andersenpa Posted November 1, 2009 Share Posted November 1, 2009 For the students and newbies. You, the intrepid on call surgical PA, arrive for Sunday morning rounds. On the Friday night you recovered an 83 yo M s/p CABG. 4 grafts (LIMA-LAD, Veins to the obtuse marginal, diagonal, posterolateral arteries). He was quite labile the first night and you managed to stabilize him with pressors and resuscitation. You find him sunday morning, POD#2, on: Epinephrine @ 2 mcg/min Phenylephrine @ 90 mcg/min SBPs are 100-130 but any attempts to wean the drugs off immediately drop his pressure. His rhythm is paced with temporary pacer wires. He is awake on 100% nonrebreather with a sat of 95%. So we have a pressor dependent pt with a high oxygen requirement. What do you want to ask the RN? What other information do you want? Any immediate plans? Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 1, 2009 Moderator Share Posted November 1, 2009 newbies.... holly crap that is way above my head - glad I don't work in the unit or I would kill the guy... Link to comment Share on other sites More sharing options...
Contrarian Posted November 1, 2009 Share Posted November 1, 2009 Epinephrine @ 2 mcg/min Phenylephrine @ 90 mcg/min So we have a pressor dependent pt with a high oxygen requirement. What do you want to ask the RN? What other information do you want? Any immediate plans? ............:mad:............ ............:(........... ^ cata = ^ O2 need/demand = ^ angina =^graft issues = where are the BBs? Link to comment Share on other sites More sharing options...
andersenpa Posted November 1, 2009 Author Share Posted November 1, 2009 newbies.... holly crap that is way above my head - glad I don't work in the unit or I would kill the guy... It is so NOT above your head. You took basic cardiology in school (hence the title). Think about low blood pressure, the starling curve all that basic stuff. Whether it's surgery or medicine, we all have core portions of the patient evaluation..... Link to comment Share on other sites More sharing options...
TXPA23 Posted November 1, 2009 Share Posted November 1, 2009 sounds like he needs a transfusion. Link to comment Share on other sites More sharing options...
andersenpa Posted November 1, 2009 Author Share Posted November 1, 2009 sounds like he needs a transfusion. Based on what???????????? Link to comment Share on other sites More sharing options...
TXPA23 Posted November 1, 2009 Share Posted November 1, 2009 Based on what???????????? hypotensive high O2 requirement s/p CABG h/h? Link to comment Share on other sites More sharing options...
andersenpa Posted November 1, 2009 Author Share Posted November 1, 2009 hypotensivehigh O2 requirement s/p CABG h/h? The first three are, by themselves, not indicators for red cell transfusion. Hypotension is not necessarily hypovolemia. High o2 requirement- indirectly related but there are 4 main causes of hypoxemia to address first. CABG pts have been shown to do better at 5 yrs out when they do NOT get transfused. h/h----> 9/27. Link to comment Share on other sites More sharing options...
andersenpa Posted November 1, 2009 Author Share Posted November 1, 2009 ^ cata = ^ O2 need/demand = ^ angina =^graft issues = where are the BBs? "cata"? No BBs yet due to hemodynamic instability..... Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted November 1, 2009 Share Posted November 1, 2009 "cata"?No BBs yet due to hemodynamic instability..... Ok I’m playing in the big kids field now but I’m gonna give it a shot. Be kind I’m only a lowly paramedic playing wanta be PA. Questions; What’s his ejection fraction? Are we monitoring central venous pressures, if so what are they? Urine output? (Ins and outs) Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 Ok I’m playing in the big kids field now but I’m gonna give it a shot. Be kind I’m only a lowly paramedic playing wanta be PA. Questions; What’s his ejection fraction? Are we monitoring central venous pressures, if so what are they? Urine output? (Ins and outs) All good questions. Preop EF was 60% CVP is 12. Pt also has a swan ganz catheter; pulmonary artery pressures are 40/20. Urine output 700 over last 8 hrs. Link to comment Share on other sites More sharing options...
Contrarian Posted November 2, 2009 Share Posted November 2, 2009 "cata"? Catecholamines... The major catecholamines are dopamine, norepinephrine, and epinephrine (which used to be called adrenalin). Catecholamines increase the B/P by a few different mechanisms, and if abused/improperly administered severely hinders the adrenal-axis to the point of dependence upon exdogenous adrenal supplementation. ABs/BBs for their "anti-Adrenergic" effect to decrease O2 demand/vaso-constriction... This was where MY mind went... with the caveat that I haven't worked with straight up Cardiology/Cardiac Surgery patients since 2005...:) Link to comment Share on other sites More sharing options...
bradtPA Posted November 2, 2009 Share Posted November 2, 2009 All good questions. Preop EF was 60% CVP is 12. Pt also has a swan ganz catheter; pulmonary artery pressures are 40/20. Urine output 700 over last 8 hrs. In recap, what we have so far is an increased PAP/CVP. Urine output is good, at just under 90 ccs/hour, so the kidneys appear to be well perfused. I would have to put pulmonary hypertension high on my list, but also would like to know the cardiac output, which would be easy to determine with the swan ganz hooked up to the CO computer. Also, a portable AP chest would be useful here. Link to comment Share on other sites More sharing options...
jwells78 Posted November 2, 2009 Share Posted November 2, 2009 High o2 requirement- indirectly related but there are 4 main causes of hypoxemia to address first.I'm thinking: I. Hypoventilation: Do we have a room air sat? ABG? What's this guy's neuro status- is he breathing adequately? II. Physiologic shunt: Pulmonary edema, pneumonia, pneumo... Do we have a CXR? What are breath sounds like? Vitals- any fever? III. V/Q abnormality: PE; Cough? CP? D-dimer isn't useful in a guy this age and so soon after the CABG...? -How does he look? -What are his vital trends? -What are his CBC/CMP trends? I'm outta my league, but Critical Care interests me... I'm kind of reaching Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 In recap, what we have so far is an increased PAP/CVP. Urine output is good, at just under 90 ccs/hour, so the kidneys appear to be well perfused. I would have to put pulmonary hypertension high on my list, but also would like to know the cardiac output, which would be easy to determine with the swan ganz hooked up to the CO computer. Also, a portable AP chest would be useful here. Cardiac Index 2.4 CXR bilateral pulm congestion/small effusions, hilar prominence, RML atelectasis no PTX, mediastinal width WNL for postop and portable film Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 Catecholamines... The major catecholamines are dopamine, norepinephrine, and epinephrine (which used to be called adrenalin). Catecholamines increase the B/P by a few different mechanisms, and if abused/improperly administered severely hinders the adrenal-axis to the point of dependence upon exdogenous adrenal supplementation. ABs/BBs for their "anti-Adrenergic" effect to decrease O2 demand/vaso-constriction... This was where MY mind went... with the caveat that I haven't worked with straight up Cardiology/Cardiac Surgery patients since 2005...:) I read you. In the setting where you haven't ruled out LV failure, negative inotropes like BBs can be deletrious. Pure afterload reducing agents are a different story...... As a side question the students can name some of these drugs......:D Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 2, 2009 Moderator Share Posted November 2, 2009 All good questions. Urine output 700 over last 8 hrs. and he weighs what? if he is a big dude this is low....and he might still be dry...but I'm guessing you guys adequately fluid resuscitated him before starting 2 pressors(fill the pump before you wip it...) (side note: "urine output is the poor mans cvp reading...."...wish I came up with that but it's from the fccs course.....). in most settings outside the icu you won't have the advantage of a cvp reading but you can put in a foley anywhere...some ems systems even have medics put them in enroute and start recording Urine output in the prehospital environment. Andersen- anyone check a serum lactate level? and I assume an abg was done as mentioned above? Link to comment Share on other sites More sharing options...
EsperPA Posted November 2, 2009 Share Posted November 2, 2009 With PA and CVP pressures such as that he may be either overloaded or poor ventricular function. CI is slightly low (though my memory may be wrong) so I want to go with the pump. Consider dobutamine (though increase myocardial O2 demand) or primacor (risk of arrhythmias)? Nesitiride may also be useful if it is overload. I also think I would stop the epi due to it's broad receptor sites. Neo can stay for the time being. Side answer: nipride As others have stated, be gentle. Just a lowly RN here. Link to comment Share on other sites More sharing options...
Contrarian Posted November 2, 2009 Share Posted November 2, 2009 What is the Post-OP EF...??? Yes, negative inotropes like BBs can be deletrious... but last I practiced Cardiology (2005)... BBs WERE indicated in "stable" LV failure/Stable HF and proven to help the overall EF and decrease O2 demand. But I'll take your word for it ... that this is NOT the answer you were looking for...;) Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted November 2, 2009 Share Posted November 2, 2009 Ok going way out on a limb here. Here are my thoughts. R/O 1)It is possible that the pt has a blown chordae causing MVR leading to pulomnary disfunction and hypotension? 2)Pericardial effusion 3)Pericarditis I would say next we need and echo. Link to comment Share on other sites More sharing options...
EsperPA Posted November 2, 2009 Share Posted November 2, 2009 I think MVR is a very good diagnosis to R/O. I just hop on the CHF band wagon 'cuz thats what I know :D Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 I'm thinking: I. Hypoventilation: Do we have a room air sat? ABG? What's this guy's neuro status- is he breathing adequately? No room air sat, but why get one if he is satting low 90s on NRB...what is a RA sat going to tell you? Neuro intact no deficit. Good respiratory mechanics. II. Physiologic shunt: Pulmonary edema, pneumonia, pneumo... Do we have a CXR? What are breath sounds like? Vitals- any fever? CXR results in previous post. Clear anteriorly, diminished bases, no wheeze/rhonchi. Afebrile. III. V/Q abnormality: PE; Cough? CP? D-dimer isn't useful in a guy this age and so soon after the CABG...? No cough. PE workup not pursued (typically uncommon this early postop in CABG pts). -How does he look? Best question yet. He is unlabored but RR is around 20. He says he is comfortable with a little sternal pain. -What are his vital trends? Stable with drug support. -What are his CBC/CMP trends? Hct stable high 20s. Creat 0.7 and stable. Replacing K. I'm outta my league, but Critical Care interests me... I'm kind of reaching Not out of your league. Good questions. Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 and he weighs what? if he is a big dude this is low....and he might still be dry...but I'm guessing you guys adequately fluid resuscitated him before starting 2 pressors(fill the pump before you wip it...) (side note: "urine output is the poor mans cvp reading...."...wish I came up with that but it's from the fccs course.....). in most settings outside the icu you won't have the advantage of a cvp reading but you can put in a foley anywhere...some ems systems even have medics put them in enroute and start recording Urine output in the prehospital environment. Andersen- anyone check a serum lactate level? and I assume an abg was done as mentioned above? 83 kg. PAD is 20 so you could say full enough. "urine output is the poor mans cvp reading...."..........I like "The foley catheter is better than the PA catheter". If they pee, you're in good shape most of the time. ABG 7.44/37/76 Last lactate 1.5 Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 With PA and CVP pressures such as that he may be either overloaded or poor ventricular function. CI is slightly low (though my memory may be wrong) so I want to go with the pump. Consider dobutamine (though increase myocardial O2 demand) or primacor (risk of arrhythmias)? Nesitiride may also be useful if it is overload. I also think I would stop the epi due to it's broad receptor sites. Neo can stay for the time being. Side answer: nipride As others have stated, be gentle. Just a lowly RN here. CI 2.4 is good for postop Plus he has decent UOP Both dobut and milrinone inc arrhythmia risk....do we even know what the rhythm is? Epi- what's wrong with broad receptor activity? Neo- if you're worried about LV function phenylephrine is the wrong drug- it's pure afterload increase. Nipride- potent vasodilator- do we want that on someone who is pressor dependent? Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author Share Posted November 2, 2009 What is the Post-OP EF...??? Yes, negative inotropes like BBs can be deletrious... but last I practiced Cardiology (2005)... BBs WERE indicated in "stable" LV failure/Stable HF and proven to help the overall EF and decrease O2 demand. But I'll take your word for it ... that this is NOT the answer you were looking for...;) EF was 50% by TEE in the OR. You're spot on about BB in CHF- carvedilol is a standard agent. But right, not in unstable situations. Link to comment Share on other sites More sharing options...
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