Selfassessment case histories

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1. A 50-year-old man is admitted with an anterior myocardial infarction and develops hypotension 12 hours later with a poor urine output. His vital signs are: pulse 90 per minute, blood pressure 80/50 mmHg, respiratory rate 20 per minute, SaO2 95% on air, temperature 37°C and he is alert. What is your management?

2. A 60-year-old man is admitted to the HDU for "pre-optimisation" 12 hours before a laparotomy. He is treated normally for hypertensive heart failure and this is controlled. He has developed sepsis. He has warm, dry peripheries and his vital signs are: pulse 98 per minute, blood pressure 110/70 mmHg, respiratory rate 26 per minute, SaO2 96% on air, temperature 37-5°C and he is alert. He says he is thirsty. His PA catheter readings are as follows:

• CO = 5-5 (4-8 litres per minute), CI = 3 (1-5-4 litres per minute m-2)

How would you optimise this patient?

3. A 40-year-old man is admitted with a severe gastrointestinal bleed. His vital signs are: pulse 100 per minute, blood pressure 150/70 mmHg, respiratory rate 20 per minute, SaO2 98% on air; he is alert and has cold hands and feet. A CVP line is inserted. The first reading is 16 mmHg. The doctor decides not to give further fluid and observe the patient. What would your management plan be?

4. You are called to see a postoperative patient who has developed a poor urine output (< 0-5 mg kg-1 per hour for 2 consecutive hours). His vital signs are: pulse 90 per minute, blood pressure 120/70 mmHg, respiratory rate 20 per minute, SaO2 95% on 2 litres per minute oxygen via nasal cannulae. His chest is clear. His arterial blood gases show: pH 7-34, PaCO2 4-0 kPa (30-7 mmHg), PaO2 10-0 kPa (77 mmHg) and bicarbonate 13 mmol/l, BE - 8. His CVP reading is 12 mmHg. He has mild peripheral oedema. What would your management plan be?

5. A patient is admitted with an inferior myocardial infarction. His pulse is 40 per minute (sinus bradycardia) and blood pressure 95/60 mmHg. His urine output is satisfactory. His hands are warm, his respiratory rate is 16 per minute, temperature 36-5°C and SaO2 96% on air. What is your management?

6. You are asked to see an 80-year-old lady because she has a low blood pressure. On examination her vital signs are: pulse 70 per minute, blood pressure 90/60 mmHg, respiratory rate 14 per minute, SaO2 95% on air. She has warm hands and feet and is mobile on the ward. What other parameters would you assess and what is your management?

7. A patient has developed low blood pressure on the coronary care unit. One examination the vital signs are: pulse 180 per minute, blood pressure 80/50 mmHg, respiratory rate 18 per minute, SaO2 80% on air. He has cold hands. What is the cause of the low oxygen saturations and what is your management?

8. A 40-year-old man is admitted to ICU with hypotension causing hypoperfusion that has not responded to fluid challenges. He has a PA catheter inserted and the initial readings show:

• CO = 10 (4-8 litres per minute), CI = 4-5 (1-5-4 litres per minute m-2)

What diagnosis are these readings consistent with? What would your management be?

Self-assessment - discussion

1. Immediate management includes the following: airway and breathing should be assessed and treated before circulation. The hypotension is causing renal hypoperfusion and should be treated without delay. When any mechanical causes for cardiac failure has been excluded, the response to a fluid challenge should be assessed. When preload has been optimised, it would be appropriate to start an inotrope and assess the response to this. Intra-aortic balloon pumping should be considered. Further fluid challenges and other vasoactive drugs may be required.

2. Airway and breathing should be assessed and treated first. Ignore the PA catheter readings and assess the patient clinically. What is his normal blood pressure? Are there signs of hypoperfusion (What is the urine output and base excess)? He has warm, dry skin, is tachycardic, and says he is thirsty. He has a history consistent with volume depletion - sepsis and perhaps chronic diuretic use. A fluid challenge is indicated. In a patient with sepsis, one would expect to find a raised cardiac output and a low SVR. This patient's response has been altered by heart failure, so although these readings appear "normal", they do not indicate normal physiology.

3. After A and B, circulation is assessed by looking at the vital signs and for signs of hypoperfusion (for example, skin temperature). This patient has cold peripheries and is tachycardic. A 40-year-old man with a severe GI bleed may compensate by vasoconstriction and this raises the CVP. Single CVP readings are rarely useful. His volume status should be assessed with fluid challenges and the response of his vital signs and CVP readings to these.

4. A and B should be assessed and treated first. In terms of circulation, he has a "normal" blood pressure, but there are signs of hypoperfusion - poor urine output and a metabolic acidosis. The response of the urine output, base deficit, and CVP to fluid challenges should be assessed.

5. This patient is hypotensive but not hypoperfused. He is exhibiting the Bezold-Jarisch reflex - a response of coronary artery chemoreceptors to ischaemia causing hypotension and bradycardia. This is designed to increased coronary blood flow. Any poor urine output that occurs normally responds to a fluid challenge.

6. This patient is hypotensive but not hypoperfused. What is her normal blood pressure? No emergency intervention is indicated.

7. Airway and breathing should be assessed and treated. If the patient is alert and talking, the airway is secure. A high concentration of oxygen should be given (for example, 15 litres per minute via a simple face mask or reservoir bag mask). Assessment of the circulation reveals a low blood pressure causing hypoperfusion. His heart rate is 180 per minute and this should be treated first (Figure 6.5). In a compromised patient, DC cardioversion is indicated. A return to sinus rhythm will probably restore perfusion. His low oxygen saturations are probably caused by a weak signal from hypoperfusion and tachycardia rather than hypoxaemia - arterial blood gas analysis will confirm this.



Heart rate

Figure 6.5 The Treppe effect of heart rate on cardiac output (CO) (treppe means staircase)

8. These readings show low filling pressures (low CVP and PAOP), high cardiac output, and low systemic vascular resistance. This is consistent with a diagnosis of severe sepsis. Fluid challenges should be given to optimise filling pressures. A persistently low SVR despite this is treated with vasopressors.

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