Viva 4

A 58 year-old male, Mark, has been admitted to the ICU post semi-elective three-vessel coronary artery bypass graft, 10 days after an anterior ST-elevation myocardial infarction. The procedure was uncomplicated, however he became more hypotensive towards the end of the procedure and had an intra-aortic balloon pump (IABP) inserted to assist with separation from cardiac bypass. The surgeon has confidence with the patency of the grafts.

Mark is now 1 hr post-op in the ICU, fully ventilated and sedated, with an IABP in situ, and you have been asked to review his increasing noradrenaline requirement.

His clinical status is:

  • Heart Rate 110 beats/min sinus rhythm
  • Synchronised Intermittent Mandatory Ventilation (SIMV) 550ml x 16,
  • PEEP 8 cmH2O, FiO2 0.5, SpO2 98%
  • Blood Pressure 95/55 mmHg, Mean Arterial Pressure (MAP) 65 mmHg
  • Noradrenaline 0.3 mcg/kg/min (has doubled in last 30 min) IABP @ 1:1 49
  • Urine output 5ml for the past 1 hour
  • Mediastinal drains 10 ml in the past hour
  • Temperature 34.9oC
Describe your immediate assessment of the patient.?

Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.