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Case #18: Sucking Wind


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You, the intrepid on call surgical PA, return from a relaxing weekend to your Monday morning call shift. You are called to see an ICU patient who had been operated on the previous Thursday.

 

61 yo M s/p CABGx4, who is lying in bed on BiPAP. Night RN tells you that he has been on 100% FiO2 for the whole weekend and maintaining sats in the high 80s to low 90s.

You ask him how he’s doing, and in his broken Russian-English he says “OK”. Has motions to have the BiPAP mask off to talk. You do so, and in the 1-2 minutes it takes you to answer his questions, he desaturates to 83% on RA.

 

The nurse wants to know the plan, as she is getting ready to report out to day shift.

 

These cases start from square one and are best for students, but all are invited to play along and nudge the case in the right direction!

 

 

What are your first questions and things you want to do?

 

Afebrile
SR 87
BP 138/70 (87)
Spo2 90% RR 23

 

 

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Medications?Dopamine 2 mcg/kg/min, MIVF @ 45. Zosyn day #2. ASA, amiodarone 40 q8, bumex 1 q12 IV, statin. Able to tolerate off bipap for PO meds.

What lines (aline, swann) and monitoring are on? Svo2? RIJ CVL and Aline. No swan (thus no svo2)

Hemodynamic trends we need to know?stable BPs overnight, was actually on phenylephrine overnight but was weaned. Solid pressures with weaning support. You actually try to stop the dopamine to see if it works.

Recent ABG? Get another 7.42 / 47 / 61 / 29

Recent CXR? Get another small bilateral pleural effusions L>R, adequate aeration, ? L base segmental collapse, mediastinal width WNL

CBC and changing trend daily CBCs:

WBC 12118

H/H 12/36 for 3 days

plats WNL

Heart and lung sounds

clear heart tones, no murmur

lungs poor/mod inspiratory effort, diminished L base

Pulses?

2+ throughout

Admit surgery is not my forte

doing good so far

 

 

 

Oh and how does he look? nice and pink or gray and ashy? BP looks good, but I'd still like to know

He has good color and is more talkative than you would expect with his level of oxygen support needs

 

-When you ask for labs think specifics as they relate to diagnoses, eg WBC or hct specifically. Rule in/rule out your ddx (which we don't have yet). General comment not pointed at you.

-

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Well a few of what I was thinking in no particular order with some very low suspicion:

Pulm HTN

PE

Fluid overload

Anemia

Hemorrhage with hypotension masked by vasopressors

Atelectasis/effusion/ards/ect

Heart failure

 

Wanted to see if we had a swann which would be nice to ensure proper CO

H/h

ABG to guide aggressiveness of treatment

 

 

Should have asked CVP, BUN/Cr, UOP

 

You noted adequate aeration, but perhaps and moderate effort. To further define his inspiration effort, what's his incentive spirometry? Performing proper pulm hygiene with cough/deep breathing/ect?

 

I was hoping something in the beginning would jump out at me, but finding a top diagnosis nebulous. I leaning toward a pulmonary problem.

 

Could probably use a nudge

 

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47

Well a few of what I was thinking in no particular order with some very low suspicion:
Pulm HTN
PE
Fluid overload
Anemia see the labs
Hemorrhage with hypotension masked by vasopressors see the labs
Atelectasis/effusion/ards/ect
Heart failure

 

OK- pick a list of dx studies and order based on your 1/2/3rd likelihood

Wanted to see if we had a swann which would be nice to ensure proper CO what else can give you this info besides a swan ganz
H/h see labs
ABG to guide aggressiveness of treatment ABG has been consistent for past 48 hrs...consistently bad


Should have asked CVP, BUN/Cr, UOP

12, 1.56/32 (1.03/15 preop), UOP -1.3L over past 24 hr (on bumex....which is what?)

You noted adequate aeration, but perhaps and moderate effort. To further define his inspiration effort, what's his incentive spirometry? Performing proper pulm hygiene with cough/deep breathing/ect?

 

IS weak 250-300.

encouraged coughing, minimal scant secretions

I was hoping something in the beginning would jump out at me, but finding a top diagnosis nebulous. I leaning toward a pulmonary problem.

well, yeah.....unless there's a significant NONpulmonary problem that could be causing his hypoxemia

Could probably use a nudge

 

 

S/P CABG I would definitely be doing another ECG. Cardiac enzymes.

ECG unremarkable except RBBB. TnI 5.1 but he just had CABG (POOR sensitivity post cardiotomy).

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I did notice the labs. Just retroactively giving you my differential since you noted that in the reply.

 

BUMEx is a potent loop diuretic.

 

Fick method can give you CO. I thought I had mentioned that, but on review I guess I lost it in editing.

 

Is the CVP cm h2o or mmHg? Difference between little high and high.

 

What's his pain level? Perhaps this is limiting his breathing?

 

1) PE - CT scan

2) overload vs failure - echo

3) poor effort 2/2 pain or maybe too much opioid? PFT? Pain score? Patient report? Schedule and PRN pain meds?

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didn't read whole thread but has anyone calculated the A-a gradient as a potentially helpful bit of info?

The A-a gradient will suck, for sure. 

At the bedside I use the P:F ratio which is used to grade the level of lung injury (ARDS scale), but it's just as good a measure of how well someone is oxygenating based on the alveolar O2 delivery.

 

Normal PaO2 is +/-100 and RA fio2 is 0.21, so normal P:F can be ~500 or more. 300, 200, and 100 have been the traditional cutoffs for mild ARDS (ALI, acute lung injury) and moderate and severe ARDS respectively.

 

An abnormal PF ratio is part of the dx criteria of ARDS, but having an abnormal PF does not mean you have ARDS.

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I did notice the labs. Just retroactively giving you my differential since you noted that in the reply.

 

BUMEx is a potent loop diuretic.

 

Fick method can give you CO. I thought I had mentioned that, but on review I guess I lost it in editing.

 

Is the CVP cm h2o or mmHg? Difference between little high and high.

 

What's his pain level? Perhaps this is limiting his breathing?

 

1) PE - CT scan

2) overload vs failure - echo

3) poor effort 2/2 pain or maybe too much opioid? PFT? Pain score? Patient report? Schedule and PRN pain meds?

CVP is mm Hg

Pain is moderate at best. he's not writhing but he has sternal pain which responds to opioids.

 

Why do you NOT want to order a CT?

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Plus (it's been a long time since I have been involved w/ a VQ scan) I'm not sure we can have him comply with the performance of a VQ study in his current state. Anyone out thesre who knows more (meaning: anything) about VQs please chime in

In the same boat and didn't know it would be low yield. D-dimer is definitely useless. Doppler for DVT and if negative assume no PE. Out of ideas.

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does the patient have chest tubes? what is there output? what is the patients I/Os? If the patient is s/p CABG then i would imagine that he is appropriately anticoagulated. Small pulmonary effusions on cxr can equal large pulmonary compromise. Dry the patient up, repeat cxr and sats. H&H?

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Sounds like a spiral CT would be a better choice for PE in this case. 

 

Contrast load is a bad idea with acute kidney injury

 

In the same boat and didn't know it would be low yield. D-dimer is definitely useless. Doppler for DVT and if negative assume no PE. Out of ideas.

 

As EMED suggested....duplex is poor for proximal pelvic vein thrombus. Plus, you are diagnosing a PE not a DVT.

does the patient have chest tubes? what is there output? what is the patients I/Os? If the patient is s/p CABG then i would imagine that he is appropriately anticoagulated. Small pulmonary effusions on cxr can equal large pulmonary compromise. Dry the patient up, repeat cxr and sats. H&H?

Tubes are putting out scant serosanguinous drainage at this point.

He has been aggressively diuresed over the past several days and has been 1-4 liters negative each day. Over diuresis, we presume, induced his prerenal state.

He is s/p CABG but not anticoagulated. But that is a good point. No reason to chase a PE study IF you were planning to anticoagulate him (warfarin). Routine CABG pathway is ASA only w/ SQ heparin VTE ppx.

 

At this point he is dry- perhaps pruning his kidneys.

 

Repeat CXR is the same.

Sats remain 80s-90s.

H/H stable from previous values.

 

The Nudge:

 

(reach back to your pathophysiology)

 

What are the main categories of hypoxemia?

Just like with shock you are trying to put the pt in a category. Instead of hypovolemia/distributive/obstructive etc we are trying to determine his class of hypoxemia.

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Contrast load is a bad idea with acute kidney injury

 

 

As EMED suggested....duplex is poor for proximal pelvic vein thrombus. Plus, you are diagnosing a PE not a DVT.

Tubes are putting out scant serosanguinous drainage at this point.

He has been aggressively diuresed over the past several days and has been 1-4 liters negative each day. Over diuresis, we presume, induced his prerenal state.

He is s/p CABG but not anticoagulated. But that is a good point. No reason to chase a PE study IF you were planning to anticoagulate him (warfarin). Routine CABG pathway is ASA only w/ SQ heparin VTE ppx.

 

At this point he is dry- perhaps pruning his kidneys.

 

Repeat CXR is the same.

Sats remain 80s-90s.

H/H stable from previous values.

 

The Nudge:

 

(reach back to your pathophysiology)

 

What are the main categories of hypoxemia?

Just like with shock you are trying to put the pt in a category. Instead of hypovolemia/distributive/obstructive etc we are trying to determine his class of hypoxemia.

So there are problems with diffusion (either lack of inspired or actually exchange problem at the membrane), extraction (like cyanide), delivery (like shock, HF), and carrying capacity (anemia)

 

I was initially thinking problems with exchange, but more recently thinking a a delivery problem. He didn't seem dry according to his CVP, so I was think more of a ineffective pump problem. We could try a 500cc bolus just to see if it's volume depletion and see if it decreases vasopressor need or a TTE I think would give me an answer. Or I'm way off base

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