Help me with this one.
PREOPERATIVE DIAGNOSES:
1. Mediastinal bleeding.
2. Venous bleeding from the pacemaker lead exit site.
POSTOPERATIVE DIAGNOSES: Mediastinal bleeding with laceration and confluence of the internal jugular and subclavian vein on the back wall.
PROCEDURE PERFORMED: Median sternotomy with a supraclavicular extension, division of the clavicle, control of bleeding at the confluence of the left internal jugular and subclavian vein.
INDICATIONS: A 74-year-old female who was having pacemaker lead extraction by Dr. *** and thinking that she was having increasing amount of bleeding from the lead exit site on the vein. Digital pressure was obtained and I was consulted in the operating room.
DESCRIPTION OF PROCEDURE: When I came in, the patient procedures had already started there was bleeding from the lead exit site. Dr. *** was holding manual pressure.
Emergent median sternotomy was performed and chest cavity was entered. There were adhesions seen in the pericardium and that was dissected out and the right atrium was exposed. Standard left supraclavicular extension incision was made. I was just on top of the innominate vein; however, being was on the confluence of the left internal jugular and subclavian vein posteriorly. Thus, we divided the clavicle and retracted it inferomedially, that exposed the whole confluence. Fiber suture was used to have control of the bleeding site at that time. Once that was done, the bleeding had subsided and was just a little bit ooze from the exit site. It may also be noted we were able to control by putting snares around the innominate and then internal jugular vein itself. Once that was done, the rest of the lead extraction was done by Dr. *** and he dictated that. Once the leads were out, we made sure the right atrium was completely secured using 4-0 pledgetted sutures. Similarly, after the vein extracted, we were able to close the hole in the innominate vein on the back side just at the confluence of the subclavian and internal jugular veins as well. Two Jackson-Pratt were inserted, one in the left supraclavicular incision, one separately in the pacemaker battery site and then a Blake drain was inserted into the pericardium. Once make sure that adequate hemostasis maintained, the sternum reapproximated with sternal wires and the chest wall was closed in layers. The patient was coagulopathic required blood products, FFP, platelets and cryoprecipitate. The patient had multiple units of PRBCs given as well. The patient remained intubated and transferred to the ICU in stable condition.
PREOPERATIVE DIAGNOSES:
1. Mediastinal bleeding.
2. Venous bleeding from the pacemaker lead exit site.
POSTOPERATIVE DIAGNOSES: Mediastinal bleeding with laceration and confluence of the internal jugular and subclavian vein on the back wall.
PROCEDURE PERFORMED: Median sternotomy with a supraclavicular extension, division of the clavicle, control of bleeding at the confluence of the left internal jugular and subclavian vein.
INDICATIONS: A 74-year-old female who was having pacemaker lead extraction by Dr. *** and thinking that she was having increasing amount of bleeding from the lead exit site on the vein. Digital pressure was obtained and I was consulted in the operating room.
DESCRIPTION OF PROCEDURE: When I came in, the patient procedures had already started there was bleeding from the lead exit site. Dr. *** was holding manual pressure.
Emergent median sternotomy was performed and chest cavity was entered. There were adhesions seen in the pericardium and that was dissected out and the right atrium was exposed. Standard left supraclavicular extension incision was made. I was just on top of the innominate vein; however, being was on the confluence of the left internal jugular and subclavian vein posteriorly. Thus, we divided the clavicle and retracted it inferomedially, that exposed the whole confluence. Fiber suture was used to have control of the bleeding site at that time. Once that was done, the bleeding had subsided and was just a little bit ooze from the exit site. It may also be noted we were able to control by putting snares around the innominate and then internal jugular vein itself. Once that was done, the rest of the lead extraction was done by Dr. *** and he dictated that. Once the leads were out, we made sure the right atrium was completely secured using 4-0 pledgetted sutures. Similarly, after the vein extracted, we were able to close the hole in the innominate vein on the back side just at the confluence of the subclavian and internal jugular veins as well. Two Jackson-Pratt were inserted, one in the left supraclavicular incision, one separately in the pacemaker battery site and then a Blake drain was inserted into the pericardium. Once make sure that adequate hemostasis maintained, the sternum reapproximated with sternal wires and the chest wall was closed in layers. The patient was coagulopathic required blood products, FFP, platelets and cryoprecipitate. The patient had multiple units of PRBCs given as well. The patient remained intubated and transferred to the ICU in stable condition.