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sternotomy please help

Messages
120
Best answers
0
Post operative diagnosis:
Same, cardiac tamponade, acute cardiovascular decompensation with induction of anesthesia requiring CPR, tortuous right iliac artery
*
Operation:
#1. Emergency Median sternotomy
#2. Pericardiotomy with evacuation of 1000 mL of blood
#3. TEE by anesthesia
#4. Impella CP placement via right femoral artery (percutaneous) with fluoroscopic and echocardiographic guidance (#33990)
#5. Iliac artery arteriography with fluoroscopic assistance
*
Preoperative note:
is a 70 y.o. male with severe ischemic cardiomyopathy and severe multivessel coronary artery disease being taken to the operating room for coronary artery bypass grafting.
*
Operative findings:
.
#1. Operative findings: The patient was quite dyspneic on arrival in the operating room. He was placed on the operating table and found to be hypotensive. Vasopressors were administered with resulting improved blood pressure. However on administration of anesthesia the patient had renovascular collapse with blood pressures in the 40s. CPR was carried out. Echocardiography suggested a pericardial fluid. Chest was quickly opened and pericardiotomy was performed and 1000 mL of blood were evacuated. Once the blood was evacuated no for further active bleeding was identified. Surface of the heart however was covered in fibrinous changes .despite evacuating the the bladder however gradually hemodynamics began to deteriorate further. It was felt that attempts at doing bypass surgery in the face of the profound changes in the pericardial space would be extremely difficult and that based on the anatomy it was possible to the only vessel that might be able to be bypass would be the LAD (which was also felt to be a stone double vessel per Dr. ). At this point it was felt that the safest and most appropriate therapy for cardiovascular support will be the placement of the Impella CP. There was also concern with a cardiac tamponade was secondary to a potential ventricular perforation due to the recent myocardial infarction and then any elevation of the heart and manipulation could result in catastrophic continued hemorrhage.
*
Description of operation:
The patient was placed on the operating table in a supine position and general anesthesia was administered monitoring the arterial pressure, pulmonary artery pressure, electrocardiogram, and the oxygen saturation. As noted above the patient developed acute cardiac decompensation with profound hypotension requiring significant pressor support and CPR for approximately 2 minutes. Eventually a reasonable blood pressure was achieved, albeit temporarily. The entire chest, abdomen, and legs were prepped and draped in a sterile manner. The TEE probe was placed by anesthesia and this facilitated the placement of the Impella device. A median sternotomy was performed and a pericardiotomy was immediately carried out draining 1000 mL of blood. This resulted in significantly improved hemodynamics albeit temporarily. A right groin femoral artery puncture was performed using Seldinger technique. A small 6 French sheath was placed with subsequent facilitated the placement of the Impella sheath. We were able to pass a Glidewire up into the descending thoracic aorta without difficulty. However when we attempted to place a more rigid wire were unsuccessful. A right iliac artery arteriogram was performed via the sheath demonstrated an extremely tortuous iliac vessel. Following this we passed a multipurpose catheter over this wire. The Glidewire was removed and a rigid wire was passed to the multipurpose catheter ultimately was able to be passed into the descending thoracic aorta. The regular sheath was removed and a long sheath was then passed over the rigid wire straightening out the tortuous iliac artery. The wire was then placed via the sheath passed under fluoroscopic control into the aortic root and ultimately into the left ventricle. Device was then prepared on the back table and passed over this wire into the left under fluoroscopic control into the left ventricle without difficulty. The device was activated to level P8. With good flow rates and good positioning the long sheath was removed and permanent sheath on Impella was passed into the femoral artery without difficulty. Hemodynamic improvement was immediate. The chest was evaluated and with no active bleeding single mediastinal chest tube was placed in the wound was closed in layers. TEE findings post implant demonstrated reasonably good LV function and RV function. The patient was then taken to the CVRU in serious condition.

39010
33020
33990
would these be correct
 

TWinsor

Guru
Messages
171
Location
Columbus, OH
Best answers
0
Post operative diagnosis:
Same, cardiac tamponade, acute cardiovascular decompensation with induction of anesthesia requiring CPR, tortuous right iliac artery
*
Operation:
#1. Emergency Median sternotomy
#2. Pericardiotomy with evacuation of 1000 mL of blood
#3. TEE by anesthesia
#4. Impella CP placement via right femoral artery (percutaneous) with fluoroscopic and echocardiographic guidance (#33990)
#5. Iliac artery arteriography with fluoroscopic assistance
*
Preoperative note:
is a 70 y.o. male with severe ischemic cardiomyopathy and severe multivessel coronary artery disease being taken to the operating room for coronary artery bypass grafting.
*
Operative findings:
.
#1. Operative findings: The patient was quite dyspneic on arrival in the operating room. He was placed on the operating table and found to be hypotensive. Vasopressors were administered with resulting improved blood pressure. However on administration of anesthesia the patient had renovascular collapse with blood pressures in the 40s. CPR was carried out. Echocardiography suggested a pericardial fluid. Chest was quickly opened and pericardiotomy was performed and 1000 mL of blood were evacuated. Once the blood was evacuated no for further active bleeding was identified. Surface of the heart however was covered in fibrinous changes .despite evacuating the the bladder however gradually hemodynamics began to deteriorate further. It was felt that attempts at doing bypass surgery in the face of the profound changes in the pericardial space would be extremely difficult and that based on the anatomy it was possible to the only vessel that might be able to be bypass would be the LAD (which was also felt to be a stone double vessel per Dr. ). At this point it was felt that the safest and most appropriate therapy for cardiovascular support will be the placement of the Impella CP. There was also concern with a cardiac tamponade was secondary to a potential ventricular perforation due to the recent myocardial infarction and then any elevation of the heart and manipulation could result in catastrophic continued hemorrhage.
*
Description of operation:
The patient was placed on the operating table in a supine position and general anesthesia was administered monitoring the arterial pressure, pulmonary artery pressure, electrocardiogram, and the oxygen saturation. As noted above the patient developed acute cardiac decompensation with profound hypotension requiring significant pressor support and CPR for approximately 2 minutes. Eventually a reasonable blood pressure was achieved, albeit temporarily. The entire chest, abdomen, and legs were prepped and draped in a sterile manner. The TEE probe was placed by anesthesia and this facilitated the placement of the Impella device. A median sternotomy was performed and a pericardiotomy was immediately carried out draining 1000 mL of blood. This resulted in significantly improved hemodynamics albeit temporarily. A right groin femoral artery puncture was performed using Seldinger technique. A small 6 French sheath was placed with subsequent facilitated the placement of the Impella sheath. We were able to pass a Glidewire up into the descending thoracic aorta without difficulty. However when we attempted to place a more rigid wire were unsuccessful. A right iliac artery arteriogram was performed via the sheath demonstrated an extremely tortuous iliac vessel. Following this we passed a multipurpose catheter over this wire. The Glidewire was removed and a rigid wire was passed to the multipurpose catheter ultimately was able to be passed into the descending thoracic aorta. The regular sheath was removed and a long sheath was then passed over the rigid wire straightening out the tortuous iliac artery. The wire was then placed via the sheath passed under fluoroscopic control into the aortic root and ultimately into the left ventricle. Device was then prepared on the back table and passed over this wire into the left under fluoroscopic control into the left ventricle without difficulty. The device was activated to level P8. With good flow rates and good positioning the long sheath was removed and permanent sheath on Impella was passed into the femoral artery without difficulty. Hemodynamic improvement was immediate. The chest was evaluated and with no active bleeding single mediastinal chest tube was placed in the wound was closed in layers. TEE findings post implant demonstrated reasonably good LV function and RV function. The patient was then taken to the CVRU in serious condition.

39010
33020
33990
would these be correct
33020 and 33990,51 are correct. You would not code the sternotomy as this would be included in the 33020.

Hope this helps!

Thanks,
Terri
 
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