Content of Submissions
The Cardiothoracic Surgery Reporting System is a venture into untested waters for the medical
profession. Therefore the content of vignettes will be initially restricted to clinical situations where serious consequences were avoided by anticipation, action, or reaction on the part of the surgeon or a surgical team member. The reporting of “crashes” that result in death or serious morbidity should be avoided because such situations are subject to variable interpretation and are more appropriately investigated on the institutional level. Those who wish to share their own near misses will find a model for their vignettes in the pioneering publication of Dr. Myles Edwin Lee: Near Misses in Cardiac Surgery (Butterworth-Hdeinemann, 1992).
Format of Submissions
Submitted vignettes should contain a brief Title and be followed by a Descriptive Summary of 500 words or less that describes the clinical situation, identifies a problem, and reports the solution. Suggestions for effective ways to prevent repeat future events should be included if appropriate. References may be included and will not be assessed in the word count.
Sample Vignette
Title
Air Embolism during Cardiopulmonary Bypass
Vignette
I had just completed an uneventful replacement of the aortic valve and double CABG in a 62 year old man and was terminating cardiopulmonary bypass. Cardiac action was vigorous and suddenly I noted air bubbles in the arterial line. I immediately gave the order to shut off the pump and simultaneously clamped the arterial line and fibrillated the heart by means of previously placed ventricular pacer wires. The patient was quickly placed in the head down position, the arterial cannula connection separated, the grafts occluded, and air evacuated from the ascending aorta through the arterial cannula by manual compression of the heart and ascending aorta. The coronary grafts were vented with needles. When no further air emerged and the arterial cannula was filled with blood the arterial line was reconnected and, with the aortic root vented, cardiopulmonary bypass was slowly reinstituted. There was no further appearance of air and the graft needle vents were removed. The fibrillator was turned off and we were pleasantly surprised by spontaneous defibrillation. We added more fluid to the perfusate and after a short period of CPB support successfully came off the pump with excellent hemodynamics. I feared the worst in terms of neurologic injury from air embolism. Fortunately we had the availability of a hyperbaric unit and the patient, nurse, and I soon embarked on a four hour dive. We emerged thankful for the absence of arrhythmia, bleeding, or an unstable circulation. After extubation the following morning in the ICU, the patient opened his eyes and asked for a newspaper.
Conclusion
Maneuvers to recover pumped air may be helpful – the air that comes out can’t cause injury. Hyperbaric oxygenation applied early is effective treatment for air embolism. Even an experienced perfusionist can have a moment of distraction, which in this instance caused air to be pumped from the empty venous reservoir. Redundancy in the system is essential – the next day level alarms were made standard on all venous reservoirs.