Moments from call

[BLADEMDA]

An important cause of relative hypovolemia in the perioperative setting is intra-abdominal hypertension (IAH). IAH occurs when intra-abdominal pressure increases from a normal value of 5–7 mmHg to values in excess of 12 mmHg. IAH results from intra-abdominal fluid accumulation and can occur in the setting of edema or intra-abdominal hemorrhage. The elevated abdominal pressure compromises renal preload and afterload, predisposing to renal dysfunction. If intra-abdominal pressure exceeds 20–25 mmHg, frank abdominal compartment syndrome may result, with cardiopulmonary compromise and multi-organ dysfunction24.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447626/

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[BLADEMDA]

An article from China for all the Blade haters out there:

http://www.ncbi.nlm.nih.gov/pubmed/24325112

 

[confusingleaf]

I dont think it was the albumin or the change in pressors. Some people crump. Bad outcomes hurt. But they still may not have been prevented on even the most well managed unit with the most senior staff on 24/7. This lady was teetering ever since being uncooled. She couldnt get through the case. She died then instead of 2 week, 2 months from then... If your body is THAT sensitive that 750ml of albumin and a change from epi to norepi kills you, you are not going to make it.

i don't disagree that the albumin probably wasn't the straw that broke the camel's back. they did put a TTE on her (after this all began--too long after, IMHO) and her heart was basically doing nothing. and i do believe that if you put a failing heart against a pumped up SVR without the previous inotrope that had helped her, you're probably going to run into problems.

of note, they intubated with 300 fentanyl and 8 mg etomidate. i probably would have given a small dose of versed, paralytic, and tube. if you're going down the tubes that fast you don't win much anesthetic from me. i think the anesthetic probably hastened the code but i think it would have happened eventually anyways, the LV was apparently pretty shot.

thanks for all the support. it was kind of a sh%tty day, good reminder that just getitng them through the surgery doesn't mean they're out of the woods.

 

[confusingleaf]

I am posting a link to an excellent review article on Cardiogenic shock and its treatment. I enjoyed reading it.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495097/


In analogy to septic shock, the target mean arterial pressure should be titrated to 65–70 mmHg, as a higher blood pressure is not associated with beneficial outcome with the exception of previously hypertensive patients.

• 2-
  Norepinephrine should be used to restore perfusion pressure during cardiogenic shock (strong agreement).

The only randomized study comparing two types of vasopressors—norepinephrine and epinephrine—showed that, for the same hemodynamic efficacy, epinephrine was associated with a higher heart rate, more arrhythmia, and lactic acidosis [11]. In a cohort study, De Backer et al. reported a reduction in mortality with norepinephrine when compared with dopamine [12]. Lastly, norepinephrine-induced increase in blood pressure in patients with post-MI CS is associated with an increase in cardiac index without an increase in heart rate and with increased SvO2 and reduced blood lactate [13].

• 3-
  Epinephrine can be a therapeutic alternative to the combination of dobutamine and norepinephrine, but is associated with a greater risk of arrhythmia, tachycardia, and hyperlactatemia (weak agreement).

In terms of hemodynamic effect, epinephrine clearly increases cardiac output, essentially by a heart rate effect, but is associated with severe hyperlactatemia of metabolic origin that hampers interpretation of lactate as a marker of the adequacy of tissue perfusion [14].

• 4-
  Dobutamine should be used to treat low cardiac output in cardiogenic shock (strong agreement).

thanks for this. very helpful.

and i agree with the above poster--if she had come up on epi and milrinone, epi would be the first thing that i would put back on if the patient is tanking. do what has proven to work in the patient at hand!

 

[dhb]

of note, they intubated with 300 fentanyl and 8 mg etomidate.

Haha this made me laugh
Not that it would of made a big difference anyway.

 

[ranvier]

Haha this made me laugh
Not that it would of made a big difference anyway.

Probably not but it illustrates the nuance in our day to day practice compared to what happens with house staff in the icu.

 

[confusingleaf]

Probably not but it illustrates the nuance in our day to day practice compared to what happens with house staff in the icu.

the ironic thing (is ironic the right word) is that was the ICU fellow....who finished residency with me last june.