andersenpa Posted November 2, 2009 Author 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? How would you dx that? 2)Pericardial effusion How would you dx that? 3)Pericarditis How would you dx that? Does that cause instability? I would say next we need and echo. What's a bedside technique for all this before you drag the echo tech in on a sunday? Link to comment Share on other sites More sharing options...
andersenpa Posted November 2, 2009 Author 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 What do you look for on exam etc to dx CHF? Link to comment Share on other sites More sharing options...
jwells78 Posted November 3, 2009 Share Posted November 3, 2009 EKG; look for concave upward ST elevation (pericarditis)... only because I'm sitting here at work and the PA next to me is much smarter than me... :p Link to comment Share on other sites More sharing options...
Annika Posted November 3, 2009 Share Posted November 3, 2009 He has a swan? can he wedge? He's comfy- you asked about Q's for the RN, right? I'd ask about weights, I think- even if there is 700 out, depends on what else he has going on- and what has gone in. (since our guy coming back from Cath Lab last night put out 700 when he reached us- no foley, poor guy! Don't even ask why, b/c I am sure this guy would have appreciated it, once it was in, that is) I'd also look at trends. And, if he's 83... what about AD's? I am playing in a field I have no business in, really, but love reading these....sorry if I crashed the party.... Link to comment Share on other sites More sharing options...
EsperPA Posted November 3, 2009 Share Posted November 3, 2009 I don't deal with post op cabg too much, so I get the hint I suck. :( I know neo increases afterload, but if pressure drops and I'm wrong then I want it there. I'm just not a fan of epi because of it's broad effects, prefer to be specific in most cases. Wasn't suggesting nipride, but you were asking about afterload reducing drugs. I can say these things: What is the rhythm? What does the heart sound like? Any murmurs, rub, muffled, extra clicks? How do lungs sound? Any edema? JVD? Does his sats come up if we sit him up? Did you say how the heart looked on the CXR? What's his BNP? Still say start a positive inotrope. Link to comment Share on other sites More sharing options...
bradtPA Posted November 3, 2009 Share Posted November 3, 2009 Again, to recap: we have pulmonary congestion after major surgery. I expect there was a vigorous fluid rescuscitation in the OR. Good hourly output postop, but we haven't asked you for I&Os at this point. Knowing that will help. Is there pitting edema? I haven't done ICU care since Landstuhl in 1998, but this still looks like a preload issue to me, and could use a dab of lasix to start things on the right tract.... Link to comment Share on other sites More sharing options...
andersenpa Posted November 3, 2009 Author Share Posted November 3, 2009 He has a swan? can he wedge? He's comfy- you asked about Q's for the RN, right? I'd ask about weights, I think- even if there is 700 out, depends on what else he has going on- and what has gone in. (since our guy coming back from Cath Lab last night put out 700 when he reached us- no foley, poor guy! Don't even ask why, b/c I am sure this guy would have appreciated it, once it was in, that is) I'd also look at trends. And, if he's 83... what about AD's? I am playing in a field I have no business in, really, but love reading these....sorry if I crashed the party.... No wedge done. PAD is 20. His weight is up 8 kg from baseline.400 cc positive over 24 hrs. ADs????:confused: Link to comment Share on other sites More sharing options...
andersenpa Posted November 3, 2009 Author Share Posted November 3, 2009 I don't deal with post op cabg too much, so I get the hint I suck. :( I know neo increases afterload, but if pressure drops and I'm wrong then I want it there. I'm just not a fan of epi because of it's broad effects, prefer to be specific in most cases. Wasn't suggesting nipride, but you were asking about afterload reducing drugs. I can say these things: What is the rhythm? Now you're cooking. He has a temporary (external) pacer running at 80. Now would be a good time to ask questions about the pacer. What does the heart sound like? Any murmurs, rub, muffled, extra clicks? Reg/paced, strong s1, unreliable s2. How do lungs sound? Clear/equal, diminshed bases. Any edema? 1+ tibial. JVD? Minimal. Does his sats come up if we sit him up? You sit him up and he goes up by 1%. Did you say how the heart looked on the CXR? Normal postop mediastinum, always a bit enlarged on portable CXR. No sug change in last few days. What's his BNP? Not checked. Still say start a positive inotrope. You start dobutamine and his rate stays the same and pressure drops by 15 mm hg. You stop it. Link to comment Share on other sites More sharing options...
South Side Stev Posted November 3, 2009 Share Posted November 3, 2009 With an CI of 2.4 he doesn't need an inotrope. PAP of 40/20 and RA of 12 are slightly elevated (though not atypical for a post op heart). is he A/V paced or just V paced? What is his underlying rhythm? -if he doesnt have A wires, then he might benefit from atrial kick if his native rhythm is sinus and fast enough (though we know its < 80bpm). 8kg weight gain equates to roughly ~8L fluid retained. Whats his SVR on the Epi and Phenylephrine? Whats his cough effort? Is he mobilizing secretions? Any sig pulm hx? Epi is only @ .02 ug/kg/min which is a rather small dose, pt would probably tolerate a very slow wean (.005 ug/kg/min q2-3 hrs as SBP allows). I'm not that worked up over this. Since hes POD2 I'd suggest gentle diuresis and aggressive pulm toilet +/- Mucomyst if secretions are tenacious. He has a pretty steep A-a gradient going on. I would try to come off Phenylephrine (I think its garbage for hearts - I prefer levo) and wean the Epi slowly for SBP >110. Also, ensure adequate pain control to ensure pt complies w/ pulm toilet (cough/deep breathe & incentive spirometry). Link to comment Share on other sites More sharing options...
andersenpa Posted November 3, 2009 Author Share Posted November 3, 2009 With an CI of 2.4 he doesn't need an inotrope. PAP of 40/20 and RA of 12 are slightly elevated (though not atypical for a post op heart). My thoughts as well. is he A/V paced or just V paced? What is his underlying rhythm? -if he doesnt have A wires, then he might benefit from atrial kick if his native rhythm is sinus and fast enough (though we know its < 80bpm). Good...he is being V paced. I paused the pacemaker and his underlying rhythm is actually atrial fibirllation with a ventricular response of 65. With this rhythm, his BP immediately increases by 25 points and I start weaning pressors. 8kg weight gain equates to roughly ~8L fluid retained. Whats his SVR on the Epi and Phenylephrine? About 700. Whats his cough effort? Is he mobilizing secretions? Any sig pulm hx? Decent cough but sternal pain with it......adequate secretion clearance, no pulm hx. Epi is only @ .02 ug/kg/min which is a rather small dose, pt would probably tolerate a very slow wean (.005 ug/kg/min q2-3 hrs as SBP allows). I'm not that worked up over this. Right. Since hes POD2 I'd suggest gentle diuresis and aggressive pulm toilet +/- Mucomyst if secretions are tenacious. He has a pretty steep A-a gradient going on. I would try to come off Phenylephrine (I think its garbage for hearts - I prefer levo) and wean the Epi slowly for SBP >110. Also, ensure adequate pain control to ensure pt complies w/ pulm toilet (cough/deep breathe & incentive spirometry). I use Neo is there is good LV function, it's a pure SVR issue, and there is no renal insufficiency. It's tolerated pretty well at lower doses (<60-80 mcg) IMO. I've seen other places that use norepi as the first line for more porent alpha effects. I gave a lasix challenge while weaning the pressor, which worked. So what's the CV lesson here? Link to comment Share on other sites More sharing options...
South Side Stev Posted November 3, 2009 Share Posted November 3, 2009 So what's the CV lesson here? Atrial kick accounts for roughly 1/4 of C.O. ~25% of pts s/p cabg/valve Sx go into Afib. :confused: And always check your underlying rhythm when you are pacing someone. It amazes me that quite a few nurses are scared to pause a pacemaker(they think it wont recapture). I want to know whats underneath the pacer, be it asystole or junctional, for reasons such as the above. Link to comment Share on other sites More sharing options...
South Side Stev Posted November 3, 2009 Share Posted November 3, 2009 also why no A wires in an 83yo? Not that it would have helped you in this case, other than rapid atrial pacing him out of the Afib. A surgeon I work with will anywhere from 0 - 4 wires in, depending on Sx, age, and comorbidities. I just hate getting a valve and not having A and V wires. Link to comment Share on other sites More sharing options...
andersenpa Posted November 3, 2009 Author Share Posted November 3, 2009 Atrial kick accounts for roughly 1/4 of C.O. ~25% of pts s/p cabg/valve Sx go into Afib. His blood pressure went UP when changing from V pacing to A fib. How did we add to CO? also why no A wires in an 83yo? Not that it would have helped you in this case, other than rapid atrial pacing him out of the Afib. You can't rapid A pace out of afib. You CAN rapid pace out of a flutter (large macroreentrant circuit). Re wires, surgeon preference. It's not uncommon to have V wires only for "rescue" reasons. Cases with higher incidence of AV node issues (aortic valves, septal procedures) should always have A and V wires. A surgeon I work with will anywhere from 0 - 4 wires in, depending on Sx, age, and comorbidities. I just hate getting a valve and not having A and V wires. Agree........... Link to comment Share on other sites More sharing options...
Moonwalk Posted November 3, 2009 Share Posted November 3, 2009 Good...he is being V paced. I paused the pacemaker and his underlying rhythm is actually atrial fibirllation with a ventricular response of 65. With this rhythm, his BP immediately increases by 25 points and I start weaning pressors. I am not sure I am following your logic here. What was his ventricular rate when pacing? There's no atrial kick with atrial fibrillation, whether the ventricular is conducting naturally or whether the ventricle is being paced. What caused his BP to increase by 25 points? I can understand an increase if he converted to normal sinus rhythm, but you did not indicate this had happened. Link to comment Share on other sites More sharing options...
andersenpa Posted November 4, 2009 Author Share Posted November 4, 2009 Good...he is being V paced. I paused the pacemaker and his underlying rhythm is actually atrial fibirllation with a ventricular response of 65. With this rhythm, his BP immediately increases by 25 points and I start weaning pressors. I am not sure I am following your logic here. What was his ventricular rate when pacing? There's no atrial kick with atrial fibrillation, whether the ventricular is conducting naturally or whether the ventricle is being paced. What caused his BP to increase by 25 points? I can understand an increase if he converted to normal sinus rhythm, but you did not indicate this had happened. He didn't convert. He was being paced at a V rate of 80 (with 100% capture so his actual V response was 80), and his BP improved with a slower rate. Link to comment Share on other sites More sharing options...
bradtPA Posted November 4, 2009 Share Posted November 4, 2009 Thanks for yet another super case. You sure do have a cool job compared to my daily fights to control hypertension, diabetes, and hyperlipidemia:). Link to comment Share on other sites More sharing options...
andersenpa Posted November 4, 2009 Author Share Posted November 4, 2009 Thoughts on why the BP improved? Link to comment Share on other sites More sharing options...
EsperPA Posted November 4, 2009 Share Posted November 4, 2009 Frank Starling law, like you mentioned earlier. No atrial kick, heart rate was to fast to let ventricle fill. Slowing it down allowed it more time to fill, greater stroke volume. Link to comment Share on other sites More sharing options...
Guest hubbardtim48 Posted January 10, 2012 Share Posted January 10, 2012 100% NRB is NOT 100%. First, how can something be 100% O2 if there is air-entrainment (i.e. not a tight seal and open valves). Secondly, I did a research program with the NRB and Oxy-Mask that was published in the AARC Times journal. The NRB gave approximately 60% FIO2 @ 15 l/min and the Oxy-Mask gave approximately 45% FIO2 @ 8-10 l/min using a modified version of the alveolar air equation. Just think of the first point when talking about oxygen devices, it is common knowledge that room air is diluting the 100% oxygen coming from the flow meter so please spread the word to everyone! Also, correct people if the say "what is patients X stats" (meaning SATS! Saturation!) Link to comment Share on other sites More sharing options...
dpc511 Posted January 13, 2012 Share Posted January 13, 2012 With no atrial kick, the left ventricle relies solely on passive filling. Slowing the rate increased preload for this patient. Link to comment Share on other sites More sharing options...
dpc511 Posted January 13, 2012 Share Posted January 13, 2012 Just noticed the thread was from 2009. Oops. Link to comment Share on other sites More sharing options...
JERRY Posted June 11, 2013 Share Posted June 11, 2013 Bringing this interesting case back from the dead. Since he improved simply by stopping the V pacing its possible that the restoration of AV synchrony played a major role. with V pacing the vector is right to left rather than top to bottom. atrial kick would still be gone even though the pacing was stopped. when I first read the case I also considers sepsis as a cause . Since when I'm usually stumped its usually a stinkin early infection Link to comment Share on other sites More sharing options...
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