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Notes: Blockage, Leakage, Drainage CASE EIGHT Dr. Dominique Piquette Dr. Andre Amaral Notes: PART ONE Published by Articulate® Presenter www.articulate.com 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. Published by Articulate® Presenter www.articulate.com Notes: 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. Published by Articulate® Presenter www.articulate.com 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 Allow user to leave interaction: Show ‘Next Slide’ Button: Completion Button Label: Anytime Show upon completion Next Slide - 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?” Published by Articulate® Presenter www.articulate.com 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 Allow user to leave interaction: Show ‘Next Slide’ Button: Completion Button Label: Questions: - Was the insertion of the IABP indicated? - Which complications would you anticipate with prolonged use of the IABP? Anytime Show upon completion Next Slide - What are the risks associated with the insertion of drug-eluding stents? - Why were they inserted? Published by Articulate® Presenter www.articulate.com - 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 Published by Articulate® Presenter www.articulate.com 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.” Published by Articulate® Presenter www.articulate.com 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?” Published by Articulate® Presenter www.articulate.com 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? PROPERTIES Allow user to leave interaction: Show ‘Next Slide’ Button: Completion Button Label: - Which other complications may have explained Mr. Brown's acute deterioration? Anytime Show upon completion Next Slide - Which strategies other than the echo could have helped you to rule out those other complications? Published by Articulate® Presenter www.articulate.com 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. Published by Articulate® Presenter www.articulate.com 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 Published by Articulate® Presenter www.articulate.com Notes: 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? PROPERTIES Allow user to leave interaction: Show ‘Next Slide’ Button: Completion Button Label: Anytime Show upon completion Next Slide Published by Articulate® Presenter www.articulate.com 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. Published by Articulate® Presenter www.articulate.com 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 Allow user to leave interaction: Show ‘Next Slide’ Button: Completion Button Label: QUESTIONS: - How common is right ventricular dysfunction post-cardiac surgery? - What are the risk factors? Anytime Show upon completion Next Slide - 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? Published by Articulate® Presenter www.articulate.com 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 Published by Articulate® Presenter www.articulate.com