CICM SAQ 2013.2 Q1

a) List the specific clinical and haemodynamic issues for this patient on admission to ICU.

The main clinical and haemodynamic issues identified are:

• Elderly female patient post double valve surgery.
• Pre-existing renal impairment.
• Long bypass time.
• Systemic hypotension (MAP 65 unlikely to be adequate for this patient).
• Low output state (CI, EF post bypass).
• Increased afterload / vascular impedance (SVR).
• Probable fluid responsiveness (PAWP, CVP).
• Moderate pulmonary hypertension.
• Low core temperature.

b) Outline your management of these issues.

This patient is high risk (female, age, long bypass time, pre-existing renal impairment, low EF).

Management consists of:

• Re-warming.
• Judicious fluid replacement as she re-warms.
• Improved volume state may augment CI but given poor EF unlikely to be sole intervention needed.
• Titration of adrenaline infusion, aiming for CI > 2.2
• Bedside echo to evaluate effect of fluid and increased adrenaline, exclude tamponade and check valve function (mitral regurgitation can increase PAP and decrease cardiac output).
• Consideration of other vasoactive agents (dobutamine, milrinone, levosimendan) or IABP insertion if persisting low output state.
• Assess adequacy of pacing and consider changing mode to A-V pacing (heart block common after AVR) and /or increasing rate to 90 bpm.
• Correct post-op coagulopathy and replace blood losses to maintain Hb > 80 G/L.
• Surgical review if significant blood loss via drains.
• Evaluation of any other cause of low output state e.g. tension pneumothorax, dynamic hyperinflation.
• Close monitoring of renal function and early institution of renal replacement therapy if oligo-anuric or rising creatinine.
• Consideration of inhaled nitric oxide to reduce pulmonary hypertension and RV afterload.