5e

supahfresh said:

Did my first ASA 5 yesterday on call. Unidentified middle-aged woman found down in the snow is brought in by life flight directly to our OR for rewarming under bypass. She has a core temp of 27.9 C, BP of 40s over 20s, is in V-fib and there is a heart transplant going in the next room. The other CA-1 and I did the case. What a b itch.

Any particular reason why we were made to wait to shock her until she was warmer? Is bypass the standard of care for someone in hypothermic arrest?

A few hours into the case, we noticed bruises all over her body. I think somebody beat the crap out of her. I heard that sometimes cold patients can have bruises that appear on rewarming and then dissappear rapidly. An thoughts? Do hypothermic patients have coagulation defects that could explain this?

We converted her to a-fib, and eventually to sinus. We used no narcotics and no gas. By the end of the case she was moving a little. I dropped her off at the CT ICU still intubated.

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Core temperatures that low produce a very irritable myocardium refractory to intervention. You can shock away, but it wont do any good 'til she's warm.

Bypass accomplishes two things:

1)Perfusion: Nobody is dead 'til they're warm and dead...so in the ER, CPR is perpetuated until the temp is acceptable enough that pharmacologic/electrical intervention can be tried.
If you've got the luxury of a heart surgeon and a team, bypass (obviously) provides perfusion far superior to CPR.
2)Fast, effective way to rewarm.

The coagulopathy question is a good one, Supa. I dont know the answer to that one..i.e. whether or not you'd see bruising secondary to severe hypothermia.

Better ask Mil that one.

jetproppilot said:

Core temperatures that low produce a very irritable myocardium refractory to intervention. You can shock away, but it wont do any good 'til she's warm.

Bypass accomplishes two things:

1)Perfusion: Nobody is dead 'til they're warm and dead...so in the ER, CPR is perpetuated until the temp is acceptable enough that pharmacologic/electrical intervention can be tried.
If you've got the luxury of a heart surgeon and a team, bypass (obviously) provides perfusion far superior to CPR.
2)Fast, effective way to rewarm.

The coagulopathy question is a good one, Supa. I dont know the answer to that one..i.e. whether or not you'd see bruising secondary to severe hypothermia.

Better ask Mil that one.

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Hypothermia causes severe coagulation defects and cardioverting a patient whose core temp is less than 31 degrees celsius is frequently useless as they will likely revert to v fib.

UTSouthwestern said:

Hypothermia causes severe coagulation defects and cardioverting a patient whose core temp is less than 31 degrees celsius is frequently useless as they will likely revert to v fib.

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UT brings up another useful pearl for the heart room...

Don't fudge on the patient's temperature when coming off bypass...sometimes you're ready to come off as far as every other parameter is concerned (you're ventilating, NSR/paced rhythm, SBP>90, RV looks good visually, acceptable HCT, etc etc) but its taking a while for the perfusionist to rewarm and the temp is 35.0.

Wait til the temp is near normal...if an unexpected supraventricular tachydysrhythmia arises that requires cardioversion and you're still a little cold and you've decided to come off bypass anyway, now you're in a quandry, cuz you risk v-fib with the shock..granted, not as big a risk as if the temp was real low, but a risk nonetheless.

I wait for 36.5 or greater.

Usually the perfusionist has it timed perfectly, but if they dont, wait the ten (or whatever) minutes. Its easy to get in a rush on a busy day. Dont rush when it comes to bypass separation and temperature.

supahfresh said:

Jet,

For this particular patient, they used a pulsatile flow during bypass. Why do they use a linear instead of pulsatile flow in heart cases?

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Another good question...

I'm unaware of any advantage (shown by replicated well controlled studies) of pulsatile flow over linear...as you recall there are two types of blood pumps used in bypass machines...each machine has either a roller pump or a centrifugal pump. There are advantages and disadvantages of each type, but only the roller pump is capable of pulsatile flow.

As far as I know, both types are common, so it seems there hasnt been an industry preference for pulsatile flow, although I remember it being a hot topic at some point in the past.

Mil/UT/Noy et al please chime in on this one.

Pulsatile at least in theory makes more sense but I am not aware of any studies showing better outcome.

With regards to the coagulopathy. I think you guys are touching on this but not actually mentioning the fact that hypothermia causes a DIC type of coagulopathy. You will see oozing from IV sites and a controversal treatment for DIC is heparin. I have never seen it given for this myself. I am curious, did you guys heparinize the pt b/4 going on bypass? Did you do a DIC panel? Did you give products?

I am impressed however, that she is awake and apparently doing fine. Did you have to support her BP aggressively throughout the resuscitation and if so what means did you use?

Great case.

Very cool case....I have nothing to add....wait I do.


DIC is a symptom of something else going on...so you're supposed to treat the underlying condition ...sepsis, hypothermia, retained products of conception, AFE, etc....

Trials have been done looking at ATIII in sepsis and DIC....no improvements in outcome....I'm pretty sure heparin has not been studied.

but the prevailing attitude with DIC is that if they manifest with thrombosis you give heparin...if you manifest with bleeding, then you give factors.

militarymd said:

Very cool case....I have nothing to add....wait I do.


DIC is a symptom of something else going on...so you're supposed to treat the underlying condition ...sepsis, hypothermia, retained products of conception, AFE, etc....

Trials have been done looking at ATIII in sepsis and DIC....no improvements in outcome....I'm pretty sure heparin has not been studied.

but the prevailing attitude with DIC is that if they manifest with thrombosis you give heparin...if you manifest with bleeding, then you give factors.

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Hey dudes & dudettes,
quick question for Supa did you happen to get a platelet count and ACT at the time you noticed the bruises? I've read somewhere that severe hypothermia can course massive platelet sequestration by the spleen which is easily reversible with rewarming......i think this is what we are talking about here and not frank DIC. Anyways just my 2 cents.

PS: this is an awesome board and much love for all the teaching especially from UT, JJP, Milmd, Noy, and Zippy. BTW where is Zippy?

supahfresh said:

No pharmacological support of her BP initially, just chest compressions. Later on I was giving intermittent boluses of phenylephrine. Noyac, do you think I should have done epi/atropine in the beginning?

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How can I critisize(?) when the turnout was as good as this one. I was just curious as to the amount of support needed. I would have thouhgt that you would have needed some big guns for the initial resuscitation.

Noyac said:

How can I critisize(?) when the turnout was as good as this one. I was just curious as to the amount of support needed. I would have thouhgt that you would have needed some big guns for the initial resuscitation.

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I concur...good outcome...

Supa, you da man of the hour, bro. Nice job. That lady's kids need to send you a bonus.

Now that I have more time I will tell of my experience with hypothermia. I was an intern on my ICU rotation when a woman was found in the desert apparently dead. She was a mexican crossing the boarder for greener pastures and apparently got left behind. We flew her into the Univ. and began to resuscitate her. We warmed her with IV fluids and bair huggers and whatever we could do except bypass (wish we would have tried it). She was in V. Fib, below 32 degs, and bleeding from every IV site like she was in DIC. I gave her factors, plts, and PRBC's ( total waste of resources) along with bags and bags of warm IVF's. Epi or NE running pretty much the whole time. My attending said to me "keep it up till she's warm and then pronounce her." I don't remember how long it took but it seems like it was all night. Well, my story doesn't have the happy ending like yours supa, unfortunately. I think the bypass was the key factor in your outcome which I'm sure you already know.