Cardiac surgery
Scenario: A seventy-two (72) year old ex-heavy smoker underwent “on-pump” coronary artery bypass grafting (LIMA to LAD, RIMA to RCA, free radial to Circumflex). His preoperative left ventricular function was normal. It was not possible to achieve satisfactory retrograde cardioplegia so anterograde cardioplegia was employed.
He received a total intravenous anaesthetic technique with propofol and remifentanil. There were no specific problems separating from cardiopulmonary bypass but a new Right Bundle Branch Block was noted on his ECG.
In transit to the ICU he was noted to be awake and obeying commands.
Soon after arrival in ICU, he became agitated, dysynchronous with the ventilator and developed marked systemic hypotension.
Here are his first haemodynamic measurements in ICU.
|
Heart rate |
100 reg |
||
|
Systolic blood pressure |
85 |
||
|
Mean arterial pressure |
55 |
Systemic vascular resistance |
809 |
|
Diastolic blood pressure |
40 |
Systemic vascular resistance index |
1600 |
|
Pulmonary capillary wedge pressure |
20 |
||
|
Cardiac Ouput |
2.7 |
||
|
Cardiac Index |
1.5 |
||
|
Pulmonary artery systolic pressure |
60 |
Pulmonary vascular resistance |
590 |
|
Mean pulmonary artery pressure |
40 |
Pulmonary vascular resistance index |
1070 |
|
Pulmonary artery diastolic pressure |
30 |
||
|
Central venous pressure |
25 |
Introductory Question: How do you interpret these results?
Twenty out of twenty-three candidates passed this section.
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.