as several have said...we need a CC cases thread. So though i am the least experienced of the routine contributors here i will start with one from tonight.
58 y/o W male, 2 hours post 4 vessel cabg. On pump around 3 hours. Still on vent. Arrives to MICU with MAP in the tank. high 40s low 50s. On epi/dopamine/Neo/Insulin/LR/Albumin. a couple medistinal chest tubes. IJ cordis with swan in place. CI around 3.2 SvO2 52-54. HR 130s sinus tach. PAP's 40/25. Extremely dyschronus with vent, on AC/VC currently. Belly breathing. Sats mid to high 70s with waveform matching the Aline. Fio2 100%. Baseline he is a heavy smoking COPDr with chronic retention ( think is RA abg was 7.4/55/65/33/90%) No sedation at the moment. MAP is too low to turn the propofol on. Getting squirts of versed with some morphine. Chest film shows ETT in good place, lines all in good place. Complete opacification of right hemithorax. CTSurg puts a lateral Ctube in right side, nothing for return cept a small bit of pleural fluid. Sats still around 78-80, bucking quite a bit. MAP 50. Turns to you and attending intensivist and says 'ok your move".
Good case! Im an attending in a CTICU. So Ill play ☺
1) Is this guy sedated appropriately? Im putting him down. Hard. Then Im running him on propofol and fent. If the pressure is just TOO low to chance the prop, Ill use serial bolus doses of versed like you did. I like the direction the literature has gone the last decade to minimize the use of benzo infusions but surely it is too dogmatic to abandon their use entirely. I like intermittent boluses of versed until I can recover enough pressure to use prop or dexmetatomidine.
2) The white out with little return on chest tube makes me think thick mucus plus from COPD/bronchitis stuff. Id call for the bronch cart and get ready to run it down, but having addressed sedation, Im turning my attention to the
3) Interesting mix of pressors. This is a common scenario in our shop multiple milieu of pressors, all maybe doing something, maybe not, and perhaps even being counterproductive. With this guys clinical condition, my ultimate aim is to consolidate pressors, but I have to decide a few things. First, the chest tube that only put out a little pleural fluid seemingly excludes tension pneumo, and the other thing Id be worried about in any post-CT surg patient is tamponade. If either of these conditions is present, doesnt matter what I do with the pressors unless you diagnose and fix the underlying problem, patient going to need a pathology consult.
Assuming no tamponade or tension, now Im trying to figure out: Does this guy have hypotension because the heart is weak (inherently or, more likely, stunned myocardium from the pump run) or is he vasoplegic? If stunned myocardium, then the neosynephrine isnt helping the weak heart, and the dopamine, if doing anything at all, is probably just revving up heart rate. When its weak heart, Im trying to consolidate to epi, give volume (blood if Hct < 30, crystalloid if above) and be cognizant that if the right heart is weak based on the intraop TEE, he might not tolerate much rapid volume so Im using either dobutamine or milrinoine (probably milrinone in a COPD setting). If its more a vasoplegia, then volume is still the treatment, but then neo IS useful to me
as is possibly vasopressin or methylene blue.
4) ABG actually not bad for a COPDer. I already addressed the possibility of getting out mucus plugs (or even considering a COPD exacerbation nebs and steroids, please) but really, although the Sat% are concerning on the pulse ox, you told me he was 90% on the ABG. If you didnt have the white out chest xray, and if his peripheral sat monitor was reading the 90% matching your ABG of pH of 7.4, CO2 55 and sats 90% (assuming adequate Hgb for oxygen delivery), I don think youd be that worried about his pulm status under the circumstances
thats not a bad ABG for a COPDer.
5) PA pressures 40 not bad in a COPDer. If his index wasnt 3.3 Id be relying on the milrinone even more, but index looks good so Im not too focused on that for now.
6) Other things to think about in this golden hour: Make sure total chest tube output is appropriately low and diminishing (I want less than 1L in first hour, of course, or back to the OR), maintain normothermia after the pump run, follow my lactate, etc.
CHEST TUBE OUTPUT: As an aside, these are my rough guidelines for return to the OR for CT output post CABG:
1st hour: < 1L;
2nd and 3rd hour (combined): <1L
4th, 5th, 6th, 7th hour combined: < 1L.
I like the symmetry of this approach. Im obviously not waiting until I hit this exact threshold to contact the CT surgeon (Im discussing this once I start to get within about 75% of these levels) but these are rough triggers that our CT guys will take em back to the OR.
