A 76-year-old female is admitted to the ICU following elective aortic and mitral valve replacement. Transoesophageal echo assessment at the end of surgery showed an ejection fraction of 20%. Her preoperative creatinine was 340 μmol/L. Total bypass time was 240 minutes. On arrival in ICU the patient has the following indices;
a) List the specific clinical and haemodynamic issues for this patient on admission to ICU.
b) Outline your management of these issues.
a) The main clinical and haemodynamic issues identified are:
Elderly female patient post double valve surgery.
Pre-existing renal impairment.
Long bypass time.
Systemic hypotension (MAP 65 unlikely to be adequate for this patient).
Low output state (CI, EF post bypass).
Increased afterload / vascular impedance (SVR).
Probable fluid responsiveness (PAWP, CVP).
Moderate pulmonary hypertension.
Low core temperature.
b) This patient is high risk (female, age, long bypass time, pre-existing renal impairment, low EF). Management consists of:
This patient they have given you is slightly unwell. I have reformulated the answer into a systematic approach to this problem. The answer below is question-specific (as they generally should be) - a generic approach to the haemodynamically unstable cardiac surgical patient is discussed elsewhere.
Frederick A. Hensley, Jr., M.D., Donald E. Martin, M.D., Glenn P. Gravlee, M.D. A Practical Approach to Cardiac Anaesthesia, 3rd ed. Sibylle A. Ruesch and Jerrold H. Levy. CHAPTER 9. The Postcardiopulmonary Bypass Period: A Systems Approach. 2003 by LIPPINCOTT WILLIAMS & WILKINS
André, Arthur C. St, and Anthony DelRossi. "Hemodynamic management of patients in the first 24 hours after cardiac surgery." Critical care medicine 33.9 (2005): 2082-2093.
Eagle, Kim A., et al. "ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery)." Circulation 110.14 (2004): e340.
Goepfert, Matthias SG, et al. "Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients." Intensive care medicine 33.1 (2007): 96-103.