Rajan .
- Think simple – the lowly Foley’s catheter saved the day . Attempting to clamp the bleeders would have been disastrous !