CICM SAQ 2013.2 Q1
Questions
A 76-year-old female is admitted to the ICU following elective aortic and mitral valve replacement. Transoesophageal echo assessment at the end of surgery showed an ejection fraction of 20%. Her preoperative creatinine was 340 micromol/L. Total bypass time was 240 minutes.
On arrival in ICU the patient has the following indices;
- Temperature 35C
- Atrial pacing (AAI) 80/min
- Systemic blood pressure 85/55 mmHg
- Pulmonary artery pressure 60/30 mm Hg
- Cardiac index 1.5 litres.min.m-2
- Systemic vascular resistance 1700 dyn.sec.cm–5
- Pulmonary artery wedge pressure 10 mmHg
- Central venous pressure 8 mmHg
- The patient is currently on adrenaline 4μg/min by infusion.
a) List the specific clinical and haemodynamic issues for this patient on admission to ICU.
b) Outline your management of these issues.
Answers
Answer and interpretation
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.
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CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
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