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Blockage, Leakage, Drainage
CASE EIGHT
Dr. Dominique Piquette
Dr. Andre Amaral
Notes:
PART ONE
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Notes:
You are covering the cardiovascular ICU today.
You are admitting a new patient who came from
the cath lab after a percutaneous coronary
intervention (PCI) and who had an intra-aortic
balloon pump inserted. You gather the following
information from the chart:
Notes:
Cardiology
66 y.o.
PMHx :
HTN
Dyslipidemia
DM type 2 x 5y  CRF creat=130 (?)
Rx x admission : ASA / plavix / eptifibatide and heparin IV /
carvedilol / digoxine / lipitor / ramipril (on hold) /
metformin & glycophage (on hold)
All:
Penicillin (rash)
Ex-smoker : d/c 5y ago – No EtOH
Hx :
Patient admitted to referring hospital 24hrs ago with CP
x 36hrs, ECG changes, and positive trops. Persistent CP
despite optimal Rx therapy, and rising trops. Transferred
to SHSC for angio.
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Angio Results
Main Left  40%
Prox LAD 99%  Culprit?  PCI + Drug-eluting stents x 2
 flow TIMI 3 post procedure
Cx 80%
RCA 70% diffuse
No ventric. done.
Progressive SOB and recurrent low BP during PCI requiring IV
pressors + ETI by anesthesia.
IABP inserted post-procedure – no complication
Transfer to ICU
Notes:
CVICU
N:
Pt arousable, but inconsistently obeying.
No sign of lateralization.
CV: Augmented MAP 62 on dopamine 15 levo 5
HR 110 (a.fib)
No murmur.
Resp: PS 14 FiO2 60% Peep 5
Chest : bilat crackles
X-ray : bilat infiltrates + pl effusions x 2 – IABP position OK
ABG : 7.32/32/75/19
GI : Abdo soft
GU: U.O. 50cc during angio
Blwk pending
HI: T 35.4
You also take a look at the IABP waveform.
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Notes:
Questions:
- Is the timing of the
balloon inflation
appropriate?
- Is the timing of the
balloon deflation
appropriate?
- What are the
advantages of increased
diastolic pressure during
balloon inflation?
PROPERTIES
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- What difference do you
expect between the
systolic pressures of the
assisted beat and unassisted beat?
Notes:
“Can you please call the perfusionist
to readjust the IABP? It doesn’t
inflate at the right time. I would also
go up on the levo to keep an
augmented MAP above 65, and wean
down the dopamine if you can. We
need an echocardiogram. I am going
to call them.”
“Are you planning to
extubate him soon? If
not, can I have an
order for some
sedation?”
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Notes:
“Well, he’s still on 60%. It might
be a better idea to switch him
to assisted-controlled
ventilation anyway, and let’s
increase his PEEP when our BP
gets better. Oh, and can you
send a central venous blood
gas?”
“I am going to need another
central line. Everything is
running through a femoral that
they put in the cath lab.”
Notes:
Objectives:
-To understand the
indications, rationale, and
complications of cardiac
percutaneous
interventions.
-To discuss the
indications,
contraindications,
mechanisms of action,
proper adjustment, and
complications of IABP.
-To discuss heart-lung
interactions in
mechanically-ventilated
patients.
PROPERTIES
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Questions:
- Was the insertion of the
IABP indicated?
- Which complications
would you anticipate with
prolonged use of the
IABP?
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- What are the risks
associated with the
insertion of drug-eluding
stents?
- Why were they inserted?
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- Why could switching to
an assisted controlled
mode of ventilation be
helpful for this patient?
- Would you do anything
else to improve the
patient's oxygenation at
this point?
Notes:
PART TWO
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Notes:
Three days later, you are on call in the cardiovascular ICU.
You’re happy to see that Mr. Brown has significantly
improved since his admission. His vasopressors were
weaned off 36 hours after his PCI. The IABP was removed
early this morning, and the patient was extubated in the
afternoon.
His cardiac echo completed 48 hours ago showed a
moderate to severe LV dysfunction (grade 3) with a
normal RV and a mild mitral regurgitation. The patient
has been stable all day, and you have been told at the
beginning of your call that he’s waiting to be transferred
to Coronary Care Unit when a bed is available.
Around 4:00 AM, you get a phone call.
Notes:
“You need to come and
reassess Mr. Brown right
away. He doesn’t look
good at all.”
“What’s the problem?”
“He suddenly got worse over the last
20 minutes. His sat started to drop and
now he’s in huge respiratory distress.
He really doesn’t look good. And his BP
is also dropping in the 80’s…”
“Do a chest x-ray and an ECG, call the
RT, and get some levophed
(norepinephrine) ready. We might
have to intubate or at least to put him
on BiPAP. I am on my way.”
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Notes:
When you get to the bedside, the patient is in
florid respiratory distress. The saturation is 85%
on a non-rebreather, RR is 40, BP is 80/50, and
HR is 120 (still in atrial fibrillation).
On auscultation, the patient presents bilateral
coarse crackles. You can’t hear any heart sounds
with all the respiratory noises. He’s still opening
his eyes to voice, but looks mottled. The ECG
doesn’t show any change compared to the one
done in the morning.
“There is something terribly wrong here. Ok,
forget about the BiPAP, this is not going to work.
We’re going to intubate, and get me the
cardiology resident stat to do a cardiac echo.
Have you started the levo?”
“I am already at 15mcg/min, and the
BP doesn’t pick up at all. Which
medications do you want for the
intubation?”
“Probably only a lot of local
lidocaine, but let’s have some
fentanyl and etomidate handy if
we need it. Can you also prepare
some epinephrine? I think we’ll
need a drip.”
“And you know that the patient doesn’t
have a central line anymore, right?”
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Notes:
You intubate the patient with minimal sedation.
The cardiology resident arrives at the bedside to
perform a stat echo.
Notes:
“Was he known for a severe
mitral regurgitation? Because
that’s really not subtle now…”
“No, that’s new. Can we get the
cardiac surgeon stat please? And call
anesthesia also to let them know that
Mr. Brown will likely need to go to the
OR. Can we also check with the blood
bank to make sure we have some
blood ready? And let’s tolerate a
systolic BP of 85ish. I don’t think we
should use the levo at all, so start
some epi if we need something.”
Notes:
Objectives:
-To recognize and
manage acute postmyocardial infarct
complications.
-To understand the
challenges related to ETI
in the context of impeding
cardiac arrest.
Questions:
- What are the potential
causes for the new MR?
- How does this finding
change your
management?
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- Which other
complications may have
explained Mr. Brown's
acute deterioration?
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- Which strategies other
than the echo could have
helped you to rule out
those other
complications?
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Notes:
PART THREE
Notes:
Twenty-four hours later, you are back in the
cardiovascular unit. The patient had a surgical
repair of his mitral valve and 3 CABGs done.
Despite multiple attempts, it was impossible to
reinsert an IABP.
Mr. Brown came back from his surgery on 3
pressors and with high O2 requirements. The
post-op transesophageal echo showed only a
mild residual MR, LV function grade 3, and a new
moderate RV dysfunction.
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Notes:
Within the first six hours following his surgery,
his chest tubes drained 1.2 liters of hemorrhagic
fluid, so he was transfused 3 units of RBC, 4 units
of FFP, and 2 pools of platelets. He also received
5g of tranexamic acid, but the patient didn’t go
back to the OR.
As part of your daily assessment, you review the flow sheet to
try to understand the course of the events overnight.
Time
21h
3h
6h
BP
95/60
88/55
92/58
HR
110
120
118
16
48/28
22
2.3
14
48/25
26
2.1
12
43/21
26
2.0
CVP
PAP
PACWP
CI
INFUSIONS
Epi (mcg/min)
Milrinone
(mcg/kg/min)
Vaso (U/h)
5
5
↑7
7
0.5
2
0.5
2
↑ 0.75
2
0.75
2
U/O (cc/hr)
15
10
10
7.28
43
35
17
62
7.28
42
32
17
58
7.27
44
30
16
52
MVBG
pH
PCO2
PaO2
HCO3
SatO2
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Notes:
“So, what do you
want me to do with
the pressors now?”
“The hemodynamic values
don’t make any sense. Can
I see the wedge waveform
on the monitor please?
And was a chest x-ray done
this morning?”
“Yes, he had a
CXR. And here is
your tracing.”
Notes:
Questions:
- How would you describe
the variations of the
wedge during the
respiratory cycle?
- Is that the type of
pressure variation that
you would expect when
you inflate the balloon?
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Notes:
“So where did you take your wedge
again? Maybe the patient needs a
fluid change. But maybe we should
repeat an echo before. Let me talk
to my staff.”
“And what about the
amiodarone infusion? He’s been
on it for more than 24 hours
now, but he’s still having tons of
PVCs?”
“Let’s talk about this on
rounds. Maybe we should ask
the Electrophysiology Service
for a consultation . You can
give him another 2g IV of
magnesium for now. It won’t
do any harm.”
Three weeks later, Mr. Brown is waiting for a bed on
the ward. After his cardiac surgery, he required a
few days of inotropic and vasopressor support
before his hemodynamic finally improved. His ICU
stay was further complicated by a severe delirium,
an acute kidney injury, and a ventilator-associated
pneumonia. He failed his first extubation, but now
appears stable 3 days after the second attempt.
A repeated echocardiagram 2 weeks after his
surgery showed a grade 3 left ventricular
dysfunction, a mildly depressed right ventricular
function, and a functional mitral valve. The
Cardiology Team will make to final adjustments to
his now impressive list of medications.
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Notes:
Notes:
Objectives:
-To recognize and
manage post-cardiac
surgery bleeding
complications.
-To discuss the differential
diagnosis, investigations,
and management of
shock post-cardiac
surgery.
-To interpret appropriately
the tracings of pulmonary
artery catheter.
PROPERTIES
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QUESTIONS:
- How common is right
ventricular dysfunction
post-cardiac surgery?
- What are the risk
factors?
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- What are the potential
causes of post-cardiac
surgery bleed?
- Which strategies are
available to the intensivist
to minimize these
bleeding complications?
- How do you explain his
low cardiac output?
- How would you manage
the patient at this point?
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Notes:
References
Santa-Cruz, R.A., Mauricio G. Cohen, M.G., Ohman, E.M. Aortic counterpulsation: A
review of the hemodynamic effects and indications for use. Catheter Cardio Inte. 67 (1),
68-77 (2006).
Wilansky, S., Moreno, C.A., Lester, S.J. Complications of myocardial infarction. Crit
Care Med. 35 (8), 309-433 (2007).
St. André, A.C., DelRossi, A. Hemodynamic management of patients in the first 24 hours
after cardiac surgery. Crit Care Med. 33 (9), 2082-2093 (2005).
RCPSC OBJECTIVES
6.2.
CardiovascularDysfunctio
n
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 non-invasive
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
6.2.2.5. management
shock syndromes, with
emphasis on the
pathophysiological events
leading to and resulting
from the shock state
6.2.2.6. heart-lung
interactions
6.2.2.7. surgical
interventions in patients
with cardiac disease,
including perioperative
management of the
cardiovascular surgery
patient
6.2.2.8. acute valvular
heart disease
6.2.2.9. acute coronary
syndromes
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