Joe Bloggs is a 90 year old gentleman admitted from Casualty with chest pain. He is noted to look unwell. He is an ex-smoker and tells you he has mild emphysema and high blood pressure. He is clammy, tachypnoeic and hypotensive. He tells the ED intern looking after him that he was gardening when he started to feel a heaviness in his chest. He says he has been having this heaviness on-and-off for the past 6 months, particularly when climbing the stairs. He had seen his GP who thought he might have angina and he had been commenced on metoprolol 25mg BD and aspirin. His GP referred him to a Cardiologist, but he missed his appointment.
He was treated with morphine and cautious fluids in ED, but his chest pain did not subside. His ECG was reviewed by the Registrar on duty who spotted inferolateral ST segment elevation. She quickly rang the Cardiologist on call who arranged an urgent angiogram. The results are urgently faxed to the CICU floor (see angio.pdf below).
An urgent theatre slot was made and the patient underwent emergency on-pump CABG. A Swan-Ganz catheter and 4-lumen CVC were inserted. Anaesthesia was complicated by runs of atrial fibrillation and non-sustained VT. Sternotomy was performed. Cardiopulmonary bypass was established with bicaval cannulation and cardioplegia. Four grafts were carried out, LIMA to LAD, SVG to LCx, RCA and PDA.
The surgeon commented frequently that the surgical field was complicated by bleeding and by small calibre friable vein grafts, leading to a CPB time of 128 minutes. He also complained of ineffective cardioplegia (myocardial contraction was noted during bypass).
On rewarming the patient, the intraoperative TOE shows a severely dilated, poorly contracting RV, TAPSE 0.5cm, poor radial function with moderate TR. PA pressures were noted to be 70/48mmHg. The left ventricle was only mildly impaired with mild-moderate MR. A loading dose of milrinone was given and the IABP recommenced. He remained unstable coming off bypass requiring high doses of milrinone, adrenaline and vasopressin to maintain BP.
He is hastily brought round to CICU, where a tired Anaesthetist hands the patient over to you. Shortly afterward, you review the patient. The nursing staff have given a fluid challenge and have documented their observations. (See numbers.pdf below).
How should we manage these patients? Comments please!
Next week I will post a useful paper on RV failure and a presentation on the use of vasoactive drugs in CICU.