Sunday, September 9, 2007

Clinical Conundrums in Critical Care






Here is a foretaste of topical debates you can expect at the 2007 Annual ASCCA meeting in San Francisco. We invite you to express your views as comments and to prepare for lively discussion!


Posted on behalf of Dr. Avery Tung

Clinical Conundrums:
A 59 yr F with metastatic ovarian cancer undergoes pelvic exenteration under GA.


Her past medical history includes COPD, CHF, OSA, HTN on an ACEI, obesity, and NIDDM. She has previously undergone radiation and chemotherapy (Mitoxantrone). She has no allergies, and was taking Enalapril, Lasix, Metoprolol, Metformin, inhaled Beclomethasone and Albuterol 2x/day preoperatively.

She has previously had uncomplicated GA for a knee arthroscopy. Her exercise tolerance is fair…she has to rest after climbing 1 flight of stairs…but can walk 3 blocks and work in the garden without become short of breath. She can lay flat. An echocardiogram done 6 months ago reveals EF=35%, mild MR

Her preoperative vital signs were: HR 79, BP 150/90, RR 20. SpO2 on RA was 93%. BMI = 30 (86kg, 5’5”) with mild ascites on CT scan. Hct 41%, Cr 1.2, HCO3 = 32 meq/dl, K = 3.5.

The case was 8 hours long. EBL was 500cc, 800cc ascites were drained, and U/O was 170cc. Total intake included 6.5L crystalloid, 3U PRBC, 2FFP.

Abg 1 hr prior to case end was 7.32/41/128 on 100% FiO2

The patient was left intubated and brought to the ICU postoperatively. On admission, she was sedated and unresponsive. BP 108/40, HR 105. Her lines include 2 18G IVs and a R radial arterial line. Abg: 7.30/45/82 on 50% with PIP = 42 cm H20. BE = -5, Hct = 28, HCO3 = 19.


  1. Perioperative beta blockade in patients chronically on beta blockade is now a SCIP measure. This patient was on a beta blocker preoperatively. Would you restart beta blockers at this time?
  1. Would you implement lung protective ventilation in this patient (PIP <30)?
  1. This patient has no central access. Would you place a central line?

Over next 4 hours U/O (cc per hour) is low: 15, 15, 10, 5 despite Lactated Ringers infusing at 150cc/hr IV. BP 105/60, HR 95, JP draining 100/hr serosanguinous fluid, Abg 7.28/45/85 on 60%.

The urine output is low. How would you react?:

a. Continue to observe
b. Crystalloid 500cc IV fluid bolus
c. Albumin 250cc IV fluid bolus
d. More information?

You elect to seek more hemodynamic information:
Which hemodynamic monitor would you choose?

a. Echocardiogram
b. CVP
c. PA catheter

Which measure of circulatory function would you want?

a. SvO2 >65%
b. CVP >13
c. Lactate < >d. U/O >20 cc/hr


CXR now shows mild pulmonary edema. Abg now 7.26/52/60 on 60%. PIP = 36 and Hct = 26%. CVP = 14

Would you transfuse this patient?


The patient develops sepsis and ARDS. After 6 days, bowel function has not yet returned. Prealbumin = 11 and AM glucose = 196.

  1. Would you begin TPN?
  2. Would you initiate an insulin drip?




21 comments:

Mitch Keamy said...

Hey! Congratulations. Just got an e-mail from O'Conner. This looks great! I've posted a blog link at The Ether Way, and since I'm an old intensivist, I'll be around to read your stuff.

Thanks!

Mitch Keamy said...

So, beta blockers here have two rationales; myocardial remodeling with her cardiomyopathy, a chronic issue, and ischemic protection, an acute issue. Since there is no mention of preop ischemia eval, and with hx of NIDDM, I think you've gotta reinstitue beta-blockers withan eye to other intercurrent issues, like sepsis later on. CVP certainly, especially if you can pass one with a saturation probe. lung protective vent certainly, echo eval of ventricle as opposed to pa cath. Sepsis-ARDS-day 6 = re-exploration, from where I sit.

cheers!

Mitch

Long Nguyen said...

There are several issues that I would like to touch on:

1. I agree with Mitch. Source control is key in any septic patient. This patient needs blood cx, BAL, a CT scan or re-exploration.

2. The issue with blood transfusion is a tricky one. If we go strictly by the TRICC trial the simple answer would be no. Since there are no active signs of myocardial ischemia (ie. EKG changes or troponin leak).

On the other hand, without central venous access one cannot monitor a central mixed venous saturation. If we had a CV catheter, and the mixed venous was <70% I believe that we need to transfuse. This will also aide us in the UOP predicament.

3. Although this patient appears to have and ileus and GI absorption is questionable, there are some evidence out there that the anti-inflammatory plieotrophic effects of statins may improve outcome in sepsis. Perhaps with the approval of an IV statin this topic can be further explored.

david said...

Hey..this is really important! My name is Rob Vaughn. I'm an anesthesiologist (who doesn't do critical care!) in private practice. I have a website - perioperativebetablockade.com. I developed an interest in the subject some years ago and have been following it carefully for awhile. I've spoken to several of the investigators including Juul and Yang.

Perioperative beta blockade is NOT a SCIP measure and shouldn't be. At least what's been passed through in our hosptital.

Continuation of beta blockers for patients on bblockers IS a SCIP measure, to avoid withdrawl.

As well, contrary to popular belief, the AHA/ACC does not clearly recommend (class I) periop BB except in one circumstance: patients who have reversible ischemia on provocative testing (Poldermans - DSE+) who are coming for major vascular surgery (NOT CAROTIDS!).

None of the patients in the Mangano, Poldermans, Raby, Urban, Yang or Juul RCTs were critical care players before the institution of periopBB.

You may know that the total number of patients randomized in the Mangano and Poldermans trials showing benefit - was 312. The subsequent, more recent trials -yang and Juul - had a combined n of 1418 and showed no benfit.

The Lindenhauer analysis in NEJM was the first to show that the highest risk patients may show benefit, but the lower risk patients may be HARMED. This study was the first to show any possible harm by periop BB, and clearly should dissuade those thinking that periop BB should be mandated. (though the Lindenhauer was a retrospective look, it was huge.)

Please use my website as a reference, and tell me if you think it's got weaknesses!

I think of it as my little contribution to medicine!

thanks - rob vaughn.

Mitch Keamy said...

Hey Rob; we can't come to your site if you don't enable viewing your profile or give us a URL.

Mitch

Mitch Keamy said...

woops! just saw it in there on a second read!

Christine said...

Oh, just like in residency!

Seriously, in my private practice, this patient would have had an art line, CVP and echo intraop, *especially* since the echo reported is 6 months old -- is that EF still 35%, better or worse?

The patient was run dry intraop, so their low urine output is not surprising -- she needed 9 liters of crystalloid or so just to stay even (even accounting for the PRBC and FFP).

With her underlying cardiac disease and poorly described pulmonary disease (peak flow? baseline ABG? abnormal pO2 intraop on 100%), being able to corrolate the cardiac filling volumes via echo with the pressures of a CVP or PA line would be quite helpful. And I'd like to see what PEEP does to her cardiac function.

I'd hold off on the beta blockers for a few hours, because that tachycardia of 105 is one of the things you should follow as you complete your fluid resuscitation.

Did the surgeon place a drain? If so, have you checked a creatinine on the drainage? Have you checked intra-abdominal pressures? At what point do you ask the surgeon to re-explore her? (always a difficult question)

These cases occur in private practice just like in academics, only we have to be much more proactive in the OR, because there isn't someone in-house 24/7.

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