Routine pp heart

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pd4emergence

pd4emergence

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50 ish year old lady scheduled the day before for mv replacement, h/o dm, htn, rheumatic fever s/p avr x 2 (clotted her first one b/c she quit taking her coumadin), good ef, relatively normal coronaries, pa's in the 70 range at her cath the day before. CT surgeon placed a line preop the night before and started milrinone. As usual, I get there at the regular time start seeing the patients in my other rooms (our hearts get seen preop and usually go straight to the room) and get a page from the crna in the heart room "this looks bad real bad". I go back to the heart room and sure enough he was correct. I find my patient sitting upright, in obvious resp distress, sats are in the mid 80's, the crna has managed to get an Aline in and they have just hooked her neck line to the transducers. I see a red Aline tracing of 150-160s syst and a pa cath tracing of about the same. I will go ahead and say that everything was hooked up correctly, and the transducers were at the level of the pts heart and were probably rezeroed at least twice.
 
Surgeon cannulates the groin vessels preinduction. Induce. IF she tolerates, great. WHEN she doesn't, go on pump.
 
pd4emergence said:
50 ish year old lady scheduled the day before for mv replacement, h/o dm, htn, rheumatic fever s/p avr x 2 (clotted her first one b/c she quit taking her coumadin), good ef, relatively normal coronaries, pa's in the 70 range at her cath the day before. CT surgeon placed a line preop the night before and started milrinone. As usual, I get there at the regular time start seeing the patients in my other rooms (our hearts get seen preop and usually go straight to the room) and get a page from the crna in the heart room "this looks bad real bad". I go back to the heart room and sure enough he was correct. I find my patient sitting upright, in obvious resp distress, sats are in the mid 80's, the crna has managed to get an Aline in and they have just hooked her neck line to the transducers. I see a red Aline tracing of 150-160s syst and a pa cath tracing of about the same. I will go ahead and say that everything was hooked up correctly, and the transducers were at the level of the pts heart and were probably rezeroed at least twice.
Click to expand...

Did they put the pa in the carotid?
 
urge said:
Did they put the pa in the carotid?
Click to expand...

This was one of my first thoughts, I called the ct guy and he said her pa's were 60 to 70 on the same pa the night before, and had improved some with the milrinone. The story from the unit was that her pa's had progressively increased over the previous 3 hours or so. He came on into the room to take a look. Pt could not tolerate laying flat at all, at this point her sats were hanging around 90, but she would get extremely anxious with anything less than about 40 degree head up. She was also starting to get pretty combative.
 
Don't Heparinize.
Get a chest xray look for hematoma/trachea midline and r/o pneumo. Consider Angio.
With PA's tracing in the 160's with an exact wave form as your a-line you're likely in the carotid. What are the PA and A-line diastolics?
I've seen some pretty similar tracings on some patients with correct line placements.
In the mean time, get an ABG and VBG at the same time. Then compare the numbers.
It it's a carotid puncture, consider continuing with the sternotomy and call a vascular surgeon to weigh in on the scenario.

If your CRNA did get a pneumo, there is likely lung paranchymal damage (from the cordis/Mac cather dilator ) and you are going to get a lot of frothy stuff coming out your ETT.

Depending on your findings and how tuned up you can get your patient you may proceed or cancel and come back.
 
urge said:
It doesn't explain the respiratory distress, though.
Click to expand...
Rapid and impressively expanding neck hematoma and tracheal shift. (seen it - thank God I wasn't the one that did it)
 
pd4emergence said:
This was one of my first thoughts, I called the ct guy and he said her pa's were 60 to 70 on the same pa the night before, and had improved some with the milrinone. The story from the unit was that her pa's had progressively increased over the previous 3 hours or so. He came on into the room to take a look. Pt could not tolerate laying flat at all, at this point her sats were hanging around 90, but she would get extremely anxious with anything less than about 40 degree head up. She was also starting to get pretty combative.
Click to expand...

What is the cvp? That should tell if it's systemic or pulmonary.

Can you do a transthoracic echo?

Did the MR/MS get acutely worse?
Did she clot her aortic valve again?
PE? Legs look ok?

This lady needs a tube, but she is going to code the moment you tube her. I would not rush into that yet.

I'm surprised the icu let this woman go to the or.

I vote for PE.
 
Either way, sounds like this lady is going to need to be intubated very soon for respiratory distress. If it is in the carotid you will be able to figure that out soon via transducer waveform and or ABG or TEE probe. If it is in the carotid you have at least part of the answer. Impending RV failure if not in carotid. Assuming you do not anticipate difficult airway, Go to sleep with your favorite anti-death induction, hyperventilate, with 100% O2, paralyze. Milrinone, Levophed, Epi, and CT surgeon very close by.
 
dr doze said:
Either way, sounds like this lady is going to need to be intubated very soon for respiratory distress. If it is in the carotid you will be able to figure that out soon via transducer waveform and or ABG or TEE probe. If it is in the carotid you have at least part of the answer. Impending RV failure if not in carotid. Assuming you do not anticipate difficult airway, Go to sleep with your favorite anti-death induction, hyperventilate, with 100% O2, paralyze. Milrinone, Levophed, Epi, and CT surgeon very close by.
Click to expand...

:laugh::laugh::laugh:

I like that phrase.... 👍
 
urge said:
What is the cvp? That should tell if it's systemic or pulmonary.

Can you do a transthoracic echo?

Did the MR/MS get acutely worse?
Did she clot her aortic valve again?
PE? Legs look ok?

This lady needs a tube, but she is going to code the moment you tube her. I would not rush into that yet.

I'm surprised the icu let this woman go to the or.

I vote for PE.
Click to expand...


I don't understand why you would not rush to tube her? She's getting progressively combattive due to her hypoxia and could kill herself. Unfortunately you're in a catch 20/20 situation. Her PVR is going sky high (acidosis, hypoxia, anxiety, hypercarbia) and this can't be good for her crappy valve! Or I should say her valve is not helping to relieve anything!

How about 100% FiO2, Etomidate/Fentanyl/Versed, Milrinone, hyperventilate, Nitric? Get ready to code prn.
 
This wasn't a left sided line was it? In years past I've seen some people thread the PA catheter to 70cm cuz it was a "left sided" line and needed to travel further... You'll get a PA wave form on your CVP if it is threaded that far.

Low on the differential but, have the abx already been given?
 
pd4emergence said:
This was one of my first thoughts, I called the ct guy and he said her pa's were 60 to 70 on the same pa the night before, and had improved some with the milrinone. The story from the unit was that her pa's had progressively increased over the previous 3 hours or so.
Click to expand...

This has me wondering....

Was there a second cordis/cvp placed or are you going off of the line the surgeon placed?

Carotid + pneumo/paranchymal damage
Acute/worsening valve fxn (anxiety/tachycardia in a MS patient, chordae rupture, etc)
LV/RV failure, MI
PE
COPD exacerbation
Allergic
 
If she's crumping...tube her and drop a TEE and see what the RV, AV and MV look like.

Fun case so far.
 
For those questioning line placement, it sounds like this was a pac placed by someone who knew what try were doing, which had been giving believable pa numbers before. I see no reason to suspect it's somewhere like the carotid all of a sudden.

My money is on acute PE. Regardless, assuming you have a tte probe on your machine, do a quick surface echo and see what the right heart is doing, and look at the PA to see if there's a big booger you can see.
 
urge said:
What is the cvp? That should tell if it's systemic or pulmonary.

Can you do a transthoracic echo?

Did the MR/MS get acutely worse?
Did she clot her aortic valve again?
PE? Legs look ok?

This lady needs a tube, but she is going to code the moment you tube her. I would not rush into that yet.

I'm surprised the icu let this woman go to the or.

I vote for PE.
Click to expand...

Rookie question, but why would you avoid the tube right now? I know her stats came up from the 80's to the 90's but she is becoming combative and isn't tolerating change in position.
 
BF2BC EMT said:
Rookie question, but why would you avoid the tube right now? I know her stats came up from the 80's to the 90's but she is becoming combative and isn't tolerating change in position.
Click to expand...

Once burned twice shy...

With her valvular pathology, poor status, possibility of pe..... I don't think she will survive a code without going on bypass. Being a redo, sternotomy will be tough. I would put two large arterial and venous lines in the groin that can be wired for cannulas (likr Hawaian suggested)if she codes before tubing her.

I would put a nonrebreather and call cardiology for a tte while the lines are done. Hopefully they come.
 
urge said:
Once burned twice shy...

With her valvular pathology, poor status, possibility of pe..... I don't think she will survive a code without going on bypass. Being a redo, sternotomy will be tough. I would put two large arterial and venous lines in the groin that can be wired for cannulas (likr Hawaian suggested)if she codes before tubing her.

I would put a nonrebreather and call cardiology for a tte while the lines are done. Hopefully they come.
Click to expand...

So what if Cards comes and says "Her RV is in failure" and the RV looks like floppy dilated mess? What would you do?

I like the pre-surgical cannulation idea

As mentioned earlier, her mortality chance is approaching 100%
 
sevoflurane said:
This has me wondering....

Was there a second cordis/cvp placed or are you going off of the line the surgeon placed?

Carotid + pneumo/paranchymal damage
Acute/worsening valve fxn (anxiety/tachycardia in a MS patient, chordae rupture, etc)
LV/RV failure, MI
PE
COPD exacerbation
Allergic
Click to expand...


The surgeon placed this one. As somebody mentioned earlier, I looked at the cvp and it was in the 20's. This plus the fact that they were getting reasonable number per the surgeon the night before, I was sure that it was a venous catheter.
 
Hawaiian Bruin said:
Surgeon cannulates the groin vessels preinduction. Induce. IF she tolerates, great. WHEN she doesn't, go on pump.
Click to expand...


This is a great thought. I had the cv guy in the room and we did not talk about this option. I did not think of it but may have if this lady was not so uncooperative. Honestly it was all we could just to keep her on the table.
 
If the aline is in, just send a gas from the CVP and from the aline. This would confirm your diagnosis of carotid placement. Also, the waveform of a PA tracing is different in the downslopeing of the waveform versus arterial difficult to explain but I know it when I see it.
 
After discussion with the ct guy, he felt like it was one of her valves, either she clotted her mechanical av or may she had clot that closed what little area she had left of her mv. we did talk about the possibility of pe but this was not as likely due to the fact that she was therapeutic on her coumadin when she came in, had been on a heparin gtt since admit and responding appropriately from a ptt standpoint. I agreed that it was probably not a pe b/c her systemic pressures were fine or elevated. I have not seen an acute pe that that caused this significant pa pressures that was not followed pretty quickly by cv collapse. Her resp distress was not an upper airway thing, her neck looked fine and the line was placed easily with one stick via ultrasound. While we were deciding what to do We were steadily working to get het sats up. I had my crna assist her with the mask and her sats did come up. I also maxed her milrinone out and started some nitro trying to get her pa's down to something compatible with life. I also gave about 100mcgs of fentanyl to help with her anxiety. She did eventually lay back against an almost upright bed and her pa's came down from the 150's to the low 100's. What would you have done next?
 
If she looked out of immediate distress and looked like she would not need intubation for respiatory failure, cardiology for transthoracic echo. I also think that sleeping her and doing a TEE would be reasonable.
 
Flolan? Hyperventilation (although she might be doing that on her own already given the anxiety)?
 
pd4emergence said:
She did eventually lay back against an almost upright bed and her pa's came down from the 150's to the low 100's. What would you have done next?
Click to expand...

Whoa....! How long did they stay up there?

😱

I woulda taken a deep breath and reached for the toilet paper....!

I then woudl get those PA's further under control.... 100 systolic is still supah high + diagnosis (echo, angio, etc.)
 
Honestly, how long can she sustain herself with PA pressures like that? You said before her pressures had been creeping higher and higher for 3 hours? How is her RV not completely shot?

Recently had a pt who clotted off their St Judes mitral, the surgeon showed how one leaflet was completely shut and had a massive clot behind it. They acutely decompensated, LV was already bad and then the RV went, got a bivad placed and the RV was able to recover.
 
I should also say that the cv guy tells me at this point that her mv valve area is .6 and her gradient was more than 30 on a very recent echo.
 
pd4emergence said:
After discussion with the ct guy, he felt like it was one of her valves, either she clotted her mechanical av or may she had clot that closed what little area she had left of her mv. we did talk about the possibility of pe but this was not as likely due to the fact that she was therapeutic on her coumadin when she came in, had been on a heparin gtt since admit and responding appropriately from a ptt standpoint. I agreed that it was probably not a pe b/c her systemic pressures were fine or elevated. I have not seen an acute pe that that caused this significant pa pressures that was not followed pretty quickly by cv collapse. Her resp distress was not an upper airway thing, her neck looked fine and the line was placed easily with one stick via ultrasound. While we were deciding what to do We were steadily working to get het sats up. I had my crna assist her with the mask and her sats did come up. I also maxed her milrinone out and started some nitro trying to get her pa's down to something compatible with life. I also gave about 100mcgs of fentanyl to help with her anxiety. She did eventually lay back against an almost upright bed and her pa's came down from the 150's to the low 100's. What would you have done next?
Click to expand...

pent sux tube?

I would at least get some nitric in the room.
 
pd4emergence said:
The surgeon placed this one. As somebody mentioned earlier, I looked at the cvp and it was in the 20's. This plus the fact that they were getting reasonable number per the surgeon the night before, I was sure that it was a venous catheter.
Click to expand...

That's a surprisingly low cvp for a PA pressure of over 100.
 
If she can clot a valve she can throw a PE as well, so I'd think both are still on the table. Probably hard to cannulate groins if she's sitting. Can we make her MS a little better? Is her HR 150?
 
So this is what I ended up doing. After doing what we could to get her sats up ie assisted ventilation, and optimization of pa pressures using milrinone, and nitro, she still needed to be intubated. Pa's were down to around 100, sats were upper 90's, bp was around 140 to 150 and stable, hr's after fentanyl were around 90. At this point I felt like she was as good as she was going to get. We decided to induce, put a tee in and see what was there. I gave her 6 of etomidate, another 50mcg of fentanyl, 50mg of roc, and 4 units of vasopressin, tube went in fine, her pressure dropped into the 90's for a few seconds but when the vaso hit they went back to close to baseline. Tee showed the expected severely stenotic mv, a normally functioning av, an rv that was close to as thick as the lv. Both rv and lv function looked good. Volume status looked ok as far as I could tell. During this she held her own pretty well, but I eventually started some epi and a vasopressin infusion. After some discussion we decided to proceed. We made it to bypass without a lot of difficulty, bp's stayed in the low 100's, and her pa's hung around in the 80's. We made it to bypass, he fixed her valve, coming off it was a little touch and go but not as bad as I expected. Took her to the icu, she extubated after about a day and a half, stayed in the unit another 2 days where she was put on bipap at night, she spent 8 days total post op in the hospital and was d/ced home.
 
pd4emergence said:
So this is what I ended up doing. After doing what we could to get her sats up ie assisted ventilation, and optimization of pa pressures using milrinone, and nitro, she still needed to be intubated. Pa's were down to around 100, sats were upper 90's, bp was around 140 to 150 and stable, hr's after fentanyl were around 90. At this point I felt like she was as good as she was going to get. We decided to induce, put a tee in and see what was there. I gave her 6 of etomidate, another 50mcg of fentanyl, 50mg of roc, and 4 units of vasopressin, tube went in fine, her pressure dropped into the 90's for a few seconds but when the vaso hit they went back to close to baseline. Tee showed the expected severely stenotic mv, a normally functioning av, an rv that was close to as thick as the lv. Both rv and lv function looked good. Volume status looked ok as far as I could tell. During this she held her own pretty well, but I eventually started some epi and a vasopressin infusion. After some discussion we decided to proceed. We made it to bypass without a lot of difficulty, bp's stayed in the low 100's, and her pa's hung around in the 80's. We made it to bypass, he fixed her valve, coming off it was a little touch and go but not as bad as I expected. Took her to the icu, she extubated after about a day and a half, stayed in the unit another 2 days where she was put on bipap at night, she spent 8 days total post op in the hospital and was d/ced home.
Click to expand...

That is prett F-ing impressive. Good work on everyone's part. 👍
 
Why did her PA's get to the mid 150's systolic from a baseline of 60-70's?
That is super unusual even with critical MV disease.
She's lived with her diseased valve for this long... what caused her to tip the other way over the course of 3-4 hours?
I see PA's in the 60-70's all the time (today they were 65-75ish going onto bypass) and I can honestly say that I have never seen a PA pressure's that measured in the mid 150's. Suprising the RV looked that good. Not suprising her RV looks like her LV with those numbers and her MS. If she was 80 y/o she woulda been toast. 50 is young for 2 AVR's and MV's.
Over 100 is like once every year or two for me.

My spider sense is telling me that something doesn't fit.

Solid case to have seen those numbers and made it out in one piece. 👍
 
sevoflurane said:
Why did her PA's get to the mid 150's systolic from a baseline of 60-70's?
That is super unusual even with critical MV disease.
She's lived with her diseased valve for this long... what caused her to tip the other way over the course of 3-4 hours?
I see PA's in the 60-70's all the time (today they were 65-75ish going onto bypass) and I can honestly say that I have never seen a PA pressure's that measured in the mid 150's. Suprising the RV looked that good. Not suprising her RV looks like her LV with those numbers and her MS. If she was 80 y/o she woulda been toast. 50 is young for 2 AVR's and MV's.
Over 100 is like once every year or two for me.

My spider sense is telling me that something doesn't fit.

Solid case to have seen those numbers and made it out in one piece. 👍
Click to expand...



Here is what i think happened. She had her cath the afternoon before, she apparently was a pretty anxious lady and got a fair amount of demerol and versed, gets back to the unit, gets some more versed for her pa cath placement later that night. At some point she got an ambien and some phenergan because she was nauseated. She also has a history of osa. They told me in the unit her sats dropped into the low 90s and stayed there for a while then her pas started going up. When she left the unit they were 110 or so and she was starting to decompensate. I think she got over sedated, hypercarbic/hypoxic and it pushed her over the edge.
 
Critical MV area of .6 cm2 + exacerbation of pulmonary hypertension + anxious and tachycardic COPD patient is a deadly combination.

I can't think of many other comorbidity combo's that I fear more. I think I'm more fearful of pulm. htn. with critical MS than pulm htn. with critical AS.

Strong work man.
 
sevoflurane said:
Critical MV area of .6 cm2 + exacerbation of pulmonary hypertension + anxious and tachycardic COPD patient is a deadly combination.

I can't think of many other comorbidity combo's that I fear more. I think I'm more fearful of pulm. htn. with critical MS than pulm htn. with critical AS.

Strong work man.
Click to expand...

the answer
 
Oggg said:
Thx for the great case.

Do you remember her PA pressures coming off bypass?
Click to expand...

They were 80's to 90's. I think the thing that saved her was she had a good pump and no real coronary disease, with either a bad pump or coronary disease I don't think she would have made it.
 
Narcotized said:
With a CVP appearing tracing, and then PA pressures that equaled systemic pressures, did you ever consider you went through a patent foramen and actually were measuring left sided pressures?
Click to expand...

The surgeon put the line in the night before. It was giving reliable readings when it was put in. The fact that we had the pa cath preop probably also saved her, i doubt we could have gotten it in that morning.
 
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