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CASE PRESENTATION
DR. SUKESH P V EMERGENCY MEDICINE
FINAL YEAR POST-GRADUATE
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POST OPERATIVE DAY 0 ( 12.4.17 )
• Call received from post operative ward in view of hypotension immediately post emerg LSCS.
• On arrival : VITALS : PARAMETER VITALS
PATIENT CONSCIOUS , COHERENT WITH MILD RESPIRATORY DISTRESS
BLOOD PRESSURE 80/60 mmHg
HEART RATE 104 bpm
RESPIRATORY RATE 24cpm
TEMPERATURE AFEBRILE
PAIN NIL
SPO2 84% on RA
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PRIMARY SURVEY PRIMARY SURVEY
AIRWAY SPEAKING IN FULL SENTENCES
BREATHING MILD TACHYPNEA
CIRCULATION COOL PERIPHERIES , CRT 4 SECONDS.
Immediate ECG , CHEST XRAY , ARTERIAL BLOOD GAS ANALYSIS & BEDISDE 2D ECHO WAS PERFORMED.
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SECONDARY SURVEY : • GENERAL: oriented to time place and person • HEAD : ATRAUMATIC , GCS 15/15 . • EYES : Pupils normal size reacting bilateral. • NECK : Full range of motion , no JV distension , no
stridor. • ORAL : Normal dentition , no secretions , no
swellings. • CHEST & LUNGS : No deformity ,bilateral basal fine
end inspiratory crepitations present. • HEART : HR: 104 bpm , BP : 70/40 mmHg , no s3
gallop
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SECONDARY SURVEY
• ABDOMEN : Soft , no distension , no guarding/rigidity , wound healthy.
• UROGENITAL : normal • EXTREMITIES : cool peripheries , feeble
pulsations. • BACK : Normal • NEURO : GCS 15/15. • NO Lymphadenopathy.
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PROVISIONAL DIAGNOSIS
• SEVERE LEFT VENTRICULAR DYSFUNCTION SECONDARY TO PERIPARTUM CARDIOMYOPATHY WITH PULMONARY ODEMA
• Essential 3 criteria : 1. Heart failure during peripartum period 2. Ejection fraction < 45% 3. No other cause of heart failure. • SEPTIC SHOCK • HYPOVOLEMIC SHOCK
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ECG :
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CHEST XRAY
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• 2D ECHO : RWMA PRESENT with apical hypokinesia and LAD territory hypokinesia.
• Ejection fraction : 28% • Inferior vena caval diameter 1. IVCi = 1.54cms 2. IVCe = 1.7cms • There was less than 50% compressibility.
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ARTERIAL BLOOD GAS ANALYSIS
pH 7.40
pCO2 28.2mmHg
pO2 51.8 mmHg
HCO3 19.3 mmol/L
PaO2 / FiO2 259
PAO2 – PaO2 55.6
COMPLETE BLOOD PICTURE
TLC 13,000/cumm
Hb 11.5 gm/dl
Platelets 2.3 L/cumm
SERUM ELECTROLYTES
Sodium 132 mmol/L
Potassium 4.4 mmol/L
Chloride 106mmol/L
RFT NORMAL
LFT NORMAL
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FINAL DIAGNOSIS
1. SEVERE LEFT VENTRICULAR DYSFUNCTION SECONDARY TO PERIPARTUM CARDIOMYOPATHY WITH PULMONARY ODEMA POST EMERGENCY LSCS.
2. SEPTIC SHOCK 3. HYPOVOLEMIC SHOCK
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PROBLEM BASED APPROACH
1. HYPOTENSION secondary to severe left ventricular dysfunction.( 2D ECHO )
2. Pulmonary odema with type 1 respiratory failure. ( ABG )
3. Post operative period of emergency LSCS.
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CRITICAL ACTIONS TAKEN
• O2 SUPPLEMENTATION @ 6LIT/MIN VIA VPD. • NON INVASIVE VENTILATION STANDBY. • RESTRICT INTRAVENOUS FLUIDS • INJ. DOBUTAMINE 5mcg/kg/min IV
CONTINOUS INFUSION. • HEAD END ELEVATION UPTO 30 DEGREES.
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CRITICAL ACTIONS :
• ON 13.4.2017 , 2 00 AM ,as patients’ hemodynamics were not improving significantly , inj noradrenaline 0.01mcg/kg/min was initiated.
• And for better hemodynamic monitoring an invasive arterial line was introduced into the right femoral artery and triple lumen central venous catheter was introduced into the right subclavian vein.
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POST OPERATIVE DAY 1
VITALS : PARAMETER VITALS
PATIENT CONSCIOUS , COHERENT
BLOOD PRESSURE 98/62 MMHG ON INOTROPIC SUPPORT
HEART RATE 102 BPM
RESPIRATORY RATE 22CPM
TEMPERATURE AFEBRILE
PAIN NIL
SPO2 100% ON FIO2 OF 0.5
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POD 1
• Patient had mild inspiratory crepitations LEFT > RIGHT .
• URINE OUTPUT was maintaned more than 0.5ml/kg/hour.
• Ejection fraction was at 28%.
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POD 1 TREATMENT
• INOTROPIC SUPPORT with dobutamine and noradrenaline was continued at the same doses to maintain MAP > 65mmHg.
• IVF were restricted to maintainence of Urine output plus 25ml / hour.
• O2 supplementation continued with variable performance device with 6lit/min of flow
• Antibiotics were administered as advised by OBG surgeons.
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PATIENT ON POD 2 VITALS : PARAMETER VITALS
PATIENT CONSCIOUS , COHERENT
BLOOD PRESSURE 100/60MMHG ON INOTROPIC SUPPORT
HEART RATE 92BPM
RESPIRATORY RATE 22CPM
TEMPERATURE AFEBRILE
PAIN NIL
SPO2 95%ON FIO2 OF 0.4
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POD 2
• Patient had bilateral inspiratory crepitations. • URINE OUTPUT was maintaned more than
0.5ml/kg/hour. • Ejection fraction was at 34%. • Wound was healthy. • Urine output was 1345 ml with input of
1240ml. • Negative balance of 100 ml was maintained.
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ARTERIAL BLOOD GAS ANALYSIS ARTERIAL BLOOD GAS ANALYSIS
pH 7.47
pCO2 24.2mmHg
pO2 76.1 mmHg
HCO3 20.3 mmol/L
PaO2 / FiO2 190
PAO2 – PaO2 179
CKMB 74 IU/L
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TREATMENT ON POD 2
• Inotropes were continued with dobutamine (10mcg/kg/min) and noradrenaline(0.01mcg/kg/min).
• Oxygen therapy was continued with variable performance device along with intermitent non invasive ventilation.
• NIV : CPAP 10cms of H20. • Inj FRUSEMIDE 20mg IV BD was started.
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PATIENT ON POD 3 VITALS : PARAMETER VITALS
PATIENT CONSCIOUS , COHERENT
BLOOD PRESSURE 90/60MMHG ON INOTROPIC SUPPORT
HEART RATE 100BPM
RESPIRATORY RATE 19CPM
TEMPERATURE AFEBRILE
PAIN NIL
SPO2 100%ON FIO2 OF 0.2
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• CHEST was clear bilaterally , with no inspiratory crepitations.
• Urine output was well maintained. • Wound was healthy. • Ejection fraction : 39%
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POD 3 TREATMENT
• Oxygen therapy was given only at 2lit/min via VPD.
• Inotropic support continued at doses to maintain MAP >65mmHg.
• Cardiologist consultation was taken and as advised patient was started on TAB ECOSPRIN 150mg stat , TAB ROSUVASTATIN 10mg OD.
• Non invasive ventilation on standby.
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• From post operative day 4 to 6 gradually inotropic support was tapered and removed after the hemodynamics were maintained without support.
• Ejection fraction improved from 28% on day 0 to 54%.
• Chest was clear bilaterally. • SPO2 on room air was 99%. • Arterial and central line were removed.
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• Patient was shifted to respective ward after hemodynamic stability was ensured with vitals at the time of shift as follows :
VITALS
HEART RATE 86BPM
BLOOD PRESSURE 110/80 MMHG WITHOUT SUPPORT
RESPIRATORY RATE 18CPM
TEMPERATURE AFEBRILE
PAIN NIL
SPO2 99% ROOM AIR
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THANK YOU!!!