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Ann Thorac Surg 1999;67:1291
© 1999 The Society of Thoracic Surgeons

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Invited Commentary

^a Section of Thoracic and Cardiovascular Surgery, The University of Oklahoma, P.O. Box 26901, South Pavilion, 4SP-250, Oklahoma City, OK 73190 USA

Invited commentary

Managing a patient with massive hemoptysis that occurs while the patient is fully heparinized is a daunting experience that is often fatal. With the seemingly irrevocable dissolution of the cardiothoracic surgeon into either a cardiac or a thoracic surgeon, management of these cases may become not only tenuous but suboptimal, as more and more of the younger generation of cardiac surgeons today have little experience with the rigid bronchoscope.

Smythe and colleagues report their experience with 3 such patients; using the rigid bronchoscope, the source of bleeding could be clearly identified in all 3, and adequately controlled in 2. One patient died intraoperatively, 1 died of sequelae of the hemorrhage, and 1 survived the ordeal. In their management the authors stress the importance of the rigid bronchoscope to adequately clear the airway and simultaneously maintain ventilation, and offer an algorithm to manage future cases. All this makes good sense and should be reviewed by surgeons doing open heart procedures.

As is generally the case, most complications are easier to prevent than to treat. In this regard the following points are worth repeating: (1) the balloon of a Swan-Ganz catheter should not be inflated, nor should the catheter be advanced to wedge the tip until the heparin has been reversed and bleeding is controlled; using the diastolic pulmonary artery pressure is perfectly adequate; (2) resist the temptation to suction the endotracheal tube while the patient is on bypass or heparinized—if secretions are present, these need to be cleared before bypass is instituted; and (3) if suctioning is absolutely necessary while the patient is heparinized, the suction catheter tip needs to be withdrawn a centimeter after resistance is encountered before applying suction to avoid traumatizing the mucosa and thus precipitating hemorrhage. This should be preceded by instilling 1 to 2 mL of a 1/10 dilution of epinephrine solution into the endotracheal tube to vasoconstrict the tracheal mucosa before suctioning.

Finally, the authors are to be complimented for reemphasizing the continuing need for dexterity among cardiothoracic surgeons in the assembly and use of the rigid bronchoscope without which the management of these patients is all but futile.

Related Article

Management of exsanguinating hemoptysis during cardiopulmonary bypass

W. Roy Smythe, Robert C. Gorman, William M. DeCampli, Thomas L. Spray, Larry R. Kaiser, and Micheal A. Acker
Ann. Thorac. Surg. 1999 67: 1288-1291. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christopher J. Knott-Craig Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Knott-Craig, C. J. Search for Related Content PubMed Articles by Knott-Craig, C. J. Related Collections Related Article