A 64-year-old female patient has been ventilated in your ICU for 36 hours with septic shock and is receiving significant doses of noradrenaline and vasopressin. On the morning review you note her troponin level is elevated to over 10 times the normal range for your institution.
a) How do you interpret the raised troponin level in this setting? (40% marks)
b) Outline your assessment and management plan specific to the raised troponin level.
Interpretation of raised troponin- should not be used in isolation in this patient. The measured value of troponin is high and should not be ignored or dismissed. If unexpected, repeat the test. Symptoms of chest pain are not easy to elicit in the ventilated patient. Troponin leak in this setting may be due to myocarditis associated with sepsis, acute cardiomyopathy, Takotsubo disease given high dose vasopressor or a STEMI or NSTEMI or right ventricular disease. Elevated troponin in renal failure should also be considered if relevant. Elevated troponins are associated with poor outcomes in septic patients.
Management plan- Comprehensive clinical assessment especially cardiovascular and haemodynamic assessment. Look for recent, rapid increase in vasopressor requirement, signs of cardiogenic shock. Review ECG for any evidence of STEMI or other new changes, Review CXR for new pulmonary oedema/heart failure. Echo- transthoracic or if available TOE is mandatory to look for any regional wall motion abnormalities that may be new. Evidence of global changes on echocardiography may indicate acute cardiomyopathy e.g. Myocarditis. Look for classic changes of Takatsubo’s.
Further management will be determined by ECG and echo findings. Cardiology review, anticoagulation, careful consideration of thrombolysis or angioplasty if STEMI or regional changes on echo with consideration given to haemodynamic instability and challenges of transfer and management in cardiac catheter lab. Role of IABP in global hypokinesis related to acute cardiomyopathies.
Troponin increases in septic patients is thought to be associated with poor prognosis
This question is identical to Question 6 from the first paper of 2017, and so is this answer:
What could this raised troponin mean?
Assessment and management plan:
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