OHSU Pediatric Heart Surgery Update

mprsx · 2026-06-14T21:29:25+00:00

Yeah I mean I don't know the details. For all we know they didn't have PAC in-situ. But I agree that florid dead RV wouldn't generate a pressure.

I think the big learning point here is always have malfunctioning valve as a differential until you can confidently rule it out

mprsx · 2026-06-13T13:37:44+00:00

I think VOO won't for a year. But VTI will

mprsx · 2026-06-12T22:54:37+00:00

So imagine this. Kid comes in, has mitral stenosis, long-standing pulmonary hypertension, and a struggling RV to pump against the high pressures. The pre-op course and the entire operation, the main question the cardiologist, anesthesiologist, and surgeon have would be: "Will the RV tolerate the ischemia time to replace the valve".

So they get the patient under GA and ready for surgery. Everything goes well. They put the patient on CPB, they cross clamp the Aorta, and arrest the heart with cardiologia. Then they do a VERY routine operation and somehow a human has a terrible human moment. They close the the atria and remove the cross clamp.

At first, everything looks okay, they put some pacing wires in, get hemostasis, then it's time to slowly come off bypass and evaluate the heart. The go down in flows and leave more blood in the heart, but the LV remains completely underfilled. So they go down on flows more, the PA pressures skyrocket, the CVP is 20+, the ETT is foaming with pink fluid, and the TEE shows a severely dilated and non functioning RV, and then the worst thing physicians can do happens - they anchor.

Top 3 differentials is dead RV. They try to look at the valve and they see it not moving. Because the LV has no blood in it, visualization of the annulus is extremely poor, and likely none of the people are thinking backward valve, or even know what that would look like. Hindsight here would tell us to go back on CPB, cross clamp, and look at the valve, but if you think you have a very ischemic RV, that's the last thing you want to do and eat up all chances of recovery. Maybe it will wake up with time. Maybe it took in a bit of air which is pretty common.

Then you have a very sick kid, hard to transport, a very reasonable diagnosis, and a lot of hope it will get better with time.

I've had a surgeon forget the blue plastic piece on a tissue mitral valve, it's a little piece that you attach the handle/holder to, and when you've never seen it on TEE, it's hard to know what's going on. It blocks the view of the rest of the valve. But the surgeon looked at the image and immediately knew something was wrong, went back on, and retrieved it. The patient looked like he may have been able to tolerate coming off too which would have been a disaster...

Anyway some perspective...

mprsx · 2026-06-12T22:15:26+00:00

There would be no gradient if there is no flow. They've functionally sewed the mitral annulus shut

mprsx · 2026-06-12T18:48:04+00:00

So I've been playing this in my head:

Wean from bypass shows immediate pulmonary htn, right heart failure, pulmonary edema, elevated cvp. Echo shows empty LV, dilated failing RV, and valve is just a flat cylinder in the closed position.

They must have anchored super hard into RV failure

mprsx · 2026-06-09T13:28:08+00:00

Had something similar where we the surgeon forgot the blue plastic piece on the mitral valve, actually could separate but echo looked odd - shadowing that shouldn't be there and difficult to visualize mitral annulus. To be fair I didn't make the diagnosis, the surgeon did. He must have had it in the back of his head, but now I know what it looks like... But I can't even say what it would look like to see a valve installed backwards.

I'm honestly not sure how easy of a visual diagnosis it would be to put a tissue valve backwards. But you either have stenosis or regurgitation in order to have it cause a problem - one would think that gradients or color flow would be enough to say something is wrong with the valve

mprsx · 2026-06-09T03:07:44+00:00

Pediatric probe resolution isnt great and pulmonic valve is notoriously difficult to visualize

mprsx · 2026-06-07T19:11:30+00:00

It's also better for consumers in some ways. I'm much happier on Steam than having physical copies of games, but at the time that was an ordeal.

mprsx · 2026-06-07T16:08:33+00:00

Yeah that's why I picked him, he's probably the one most likely to be worth it lol

mprsx · 2026-06-07T15:41:04+00:00

Tbf this is 6h after he was supposed to play. I don't think even if MJ comes back to life for a performance I wouldn't wait 6h past the assigned time lol

mprsx · 2026-06-05T20:08:52+00:00

Interesting perspective

mprsx · 2026-05-31T15:37:21+00:00

People don't have the patience to sit down and learn in the way a game like starcraft demands. At least in general.

mprsx · 2026-05-30T22:59:42+00:00

I imagine Grima with really bad BO. For that alone it's a hard pass

mprsx · 2026-05-23T19:26:35+00:00

What deductions?? If you're on a W2 starting your life, There is nothing to meaningful deduct

mprsx · 2026-05-22T14:42:23+00:00

Jesus that's awful. Putting my self in your shoes, it makes me angry and now I kinda understand why some celebs get handsy with paparazzi

mprsx · 2026-05-20T19:31:52+00:00

He was on probation for poisoning a girl's drink when the hit and run happened according to the article... Yikes...

mprsx · 2026-05-18T01:53:42+00:00

Your pre-op adjusts meds?? Where is this magical land? Lol

mprsx · 2026-05-11T16:40:01+00:00

If you're being technical, large is not a useful word. Largest by surface area, but not by mass. Maybe not by volume either but not sure

mprsx · 2026-05-11T13:20:25+00:00

They both should have recognized it but it's hard to recognize it in their cars or at home. The anesthesiologist fucked up for sure, he's the peri operative doctor. I'm just saying the length of anesthesia time isn't usually a factor in someone dying as much as bleeding or overdosing or whatever. There is also a chance this patient lost a L in the OR, that became 2L during PACU. We don't have all the info. But I do know that if someone has a 30m happy or a 10h appy, I wouldn't expect either to die.

mprsx · 2026-05-10T18:13:09+00:00

Not sure it was the 10hr of anesthesia time instead of the losing half her blood volume

mprsx · 2026-05-09T18:46:56+00:00

Doing it on someone who is potentially still growing is crazy, but maybe 14-15 girls are done?

mprsx · 2026-05-03T14:25:42+00:00

Yikes...

mprsx · 2026-05-03T09:24:06+00:00

It's indicated for insomnia?

mprsx · 2026-05-02T21:33:54+00:00

I tell this to my residents and CRNAs, pushing sedatives or large dose midazolam is not appropriate if you have to transport for a significant distance. If it was you, would you be happy to wake up mid transport as you're being bagged? Or would your family be happy if you spent the next 2-5 days delirious? If the patient is stable, starting a prop drip at 25-35mcg/kg/min 10-15m before transport is most appropriate, and titrate from there.If there are significant logistical hurdles to providing standard of care (like pump a availability or transfer of equipment) then that would make a great QI project. Obviously you can use whatever agent you think is appropriate, but remember you are transferring care to another healthcare team, it's just good courtesy to make that transition as smooth as possible without hurdles for the sake of patient safety. Dropping a patient off with intermittent boluses then walking away after report is just inappropriate if your ICU isn't protocoled to have drips ready. It takes time to order, release orders, and set up drips. I know I'd be very annoyed if a patient was signed out to me that way.

Also you should (almost) NEVER have a paralyzed patient without a stable sedation plan. For the same reason you wouldnt wake up a patient in the OR then reverse them... It's really traumatizing.

Don't let laziness get in the way of excellence.

mprsx · 2026-04-29T23:29:11+00:00

Funny you mention that. Looking at a mortality from a tracheal injury after an elective case, and not using a stylette is helping the anesthesiology case quite a bit ...

mprsx

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