Emergency right anterior thoracotomy with attempt of controlled of bleeding

sandy06

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PREOP DIAGNOSIS:
Mediastinal bleeding.

POSTOP DIAGNOSIS:
Mediastinal bleeding.

PROCEDURE PERFORMED:
Emergency right anterior thoracotomy with attempt of controlled of
bleeding, emergency placement of left femoral artery and vein
cardiopulmonary bypass, an emergency redo sternotomy and control of
bleeding.

SURGEON:
A , M.D.

DESCRIPTION OF PROCEDURE:
Briefly, the patient was identified in the intensive care unit with
copious amount of blood emanating from the chest tube. The patient
was hemodynamically unstable, and was brought urgently to the
operating room, placed on O.R. table in the supine position. General
endotracheal tube anesthesia was given to the patient. The patient
was already intubated and already all the appropriate monitors and
lines in place from the previous open heart surgery. At this point,
the right anterior thoracotomy from the old incision was opened.
After the patient was prepped and draped preoperative antibiotics
were given to the patient. Once entering into the subcutaneous tissue
we were able to remove the sutures holding the intercostal muscles
placement and at this point, we were able to enter the intercostal
space and copious amount of blood was able to be evacuated. Once the
copious amount of blood was evacuated were able to identify a
bleeding point on the ascending aorta and attempt to visualize this
further. We were able to identify copious amount of bleeding from the
root of the aorta, so at this point, a 4 x 4 gauze was placed on the
pressure and copious amount of blood had to be infused into the
patient with the help of anesthesia and with the help of pressors and
inotrope's as well. At this point, the left inguinal incision was
reopened. We were able to enter into the subcutaneous tissue,
identifying both femoral artery and femoral vein. Urgently heparin
was given to achieve an ACT of greater than 400. At this point,
pursestring sutures were placed both the artery and vein of the
femoral area and the patient was cannulated for cardiopulmonary
bypass. The first cannula was placed was a 18-French percutaneous
arterial cannula and placed into he right femoral artery without any
difficulty. Good flow back was identified and secured to the to the
line of the cardiopulmonary bypass circuit. The venous cannula was
placed all the way to the SVC with the help of the guidance from
finger dilatation and manipulation into the right thoracic cavity. At
this point, we commenced the patient on cardiopulmonary bypass, a
crossclamped was attempted to be placed through the right
thoracotomy, but unable to be performed, secondary to the fact that
the whole entire area was with copious amount of bleeding and unable
to identified as well. So once again, a pressure dressing was placed
into the wound with using a sponge stick for control. At this point,
the redo sternotomy was opened. We were able to open the midline
sternum using a knife. We were able to enter the subcutaneous tissue
where the sternal wires were removed in their entirety. Using a
reentry saw, we were able to enter into the sternal cavity without
any difficulty and without any trauma to the cardiac structures. Due
to the fact that the patient was already on cardiopulmonary bypass,
the heart was deflated. At this point we were able to enter, a
sternotomy retractor was inserted. We were then able to open the
pericardial sac and we were able to identify staged torn aortic root.
At this point, attempt was made to reconstruct the root with a
pledget reinforced with 5-0 Prolene sutures. We were able to take
control of the bleeding. Once the bleeding was controlled, an attempt
was made to rewarm the patient, because we had cooled down to 26
degrees Celsius during the initial cannulation when the cross clamp
was unable to be placed. So at this point, the cross clamp was placed
and antegrade cardioplegia was given in an attempt to arrest heart
and aiding the hypothermia, in order to control the bleeding. At this
point, once we were able to gain control we are able to correct the
bleeding points and at this point the cross clamp was removed and the
heart began to beat. However, there was still generalized ooze coming
from the root, but overall it was better controlled and it was
decided at this point to try to wean off the cardiopulmonary bypass
and give the patient protamine. However, we are unable to wean off
cardiopulmonary bypass. The heart began to be swollen and
hemodynamically instability. At this point, with some multiple
attempts of weaning off the cardiopulmonary bypass, we deemed these
procedures futile and the patient had thus expired in the operating
room. A full disclosure was given to the patient's family and the
team involved with the patient. At this point, the cannulas were
removed and the pursestring sutures tied in place, both femoral level
and all incisions were closed. The sternum was reapproximated using
five sternal wires, and the staples at the skin and staples were used
in the groin.

Unfortunately the patient expired in the operating room, and all
attempts were made to resuscitate the patient

Can someone please help me with coding this Opt Report, I'll realy appreciate any help.
 
Last edited:

dpumford

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This looks like it was a retrun to OR after a Cabg.. If so, look at 35820 with dx of 998.11.

I don't have time to read the whole report but this is the code you use if pt is brought back to OR and the chest is reopened and explored etc. You will need mod 78 also...

Hope this helps!:)
 
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