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 gmol/L. Total bypass time was 240 minutes. On arrival in ICU the patient has the following indices:
Temperature |
35°C |
Atrial pacing (AAI) |
80/min |
Systemic blood pressure |
85/55 mmHg |
Pulmonary artery pressure |
60/30 mm Hg |
Cardiac index |
1.5 litres.min.m 2 |
Systemic vascular resistance |
1700 dyn.sec.cm 5 |
Pulmonary artery wedge pressure |
10 mmHg |
Central venous pressure |
8 mmHg |
The patient is currently on adrenaline |
4 μg/min by infusion |
a) List the specific clinical and haemodynamic issues for this patient on admission to ICU. (40% marks)
b) Outline your management of these issues. (60% marks)
The main clinical and haemodynamic issues identified are:
This patient is high risk (female, age, long bypass time, pre-existing renal impairment, low EF). Management consists of:
This question is identical to Question 28 from the second paper of 2015, and nearly identical to Question 1 from the second paper of 2013 except this patient is not on adrenaline infusion 4μg/min. The discussion section from those questions is therefore reproduced below.
A generic approach to the haemodynamically unstable cardiac surgical patient is discussed elsewhere.
Weirdly, both this question and Question 28 from the second paper of 2015 had approximately the same pass rate (95% vs. 94%). However, in 2015 examiners felt the need to make disparaging comments about the candidates (eg. " answers for the management plan were very superficial with generic statements "). Clearly, we have learned from our mistakes this time around, and have made a series of profound and specific statements.
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