| A 56 year old male patient scheduled for laparoscopic cholecystectomy with intraoperative cholangiogram with no other medical or surgical history. Team included attending surgeon, RNFA, surgical technician, circulating RN, and CRNA. This was a routine case and the experienced perioperative team have worked together on this procedure many times. Shortly after the gallbladder was removed, the CRNA verbally requested a check of the insufflator settings. The circulator provided the flow rate at 15mmHg and a pressure of 12mmHg. The CRNA asked the surgeon to “look around” the abdomen for any problems since the patient’s heart rate was “rapid (130bpm) and the QRS looked wide”. The surgeon noted a bulging, reddened area near the thoracic pericardium. The CRNA called for the attending Anesthesiologist; the patient’s QRS was becoming progressively wider and the BP was dropping. The surgeon determined there was pericardial damage from stray electrical current from the electrosurgical unit. Since this is a small facility, the surgical cardiac team was called (stat) from another nearby facility. Anesthesia stabilized the patient while the surgeon continued to assess the chest cavity for other involved areas. The circulator ran for the crash cart and chest instruments after putting a page in for extra help. (The surgical cardiac team was bringing an electric sternal saw.) The assistant director (who had previous cardiac/open heart surgery experience) scrubbed to assist on the case. The cardiac surgeon arrived (15 min. later), opened the chest and repaired a 1 cm hole in the ventricle wall with a surgical pledget. The chest was closed with sternal wire and the patient transferred directly to the ICU and later was transferred to the neighboring hospital with a cardiac ICU. |