Just came off a shift in the CTICU. I had a patient who was s/p CABG x 4. Still intubated. The patient was off of Precedex. ABG on 50% O2 was something like pH=7.37 PCO2 = 41 PO2 = 88. Chest tubes had output of 30 cc/hr. Didn't track urine output because the patient also had ESRD. Blood pressure was low so the patient was also on vasopressin 0.04U/min, Levophed 10 mcg/min, and epi 3mcg/min. The patient was also on milrinone 0.25 mcg/mg/min. I extubated the patient, but the senior resident told me he wouldn't do that and his decision seemed to be based on the Levophed. Why does this matter? I'm trying to read up on this and need help. Thanks
Levophed and extubation
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I think in a patient who cannot qualify as "hemodynamically stabile", it is not very wise. Especially with a P/F ratio like that. Not hemodynamically stabile and not oxygenating well = let him chill out a bit more.
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😵
Interesting week on the forum.
Interesting week on the forum.
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We are just a couple weeks past July. We were all there once, just not on a public forum....haha
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This patient is still needing a lot of support via inotropes. PPV actually helps unload the LV and may improve hemodynamics. If you remove it before it's time... it's almost like removing a pressor prematurely. People can have hemodynamic collapse after removal of PPV if they are not ready.
A number of mechanisms for the haemodynamic improvement observed with positive pressure mechanical ventilation and PEEP include reduced LV afterload due to decreased transmural (or transthoracic) pulmonary pressure;[33–37] reduced LV preload thereby unloading the congested heart;[38]decreased work of breathing and overall metabolic demand;[39,40] reversal of hypoxia-related pulmonary vasoconstriction; and improved oxygenation that may optimise oxygen supply to the stressed myocardium.
A number of mechanisms for the haemodynamic improvement observed with positive pressure mechanical ventilation and PEEP include reduced LV afterload due to decreased transmural (or transthoracic) pulmonary pressure;[33–37] reduced LV preload thereby unloading the congested heart;[38]decreased work of breathing and overall metabolic demand;[39,40] reversal of hypoxia-related pulmonary vasoconstriction; and improved oxygenation that may optimise oxygen supply to the stressed myocardium.
D
deleted171991
Arterial PO2 of 88 on 50% O2? Ouch. Alveolar PO2 = 0.5 (760-47) - 41/0.8 = 300 mm Hg. There is a huge A-a gradient there.
Even without the high amount of pressors needed, this patient should not have been extubated. Not before he got a good ABG on low O2/room air. I know extubation criteria are slowly going the way of PAC, but still I wouldn't extubate such a poorly oxygenating patient (and I would find and treat the cause).
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For those residents who don't like to do the math: FiO2 of 100% 02 should equal a PAO2 of about 500mmhg in healhty lungs. FiO2 of 50% should be half that... or 250mmhg. This is the redneck ( 
) way of doing it... FFP actually nailed the actual formula.
) way of doing it... FFP actually nailed the actual formula.
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So... a PAO2 of 100mmhg on FiO2 of 1.0 (100%) = ABnormal
I'm an intern in the unit a few weeks past July. No one can really trace who I am so I might as well learn from here and my reading so I don't make similar mistakes again.
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Yes! I'm all for using all resources at your disposal. More power to you.
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I love that a new intern in August is making the decision to extubate an ESRDer s/p a 4v CABG who is on 2 pressors 2 inotropes and oxygenating poorly. 
Supervisory culture may that institution may need a tweak.
Cognitus - as described above, extubation is like a cardiopulmonary stress test; it raises preload, raises afterload, increases the work of breathing (VO2 and VCO2), and lets you give oxygen less reliably. So if you're going to extubate someone, you have to know, or have a good suspicion, that they will tolerate it from all of those standpoints.
A patient with those comorbidities on 4 drips doesn't sound hemodynamically tuned up at all, and the oxygenation was marginal. Best plan would have been to let a few hours pass and see if/how oxygenation or hemodynamics improved. Your patient sounds vasoplegic, possibly volume overloaded, and with a big hit to inotropy/lusitropy and you'd expect.
Of course, to know if the hemodynamics improved, you have to have some more numbers. What was your pump and crossclamp time? Did the patient need those drips pre-pump or everything added to come off or after that? Did the patient have a Swan? Did you have PAP's, PCWP, CO/CI, SVR? One case where its usefulness in titrating drips and diagnosing the etiology of the need for those drips is obvious, IMO.
Supervisory culture may that institution may need a tweak.Cognitus - as described above, extubation is like a cardiopulmonary stress test; it raises preload, raises afterload, increases the work of breathing (VO2 and VCO2), and lets you give oxygen less reliably. So if you're going to extubate someone, you have to know, or have a good suspicion, that they will tolerate it from all of those standpoints.
A patient with those comorbidities on 4 drips doesn't sound hemodynamically tuned up at all, and the oxygenation was marginal. Best plan would have been to let a few hours pass and see if/how oxygenation or hemodynamics improved. Your patient sounds vasoplegic, possibly volume overloaded, and with a big hit to inotropy/lusitropy and you'd expect.
Of course, to know if the hemodynamics improved, you have to have some more numbers. What was your pump and crossclamp time? Did the patient need those drips pre-pump or everything added to come off or after that? Did the patient have a Swan? Did you have PAP's, PCWP, CO/CI, SVR? One case where its usefulness in titrating drips and diagnosing the etiology of the need for those drips is obvious, IMO.
PAP was about 30/15 PCP was 12-15 CO was 4.8 CI was 2.7. Does that help?I love that a new intern in August is making the decision to extubate an ESRDer s/p a 4v CABG who is on 2 pressors 2 inotropes and oxygenating poorly.
Cognitus - as described above, extubation is like a cardiopulmonary stress test; it raises preload, raises afterload, increases the work of breathing (VO2 and VCO2), and lets you give oxygen less reliably. So if you're going to extubate someone, you have to know, or have a good suspicion, that they will tolerate it from all of those standpoints.
A patient with those comorbidities on 4 drips doesn't sound hemodynamically tuned up at all, and the oxygenation was marginal. Best plan would have been to let a few hours pass and see if/how oxygenation or hemodynamics improved. Your patient sounds vasoplegic, possibly volume overloaded, and with a big hit to inotropy/lusitropy and you'd expect.
Of course, to know if the hemodynamics improved, you have to have some more numbers. What was your pump and crossclamp time? Did the patient need those drips pre-pump or everything added to come off or after that? Did the patient have a Swan? Did you have PAP's, PCWP, CO/CI, SVR? One case where its usefulness in titrating drips and diagnosing the etiology of the need for those drips is obvious, IMO.
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Regardless of high oxygen requirement, high vasoactive support, why would you ever make a big clinical decision like extubation without asking somebody senior first?
D
deleted171991
Because he's cognitus, MD, MBA, and he doesn't know yet how little he knows.
You're probably right about the supervision. Patient is fine BTW, but thanks to some reading and your input, I'll be more experienced and prudent next time.I love that a new intern in August is making the decision to extubate an ESRDer s/p a 4v CABG who is on 2 pressors 2 inotropes and oxygenating poorly.
Cognitus - as described above, extubation is like a cardiopulmonary stress test; it raises preload, raises afterload, increases the work of breathing (VO2 and VCO2), and lets you give oxygen less reliably. So if you're going to extubate someone, you have to know, or have a good suspicion, that they will tolerate it from all of those standpoints.
A patient with those comorbidities on 4 drips doesn't sound hemodynamically tuned up at all, and the oxygenation was marginal. Best plan would have been to let a few hours pass and see if/how oxygenation or hemodynamics improved. Your patient sounds vasoplegic, possibly volume overloaded, and with a big hit to inotropy/lusitropy and you'd expect.
Of course, to know if the hemodynamics improved, you have to have some more numbers. What was your pump and crossclamp time? Did the patient need those drips pre-pump or everything added to come off or after that? Did the patient have a Swan? Did you have PAP's, PCWP, CO/CI, SVR? One case where its usefulness in titrating drips and diagnosing the etiology of the need for those drips is obvious, IMO.
Don't get it twisted. I asked first. I told the attending everything I told you guys. I'm not sure I told him specifically about the levophed but he certainly knew everything else and he said it was ok to extubate. The reason I titled this thread LEVOPHED is because I'm wondering if he would have made the same decision if he knew about the levophed and the dosage. The Levophed was added shortly before my shift started and wasn't included in the order set in the computer, so I missed it when calling my attending about it. At the same time, I had read the ICU book on parameters for weaning off of intubation and it didn't have anything on pressor support in that list. I was really focusing on the blood gas numbers and the PA02/FI02>150. Also, RSBi was fine 65-70) with RR 25 or so. The patient wasn't in distress and head-lift was successful. I only got concerned when I spoke to the chief resident about it and he said he wouldn't do the same thing specifically mentioning the Levophed. That's what I've been torn up about.
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deleted171991
Before anything else, I want to point out, again, that (some) extubation criteria are slowly going the way of the PAC, because there isn't a strong correlation between those numbers and the consequences of extubating various patients. That's why experience matters so much.
However, if we are talking only about the ratio I emphasized above (by the way, it's Pa, not PA, which is the alveolar pressure), then anything under 300 should make you halt, because that's one of the criteria for ARDS (also including what was formerly known as ALI), i.e. bad gas exchange. Even in the presence of a cardiac cause, that's not a good sign.
Regarding the pressors: it doesn't really matter which, as long as they are high-dose. In your example, vaso was low-dose, epi was low dose (assuming 70+ kg patient), so indeed it was the levophed (or the cumulative effect of all three).
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I was in your shoes once... Started out intern year with the SICU/CTICU. The fact that you are asking questions you don't know the asnwers to is exactly what you should be doing. All the pieces will eventually fall together if you keep asking yourself "why". Nobody walked into intern year knowing it all. 🙂
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To demonstrate how crucial positive pressure ventilation is on cardiac work, I had a patient in the ICU post-op after a routine surgery with minimal blood loss and everything went fine. He had a troponin that was slightly elevated post op, like 0.10. He was on PS6 Peep6 Fi40 with an ABG of 7.38/38/110. His RR/VT was 20-30. He was following commands. By all reasoning, he met extubation criteria. I extubated him. In the next 30 minutes, he got more tachycardic, hypotensive, with increased work of breathing and eventually became hypoxic and stopped following commands so I promptly re-intubated him. After re-intubation, his HR and BP normalized. I checked his labs and his 8 hours post-op troponin which was drawn right before I extubated him came back at 3.0. He likely had a post-op NSTEMI and did not tolerate the increase cardiac work associated with extubation.
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All right, I think it's about time I stepped up and gave a direct answer.
Is levophed, in an of itself, a contraindication to extubation: short answer, no. I have extubated many a patient on levophed. Conversely, I have started levophed on patients who I never had to intubate. The 2 are not necessarily dependent on each other.
I think, as many members have said, the patient's overall clinical status precluded extubation in the first place. This guy was fresh out of major cardiac surgery, hemodynamically unstable on 3 pressors/2 inotropes, with a P/F ratio of 176 (remember, < 200 = moderate ARDS criteria, in terms of oxygenation). This isn't a guy on a sniff of levophed who was otherwise clinically stable. This is a guy who still had alot going on and needed more time for recovery. Hemodynamics aside, work of breathing increases oxygen consumption, an increase in which could have also set this guy over the edge.
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Yes-- thank you Triple AAA! Bottom line, the levophed wasn't the make or break here-- it was the whole picture. Perhaps this particular attending is a bit on the cowboy side and the levophed would have been the dealbreaker for them-- i.e. 2 pressors is ok, but 3 pressors isn't-- but the majority of intensivists would consider the picture you paint, levophed or not, grounds to continue mech. ventilation until the trajectory is clear.
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That is a pretty sick CABG pt. Have not seen a CABG here come out the OR with 2 ionotropes and 2 pressors and thats with 3 months of cardiac and a month in the CT ICU. How bad was his heart preop?
Don't you read? I did tell the attending
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I was wondering this myself. Did this guy have a pre-op MI with acute CHF?
The patient had at least two MIs requiring PCI but the last one was 4 years ago. What happened was that the patient had come in a month ago noticing a worse exercise tolerance. Echo was done a few days later that revealed a low EF (25-30%). Then a cath was done 2 weeks ago which revealed stenosis in multiple vessels including the ones where the patient received stents. That's what led to the CABG. So, the patient was stable pre-op, but the disease was getting worse.
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That is a great post bypass index and output with an essentially normal wedge....except that it's requiring two ionotropes plus PPV to maintain these numbers. Plus your SVR is garbage if your requiring vasopressin on top of the norepi to maintain map goal. Was he still on any nitro for LIMA spasm or had it been weaned off already? A post bypass LV that's still requiring two ionotropes and two vasopressors to perfuse the vital organs needs rest. Mechanical ventilation aids greatly in this as Sevo and FFP stated. Not only would I not extubate, I would argue that with the addition of vasopressin to Levo, and borderline low MAP he is a candidate for a balloon pump. Either way I am quite worried about the sub100 paO2 on 50% with AC and good index/outpt. the lungs are still sick. He is not hemodynamically stable enough for extubation, and is in fact moving in the other direction with the addition of a second vasopressor, not including the Epi.
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Inotropes, people. Not "ion"otropes.
Sounds vasoplegic to me, but something isn't adding up. This is the kind of patient it's impossible to make a real judgment on without being at the bedside.
Sounds vasoplegic to me, but something isn't adding up. This is the kind of patient it's impossible to make a real judgment on without being at the bedside.
The general consensus here is that the patient should not have been extubated, but my attending knew of the pressors, inotropes, CVP, and PAP. Patient was extubated that night and is actually doing well. Should be going home today actually. I guess the folks in here would exercise more caution, as I probably would next time. However, my attending was the CT surgeon that performed the CABG on the patient and was alright with the extubation. I guess he was more comfortable because he is experienced in these procedures and the patient is doing well. Go figure.
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There are a lot of surgeons who tell us that they're 'alright with the extubation', even they don't have the first clue on how to manage an airway properly. I suppose he would have also been 'alright' with us cleaning up any potential hemodynamic/airway disasters that could have resulted from a premature extubation. The reason we exercise caution is because we are brought up with the mentality of considering any and all possible disasters that could result from our actions. It is true that people become a bit more cavalier with experience, but I don't think most of us would have been that cavalier, and for good reason.
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Surgeons will say extubate whether the patient is ready or no. It's an ego thing. They think they are better surgeons if their patients get extubated early.
It's a recurring theme at my hospital.
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I don't think there is any reason to consider balloon pump on this patient. High pressor requirement is not a good reason in itself. This patient has had a shotgun approach to inotropes/pressors. Everything got started to see if it something worked. I have a gut feeling that the epi and milrinone were not needed. His pressure will most likely be better off the milrinone.
The A-a gradient is too large to extubate.
I'm not too concerned about the amount of drugs he is on if he has been stable on them.
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Per some of the earlier posts, RSBI was 65-70. Also, this guy had worsening exertional dyspnea with an EF 25-30%. I'm not sure what the baseline EF was, but clinically he seems to be in an acute CHF exacerbation secondary to ICM. A balloon pump would certainly be indicated here, and probably also an ICD.
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What the hemoglobin?
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notsureifserious.gif
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Don't understand what it is you are trying to address with the balloon pump. Index and filling pressure are fine, granted on a lot of drugs but still fine. Why do you want to over treat something that is fine risking an extremity along the way?
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Per OP description I don't get a sense of any acute CHF. My guess is patient was a same day admit coming from home.
I'm sure there are over 20 local cardiologists over there salivating at the prospect of putting an ICD, whether he needs it or not.
It was a same day admission. The patient was admitted straight for the cath lab where he stayed getting the pre-op workup before the CABG last week. The patient also had ESRD. Don't remember the h/h beforehand but I think the h/h was maybe 9.5/low 30's. Wasn't appreciably lower post-op although the patient did receive 6u PRBC during the procedure. I didn't scrub in though, but that's what I was told. BTW, what's ICM?
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Ischemic cardiomyopathy
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Worsening exertional dyspnea + low EF (possibly lower than baseline) to me suggests CHF exacerbation. But I suppose it may be sounding worse than it actually was.
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go trojans
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