Following off-bypass coronary artery bypass grafting a patient returns to the ICU. Soon after arrival he becomes bradycardic and profoundly hypotensive, unresponsive to a fluid challenge. What may cause this and what is the most appropriate course of action?
Potential causes of this scenario include:
- pericardial tamponade
- graft occlusion by clot/spasm/kinking/stitch
- complete heart block
- non-specific events: eg disconnection leading to severe hypoxia/bradycardia and myocardial ischaemia, pulmonary embolus
The most appropriate course of action is:
- bag the patient with 100%
- administer immediately available inotrope (aramine or adrenaline)
- commence ECM if pulseless
- obtain and use chest opening pack
- internal cardiac massage
- if the problem is not immediately amenable to therapy eg relief of tamponade, organise cardiopulmonary bypass to rest the heart and allow exploration of the grafts.
There is little to add to the college answer.
One would begin to manage such a patient in a similar algorithmic manner which is associated with any arrest situation. The major differences lie in the potential for open cardiac massage and return to cardiopulmonary bypass.
A systematic approach would resemble this:
Akinnusi, Morohunfolu E., Lilibeth A. Pineda, and Ali A. El Solh. "Effect of obesity on intensive care morbidity and mortality: A meta-analysis*." Critical care medicine 36.1 (2008): 151-158.
Marik, Paul, and Joseph Varon. "The obese patient in the ICU." CHEST Journal113.2 (1998): 492-498.
Ling, Pei-Ra. "Obesity Paradoxes—Further Research Is Needed!*." Critical care medicine 41.1 (2013): 368-369.