CASE PRESENTATION

DR. SUKESH P V EMERGENCY MEDICINE

FINAL YEAR POST-GRADUATE

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

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.

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

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.

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

ECG :

CHEST XRAY

• 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.

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

FINAL DIAGNOSIS

1. SEVERE LEFT VENTRICULAR DYSFUNCTION SECONDARY TO PERIPARTUM CARDIOMYOPATHY WITH PULMONARY ODEMA POST EMERGENCY LSCS.

2. SEPTIC SHOCK 3. HYPOVOLEMIC SHOCK

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.

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.

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.

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

POD 1

• Patient had mild inspiratory crepitations LEFT > RIGHT .

• URINE OUTPUT was maintaned more than 0.5ml/kg/hour.

• Ejection fraction was at 28%.

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.

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

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.

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

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.

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

• CHEST was clear bilaterally , with no inspiratory crepitations.

• Urine output was well maintained. • Wound was healthy. • Ejection fraction : 39%

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.

• 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.

• 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

THANK YOU!!!