A 76-year-old female is admitted to the ICU following elective aortic and mitral valve replacement. Trans- oesophageal echo assessment at the end of surgery showed an ejection fraction of 20%. Her preoperative creatinine was 340 μmol/L. Total bypass time was 240 minutes.
On arrival in Intensive Care Unit the patient has the following indices:
- Temperature 35C
- Atrial pacing (AAI) 80/min
- Systemic blood pressure 85/55 mmHg
- Pulmonary artery pressure 60/30 mmHg
- Cardiac index 1.5 L/min/m2
- Systemic vascular resistance indexed (SVRI) 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. (30% marks)
- b) Outline your management of these issues. (70% marks)
Answer and interpretation
a) List the specific clinical and haemodynamic issues for this patient on admission to ICU. (30% marks)
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. (70% marks)
This patient is high risk (female, age, long bypass time, pre-existing renal impairment, low EF). Management consists of:
- Judicious fluid replacement as she re-warms.
- Improved volume state may augment CI but given poor EF unlikely to be sole intervention
- 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
- 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.
- Pass rate: 94%
- Highest mark: 9.5
Additional Examiners’ Comments:
- Some answers for the management plan were very superficial with generic statements with inadequate detail e.g. “consider changing pacemaker settings”, ”order bedside echo” and lacking a consultant level approach.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.