This one has me a little confused...trying to get opinions on how others would code this one.
thanks!
PROCEDURE PERFORMED: Sternotomy, cardiopulmonary bypass, debridement of anterolateral myocardium and I&D of pericardial abscess. Bovine patch and closure from anterolateral myocardium.
.
ESTIMATED BLOOD LOSS: Not calculated.
CARDIOPULMONARY BYPASS TIME: 1 hour 12 minutes.
URINE OUTPUT: Negative.
DRAINS: 28 angle chest tube to lower chest. 32 angle chest tube and 32 straight chest tube to the mediastinum and two 19 Blake to the anterolateral mediastinum and abscess cavity.
CANNULATIONS: Medtronic 20 French aortic cannula and Edwards 28/38 RA IVC cannula.
POSTOPERATIVE CONDITION/DISPOSITION: Critical and guarded to HVICU intubated.
INDICATIONS: a 52-year-old male with a history of pericardial abscess with purulence and then drained approximately one year ago and reported to be MRSA and subsequently was reevaluated and found to have collection of the anterolateral border of his pericardium. to have a pericardial abscess. Given his history of pericardial abscess, his operative risks were discussed at length with him including his risk for sternal wound infection and mediastinitis. He was then consented and brought to the operating room.
OPERATION: was placed on the operating table in the supine position. He was given general anesthetic and once this was accomplished he was given appropriate monitoring devices and lines. foam pads were placed. We then prepped and draped in a normal sterile fashion. Timeout was done and Ancef was given as antibiotic.
We performed a primary median sternotomy in a standard fashion after an arterial venous femoral line was placed into the left groin. We used the oscillating saw to make our incision to the bone. We did this with careful attention to elevating the sternum up. Once this was accomplished we safely dissected using electrocautery to dissect the heart and pericardium off the back of the sternum until we had enough room to insert a retractor. We then inserted our retractor and slowly opened up the mediastinal space and then began to dissect off the pericardial fat, down to the level of the aorta and then worked our way up to the innominate vein which was visualized. We then directed our attention down and cleaned off this region. Once this was accomplished we were able to grasp the pericardium and elevate it up and used scissors to make a sharp incision until there was a free area just at the base of the aorta. Then we used blunt dissection and was able to get our finger within the pericardium to find free areas. We began make our incision within the pericardium up to the level of the diaphragm up to the innominate. Once this was accomplished we placed pericardial stays. At this time we had Dr. Houzy_do an echocardiogram which demonstrated small amounts of flow within the region of the pericardial abscess. Therefore raising a concern of possible continued free wall rupture or invasion of the abscess into the ventricular cavity or other vascular structures. Therefore the decision was made to go on cardiopulmonary bypass, we cannulated the aorta with 2 concentric pursestrings in a standard fashion as well as cannulated the right atrium with concentric pursestring. We used Medtronic cannula 20 French into the aorta and Edwards 28/38 and continued to the right atrium down into the IVC. These were secured with normal snares and suture tied. Perfusion informed us that we had an adequate correlation and waveform. Pre-bypass checklist was completed. Our ACT was greater than 480 and therefore we did initiate the cardiopulmonary bypass at this time. Once we were on bypass safely and established good flow, Anesthesia stopped ventilating and we proceeded to dissect the heart off of the pericardium. We carried this around inferiorly and then laterally until we reached the region near the border of the right ventricle. The pulmonary outflow tract lateral to that and we cannulated the abscess cavity numerous cultures were sent as well as some tissue and we had to evacuate this area and then tried to maintain a control over the contaminated area as we evacuated the purulence. We then continued to dissect this area open and found the cavity between this region and down inferiorly down to the level of the pulmonary veins. And this entire area was dissected free of pericardium from the heart. The epicardium was grossly invaded at this region and once we were done with our dissection it was clear that the infection was invading into the epicardium and had caused a decent amount of tissue destruction in this region. He had a large amount of gentle oozing in the area that is approximately 6 x 6 cm along the heart as well as extensive oozing from the pericardium and surrounding fat pads and tissues. We did use cautery throughout this region and then used a long Prolene transplant stitch to suture ligate the entire pericardium and the pericardial cavity circumferentially. Once this was accomplished we directed our attention to the epicardium and decided to patch over this especially given the large amount of raw surface area and bleeding and information provided by the echocardiogram which showed the ventricular wall to be particularly thick in this region below the abscess. We used Bovine pericardium and 3-0 Prolene and stitched in a baseball fashion around the patch to the heart. The tissue on the periphery of the area that as dissected was good strong epicardium and had a fair amount of scar to it. Once we were down to this we then placed two containers of BioGlue underneath the bovine patch and injected and infiltrated the entire surface of the heart underneath and then applied some gentle pressures to cease bleeding and creating a negative space. Once this was accomplished this did minimize some of our bleeding however he was still quite oozy as expected in a renal failure patient. Next we then paid attention to the rest of the pericardial well. We then discontinued the patient from bypass and weaned him down and off. Once this was accomplished the patient had adequate hemodynamics. Therefore we hooked up the venous line for perfusion to concentrate. At this time we were able to modified ultrafiltrate the 1,050 mL off in addition to the ultrafiltration of 1,350 mL during the case. We at this time placed numerous chest tubes. We placed two 32 chest tubes inferior to our incision and placed an angle at the base of the heart and a straight chest tube was laid in the anterior pericardium and placed two 19 Blake in the left costovertebral angle region. These were brought in through chest and into the abscess cavity for further drainage and irrigation down the road into the abscess cavity. We placed an angled left-sided chest tube into the left chest in standard fashion. We then used vancomycin meatballs and copiously padded throughout the sternum and the soft tissue. Prior to placing the drains note that we did irrigate with several liters of warm saline throughout this entire abscess region and pericardial well and then used a bowl of Betadine and irrigated this area out slowly being careful not to use the pump so we used the cell saver during that time. After we were done hemoconcentrating we then allowed Anesthesia to begin protamine infusion. At this time we then discontinued our venous cannula and then tied this down and noticed no bleeding. We then lowered the pressure and discontinued our aortic cannula and both concentric pursestrings were tied down with no apparent bleeding. We then did one more tour of the entire pericardial well and all the surfaces and the abscess cavity and then cauterized any residual bleeding that we had but there was still continued gentle ooze from some of the small areas. The patient had fresh frozen platelets and cryoprecipitate ordered. We then proceeded to place 7 sternal wires and then closed the subcu with 0 Vicryl, 2-0 Vicryl and then staples for the skin. Sterile dressings were applied and sponge and needle count was correct. No apparent complications were appreciated and patient was then placed on HVICU bed and taken to HVICU intubated stable but in critical condition.
thanks!
PROCEDURE PERFORMED: Sternotomy, cardiopulmonary bypass, debridement of anterolateral myocardium and I&D of pericardial abscess. Bovine patch and closure from anterolateral myocardium.
.
ESTIMATED BLOOD LOSS: Not calculated.
CARDIOPULMONARY BYPASS TIME: 1 hour 12 minutes.
URINE OUTPUT: Negative.
DRAINS: 28 angle chest tube to lower chest. 32 angle chest tube and 32 straight chest tube to the mediastinum and two 19 Blake to the anterolateral mediastinum and abscess cavity.
CANNULATIONS: Medtronic 20 French aortic cannula and Edwards 28/38 RA IVC cannula.
POSTOPERATIVE CONDITION/DISPOSITION: Critical and guarded to HVICU intubated.
INDICATIONS: a 52-year-old male with a history of pericardial abscess with purulence and then drained approximately one year ago and reported to be MRSA and subsequently was reevaluated and found to have collection of the anterolateral border of his pericardium. to have a pericardial abscess. Given his history of pericardial abscess, his operative risks were discussed at length with him including his risk for sternal wound infection and mediastinitis. He was then consented and brought to the operating room.
OPERATION: was placed on the operating table in the supine position. He was given general anesthetic and once this was accomplished he was given appropriate monitoring devices and lines. foam pads were placed. We then prepped and draped in a normal sterile fashion. Timeout was done and Ancef was given as antibiotic.
We performed a primary median sternotomy in a standard fashion after an arterial venous femoral line was placed into the left groin. We used the oscillating saw to make our incision to the bone. We did this with careful attention to elevating the sternum up. Once this was accomplished we safely dissected using electrocautery to dissect the heart and pericardium off the back of the sternum until we had enough room to insert a retractor. We then inserted our retractor and slowly opened up the mediastinal space and then began to dissect off the pericardial fat, down to the level of the aorta and then worked our way up to the innominate vein which was visualized. We then directed our attention down and cleaned off this region. Once this was accomplished we were able to grasp the pericardium and elevate it up and used scissors to make a sharp incision until there was a free area just at the base of the aorta. Then we used blunt dissection and was able to get our finger within the pericardium to find free areas. We began make our incision within the pericardium up to the level of the diaphragm up to the innominate. Once this was accomplished we placed pericardial stays. At this time we had Dr. Houzy_do an echocardiogram which demonstrated small amounts of flow within the region of the pericardial abscess. Therefore raising a concern of possible continued free wall rupture or invasion of the abscess into the ventricular cavity or other vascular structures. Therefore the decision was made to go on cardiopulmonary bypass, we cannulated the aorta with 2 concentric pursestrings in a standard fashion as well as cannulated the right atrium with concentric pursestring. We used Medtronic cannula 20 French into the aorta and Edwards 28/38 and continued to the right atrium down into the IVC. These were secured with normal snares and suture tied. Perfusion informed us that we had an adequate correlation and waveform. Pre-bypass checklist was completed. Our ACT was greater than 480 and therefore we did initiate the cardiopulmonary bypass at this time. Once we were on bypass safely and established good flow, Anesthesia stopped ventilating and we proceeded to dissect the heart off of the pericardium. We carried this around inferiorly and then laterally until we reached the region near the border of the right ventricle. The pulmonary outflow tract lateral to that and we cannulated the abscess cavity numerous cultures were sent as well as some tissue and we had to evacuate this area and then tried to maintain a control over the contaminated area as we evacuated the purulence. We then continued to dissect this area open and found the cavity between this region and down inferiorly down to the level of the pulmonary veins. And this entire area was dissected free of pericardium from the heart. The epicardium was grossly invaded at this region and once we were done with our dissection it was clear that the infection was invading into the epicardium and had caused a decent amount of tissue destruction in this region. He had a large amount of gentle oozing in the area that is approximately 6 x 6 cm along the heart as well as extensive oozing from the pericardium and surrounding fat pads and tissues. We did use cautery throughout this region and then used a long Prolene transplant stitch to suture ligate the entire pericardium and the pericardial cavity circumferentially. Once this was accomplished we directed our attention to the epicardium and decided to patch over this especially given the large amount of raw surface area and bleeding and information provided by the echocardiogram which showed the ventricular wall to be particularly thick in this region below the abscess. We used Bovine pericardium and 3-0 Prolene and stitched in a baseball fashion around the patch to the heart. The tissue on the periphery of the area that as dissected was good strong epicardium and had a fair amount of scar to it. Once we were down to this we then placed two containers of BioGlue underneath the bovine patch and injected and infiltrated the entire surface of the heart underneath and then applied some gentle pressures to cease bleeding and creating a negative space. Once this was accomplished this did minimize some of our bleeding however he was still quite oozy as expected in a renal failure patient. Next we then paid attention to the rest of the pericardial well. We then discontinued the patient from bypass and weaned him down and off. Once this was accomplished the patient had adequate hemodynamics. Therefore we hooked up the venous line for perfusion to concentrate. At this time we were able to modified ultrafiltrate the 1,050 mL off in addition to the ultrafiltration of 1,350 mL during the case. We at this time placed numerous chest tubes. We placed two 32 chest tubes inferior to our incision and placed an angle at the base of the heart and a straight chest tube was laid in the anterior pericardium and placed two 19 Blake in the left costovertebral angle region. These were brought in through chest and into the abscess cavity for further drainage and irrigation down the road into the abscess cavity. We placed an angled left-sided chest tube into the left chest in standard fashion. We then used vancomycin meatballs and copiously padded throughout the sternum and the soft tissue. Prior to placing the drains note that we did irrigate with several liters of warm saline throughout this entire abscess region and pericardial well and then used a bowl of Betadine and irrigated this area out slowly being careful not to use the pump so we used the cell saver during that time. After we were done hemoconcentrating we then allowed Anesthesia to begin protamine infusion. At this time we then discontinued our venous cannula and then tied this down and noticed no bleeding. We then lowered the pressure and discontinued our aortic cannula and both concentric pursestrings were tied down with no apparent bleeding. We then did one more tour of the entire pericardial well and all the surfaces and the abscess cavity and then cauterized any residual bleeding that we had but there was still continued gentle ooze from some of the small areas. The patient had fresh frozen platelets and cryoprecipitate ordered. We then proceeded to place 7 sternal wires and then closed the subcu with 0 Vicryl, 2-0 Vicryl and then staples for the skin. Sterile dressings were applied and sponge and needle count was correct. No apparent complications were appreciated and patient was then placed on HVICU bed and taken to HVICU intubated stable but in critical condition.
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