please help evacuation of right hemothorax

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Procedure:
#1 mediastinal exploration with evacuation of hemomediastinum
#2 evacuation of right hemothorax
#3 lysis of right pleural adhesions
#4 removal of sternal wires ×6

Intraoperative findings:
Mediastinum:
Small to moderate hemomediastinum was identified, with primary location of the thrombus over the ascending aorta. There was a small area of thrombus along the right atrium and anteriorly on the right ventricle. There was no active bleeding identified. Next

Right pleural cavity:
There was extensive, chronic adhesions involving the right pleural cavity which had to be taken down with electrocautery for the purpose of evacuation of right hemothorax. Large amount of thrombus was removed from the right pleural cavity. Areas were inspected, with no evidence of active bleeding. Next

Procedure in detail:
The patient's history and physical were updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia. She was already endotracheally intubated. Monitoring lines were already in place. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Vancomycin was given prior the incision. Next

The midline sternal incision was opened with a 10 blade scalpel. The underlying Vicryl sutures were divided with Metzenbaum scissors. The Ethibond sutures were removed from the abdominal fascia. The sternal wires were removed ×6. The rigid X plate was removed along with its 7 anchoring screws. Next

The sternal retractor was placed. Hemomediastinum was immediately evident upon entering the central mediastinal cavity. Most of the thrombus was removed from along the ascending aorta. A small amount of thrombus was removed from along the right atrium as well as anterior portion of the right ventricle. All cannulation sites as well as atrial anastomoses were found to be hemostatic. The mediastinum was then irrigated with antibiotic solution.

The right sternum was retracted and access into the right pleural cavity was easily achieved. There was extensive pleural adhesions had to be taken down with left cautery in order to gain access fully to the right pleural cavity. A proximally 450 mL of old blood was removed. Combined with the thrombus, I suspect that this approached a total of 900 mL of combined thrombus and blood. Again, the chest wall and lung were inspected and found to have no evidence of active bleeding. The right pleural cavity was then copiously irrigated with antibody solution and suctioned out. The chest tubes were then irrigated and ensure that there was no clot remaining. Angled chest tube was placed back in the right pleural cavity. An angled chest tube was placed along the diaphragm to straight chest tube was placed in the anterior mediastinum.

The sternum was then reapproximated with #7 wires. At the midsternal body, next plate was placed and secured with 7, 12 mm screws as described above previous operation. This. Abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.

The patient was transferred to the CVRU in guarded condition.

Specimens: None
estimated blood loss: Minimal
blood removed: 450 mL of blood, estimated 450 mL of thrombus
blood replaced: None
drains: Chest tubes as described
implants: X plate with locking screws for the sternum
condition at completion of procedure: Guarded
 
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