Notes:
Pipes and Tubes
CASE FIFTEEN
Dr. Dominique Piquette
Dr. Andre Amaral
Notes:
PART ONE
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Notes:
You are the fellow covering the cardiovascular
ICU (CVICU) tonight. While you’re writing
transfer orders in a level 2 ICU, you are called to
assess a new CV patient who came from the OR
after a replacement of his aortic valve and
ascending aorta. Unfortunately, you have missed
the report from the anesthetist.
You get a summary of Mr. Pin’s history by the CV RN:
Mr. Pin was seen in the E.R. earlier
today with an atypical chest pain. A
CT scan with contrast was done,
revealing an extensive type A aortic
dissection. The patient was briefly
brought to CVICU before his surgery
and quickly seen by your colleague.
He wrote an admission note…
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Notes:
Notes:
CVICU – Admission Note
74 y.o.
PMHx : HTN
Dyslipidemia
DM type 2 x 8y  CRF creat=110 in old chart
Hypothyroidism
Home Rx: fosinopril / amlodipine / HCTZ / crestor / metformin /
synthroid
NKDA
Ex-smoker : d/c 15y ago – No EtOH
Notes:
Hx :
Patient admitted with atypical CP 36h ago, non
specific ECG changes (T waves inversion), and
mildly positive trops (0.13). Initially query of PE so
PE study completed  no PE but suspicion of type
A Ao dissection…. CT completed to confirm dx.
BP initially 140/85 with HR 90/min so IV labetolol
started but dropped BP in E.R. and on levo
4mcg/min for MAP 65 on arrival to CVICU.
No echo done.
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Notes:
N:
CV:
Pt alert and oriented
MAP 62 on levo 4
HR 85 (sinus)
ECG: no ST elevation / latest trops 0.17
FiO2: 4L/min
Chest : clear x 2
X-ray : small left pl effusion
ABG : 7.32/32/75/19
Abdo soft
U.O. 250 cc x admission
Creat 145 lytes OK
T 36.4
Hb 110 WBC 11.8 Plt 190
Coag Normal
Resp:
GI :
GU:
HI:
Impression & Plan: Type A Aortic Dissection – OR pending
You have a look at the anesthetic record, and you
make the following observations:
•
•
•
The pump time was 220 min, with a circulation arrest of 18 min.
The patient received 1.5 liters of crystalloids/colloids in the OR, 2 U
of RBCs (+ blood from Cell Saver), and 1 pool of platelets.
The BP was somewhat unstable when the pt came off pump,
requiring the addition of IV epinephrine at 4mcg/min to the drip of
levophed already increased at 15mcg/min. The patient is currently
on this same amount of pressors.
• The initial CI and PAP in the OR (pre-CPB) were respectively
2.4 and 25/12, and the final values (post-CPB) were of 2.8 and
30/16.
• The urine output was about 200cc during the case.
• The patient had to be defibrillated twice when he came
off pump, but was then paced because of a slow
junctional rhythm. He’s been paced at 80/min since his
arrival in CVICU. There was no spontaneous beat when
the pacing rate was decreased to 50/min, so it was left
at 80/min.
• There is no post-op TEE report, but the RN
confirms that the anesthetist said that the valve
looked good on the post-op echo.
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Notes:
Notes:
The patient is still sedated from the surgery. His
MAP is currently 72 with a paced HR at 80/min.
His PAP are 22/12 and his CI is 2.3. The CVP is 8.
The ECG shows diffuse ST elevations in the
anterolateral leads. The patient is on a FiO2 of
50%, fully vented. The chest tubes have drained
130cc in the last 40 minutes. The abdomen is
soft. The U.O. is limited. The post-op blood work
shows:
Blood Gas Type
pH
pCO2
pO2
Bicarbonate
Saturation
FiO2
Blood Gas -Venous
pH
pCO2
pO2
Bicarbonate
Saturation
FiO2
Lactates
CBC
Hemoglobin
WBC Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelet Count
Hematocrit
ARTERIAL
7.25
48
125
17
0.98
0.5
VENOUS
7.22
54
36
17
0.63
0.5
7.35 - 7.45
35 - 45 mm Hg
80 - 100 mm Hg
21 - 28 mmol/L
0.90 - 1.00
6.1
107
15.8
13.3
3
0.6
0.5
0.1
110
0.436
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115 - 165 g/L
4.0 - 11.0 x 10E9/L
2.0 - 7.5 x 10E9/L
1.0 - 4.0 x 10E9/L
0 - 1.0 x 10E9/L
0 - 0.7 x 10E9/L
0 x 0.3 x 10E9/L
150 - 400 x 10E9/L
0.340 - 0.490 L/L
Notes:
Notes:
Calcium Profile
Calcium
1.9
2.20 - 2.60 mmol/L
Magnesium
0.75
0.70 - 1.05 mmol/L
Phosphate
1.45
0.87 - 1.52 mmol/L
Sodium
148
135 - 147 mmol/L
Potassium
4.9
3.5 - 5.0 mmol/L
Chloride
115
95 - 107 mmol/L
CO2 Total
17
22 - 30 mmol/L
Glucose- Random
9.6
4.0 - 8.0 mmol/L
INR
1.47
0.9 - 1.10 INR
PTT
35.0
24.0 - 34.0 SECS
Electrolytes
Notes:
Renal Profile
Urea
11.5
3.0 - 7.0 mmol/L
Creatinine
153
44 - 106 umon/L
507
< 195 IU/L
3
2- 6 ng/mL
<0.01
< 0.05
0.19
< 0.10 ug/L
Bilirubin - Total
10
<20.0 umol/L
AST
35
<31 IU/L
ALT
42
<31 IU/L
ALP
130
40 – 120 IU/L
CK + CK-MB
CK
mB Mass
mB Mass Fraction
Troponin T
Liver Profile (Bili/AST/ALT/ALP)
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Notes:
You decide to administer a bolus of 500cc of RL
to the patient with a repeated cardiac index
post-bolus. You ask the nurse to titrate down the
epinephrine if possible, and hope to be able to
wean off the pressors with a bit of extra fluids.
Notes:
Two hours later, you’re called back at the bedside
because the nurse had to go up on the epi that is
now at 8 mcg/min. The patient is back in his own
sinus rhythm at 110/min.
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Notes:
The patient is waking up. His chest still sounds
clear, and the vent settings are the same. The
chest tubes have drained about 120-150cc/h
since the admission, but it seems to taper down
now. The ECG is unchanged.
You administer another 500cc bolus of RL and
ask the RN to start some milrinone at 0.25
mcg/kg/min. You send another Hg, coag, and
MVBG.
Notes:
One hour later, you repeat the hemodynamic
values:
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The following blood work comes back:
Blood Gas -Venous
pH
pCO2
pO2
Bicarbonate
Saturation
FiO2
Notes:
VENOUS
7.28
43
31
16
0.56
0.5
Lactates
4.8
CBC
Hemoglobin
WBC Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelet Count
Hematocrit
101
15.3
13.5
3
0.6
0.5
0.1
95
0.418
115 - 165 g/L
4.0 - 11.0 x 10E9/L
2.0 - 7.5 x 10E9/L
1.0 - 4.0 x 10E9/L
0 - 1.0 x 10E9/L
0 - 0.7 x 10E9/L
0 x 0.3 x 10E9/L
150 - 400 x 10E9/L
0.340 - 0.490 L/L
Notes:
Doctor, I am sorry but the
MAP is still around 57…
That is a bit suboptimal…
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Notes:
Objectives:
To diagnose and
medically manage
an acute aortic
dissection.
To interpret the
hemodynamic
values of invasive
cardiac
monitoring.
To anticipate and
manage
postoperative
complications
post major
vascular surgery.
Questions:
PROPERTIES
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- How would you
have optimized
the medical
management of
this patient
BEFORE the
surgery?
- Which
information from
the CT findings
may be relevant
for the
postoperative
management?
- What happens
during an intraoperative
circulation arrest?
- What are the
implications for
the postoperative
management?
- Are you satisfied
with the
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hemodynamic
status of the
patient?
- Any suggestions
in terms of
management?
Notes:
PART TWO
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Notes:
You ask the anesthesiologist to come do an
urgent TEE on Mr. Pin. The echo reveals a
hyperdynamic LV with dynamic obstruction of
the left ventricular walls. The RV is mildly
hypokinetic, but not distended. Its function
appears similar to the pre-op echo results. The
IVC is still collapsible.
Notes:
Based on those results, you administer an extra
liter of crystalloids, and increase the baseline IV
rate at 150cc/h. You also ask the RN to stop the
milrinone, cut the dose of vasopressors by a half,
except for the vasopressin. You tell her to stop
them if no change in the BP occurs within the
next 10-15 minutes.
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Two hours later, the following values are obtained:
Notes:
Notes:
All the vasopressors are off, except for the
vasopressin at 2U/h.
You ask the RN to wean it off for a MAP > 65,
and head to your call room.
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Notes:
Two hours later, you get called by the CVICU RN
again.
The patient has been in atrial fibrillation for
the past 20 min at 140/min, and hasn’t
convert back to sinus despite an extra bolus of
Mg and K for latest blood work values of 0.8
and 3.8 respectively. Should I give
amiodarone?
Can you repeat a set of
hemodynamic values and a
MVBG ? I am on my way to
the unit.
Notes:
The results are:
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The nurse is now also having trouble to get a
wedge value and wonders if we should
reposition the PA line.
You look at the tracing transduced from the
distal port of the PA line and see the following:
Notes:
Notes:
- To recognize,
diagnose, and
manage dynamic
obstructions of
the left and right
ventricles.
- To interpret the
hemodynamic
value changes
according to the
clinical
management.
- To recognize
and address the
technical issues
related to the use
of a PA catheter.
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Questions:
- What is your
interpretation of
this tracing?
- Are you
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concerned about
this patient?
- What would you
do at this point?
- What do you
expect in terms of
short-term and
mid-term
prognosis?
Notes:
PART THREE
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Notes:
You give some amiodarone (bolus and infusion),
and decide to restart a low dose of milrinone at
0.250mcg/kg/min. You ask the RN to repeat the
hemodynamic values and a MVBG in 2 hours.
The nurse calls you back after 2 hours:
The patient is now in sinus rhythm, but there
are some technical issues with the cardiac
output line. Nobody can get a C.O. or C.I. from
the PA line. A few nurses have gone through
the usual troubleshooting measures, but we
can’t find the source of the problem…
Oh Dear… I am coming…
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Notes:
They show you the tracing resulting from the
square wave test:
Notes:
Notes:
Questions:
- How do you
obtain the square
tracing?
- Is this an
expected tracing
for a square wave
test?
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- What is the
latest part of the
tracing indicative
of?
Notes:
The rest of the values obtained are as follow:
Notes:
Questions:
- Are you aware
of another way to
estimate the
cardiac output
based on these
values?
- How reliable is
this strategy
compared to PA
catheter CO
measurements?
- What is the
square wave test?
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- How do you
interpret the
results?
Notes:
References
Kamalakannan, D., Rosman, H.S., Eagle, K.A. Acute Aortic Dissection. Crit Care Clin. 23
(4), 779-800 (2007).
Tsaii, T.T., Nienaber, C.A., Eagle, K.A. Acute aortic syndromes. Circulation. 112, 3802
(2005).
O’Quin, R., Marini, J.J. Pulmonary artery catheterization: Interpretation of tracing. Am
Rev Respir Dis. 128 (2), 319 (1983).
Pinsky, M.R. Pulmonary artery occlusion pressure. Intensive Care Med. 29, 19 (2003).
RCPSC
OBJECTIVES
6.2.
Cardiovascular
Dysfunction
6.2.1. The ability
to recognize the
problem, provide
emergency life
support, and
embark upon a
diagnostic and
management
program.
6.2.2.
Demonstrate
knowledge of:
6.2.2.2. the
principles of
invasive and noninvasive
hemodynamic
monitoring
6.2.2.3. the
pathophysiology
and treatment of
cardiac failure,
including the
pharmacology of
drugs used to
treat these
entities
6.2.2.4. basic and
complex cardiac
arrhythmias,
including
pharmacological
and
electrical
management
6.2.2.5. shock
syndromes, with
emphasis on the
pathophysiologica
l events
leading to and
resulting from the
shock state
6.2.2.7. surgical
interventions in
patients with
cardiac disease,
including
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perioperative
management of
the cardiovascular
surgery patient
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