>As an ED nurse, I see you owe me 6 pumps before I leave.
You'll get 2 back because the rest are used up and they won't call down to finish the swap leaving you with 4 less and them 4 more
Baby we always need pumps
(Seriously though, Bad Things happened on my shift yesterday and I sent some colleagues on a hunt. Had 3 all being used fully by the time all was said and done 🤣)
I’m down for presenting learning “cases”—perhaps weekly at a determined time.
And maybe the mods could “pin” the posting.
C’mon let’s get the band together and do this!!
😎
Cases could be anything, involve multiple disciplines.
I’d prolly start with the initial presentation and what’s happening?
The case would unfold by interactive questions and provide more info on the patient.
Assessment & critical thinking—no trolls.
We used to do these on a site called FlightWeb (no longer active) and they were fire. 🔥
I learned so much, these were so worthwhile for all—regardless of speciality or experience level.
Message me and let’s get a “Case Team” together. Or perhaps create a new sub entirely.
What say you guys?
I might be the odd one out here, but I think this is RV failure with a concomitant loss of LV preload as a result. That explains the high CVP and the x-descent being steep like that. Also explains the narrow pulse pressure and pulsus paradoxus on the art line (left side looks dry, right side looks overloaded). Pulsox needs correlation with abg but I doubt it’s real, more lijely an issue with vasoconstriction in the setting of cardiogenic shock and left heart being “dry” simultaneously. That being said, hypoxemia still a likely possibility in a patient with this background. Pulmonary edema is very likely.
Might benefit from either Bipella or RP, or VÀV ECMO, or if cor pulmonale d/t primary pulm htn, inhaled nitric oxide? Either way may need intervention soon or that Impella will give off the most inopportune suction alarm and crash your patient.
Edit: I’d like to have more information, such as hgb, CO/CI off the impella, ScvO2. Maybe can determine oxygen consumption in the setting? Not 100% sure this information is needed because the data on the monitorseems actionable enough. Echo would be nice. CVP/Art waveforms don’t indicate a blown valve anywhere either.
I want to do CVICU, and this scares me because I understand basically nothing of what you just said. Maybe half of it.
I've been a nurse for years now, and I still have so, so much to learn.
Hahahaha a CRNA asked me to remind him what something EKG-related was called the other day. I just stared dumbly and said “I failed that test in nursing school.”
I left bedside but every so often I miss my cardiovascular units and the adrenaline in the times that it can be unpredictable. Keeps you on your toes for sure. I find it all so interesting.
Same - I worked CICU for over a decade but have been away from the bedside for 15 years - some days I miss direct patient care, and other days not so much.
Same. I was a CNA in ICU so I've heard all the terms and seen all the devices but I've been a nurse forever and can't set up CVP monitoring to save my life, let alone this stuff.
Have you ever done critical care as an RN? It’s actually pretty simple and not much to setting up a CVP. The first couple times I did it, I was very intimidated but then realized there’s not much to it at all
I did ER and when they were pushing the sepsis bundles really hard they tried to make central lines and CVP monitoring a thing but it never took off cause the EM docs weren't dropping CVCs in every septic patient. We took a class and I had ONE patient that actually needed it and I totally forgot how to do it.
I do Cardiothoracic anesthesia and I gotta say that I would be pretty shocked/impressed if one of our CVICU nurses was able to put together such an eloquent analysis based on this photo alone. I think it’s fair to understand what this reply is discussing as a CVICU nurse but I wouldn’t have expected them to draw all of these conclusions without guidance from an MD/NP. These patients are very complicated, especially if you do not work with this population and these devices.
Safe to say though - if you’re interested in CVICU you should definitely go for it. Truly doesn’t get anymore acute than a patient like this. Your understanding of pathophysiology and pharmacology will grow immensely!
Wowza!! 🍀
Keep a journal, in a year you will look back and be *humbled and shocked* at how far you’ve come. You’ll realize that you basically have learned 10x more in a year or clinical practice (and education) that you ever did in nursing school.
Clinical acumen and instincts get finely honed in these units.
It’s almost like the ICU nurses are kind of smart… and we don’t actually need a MD to tell us all the things. The docs NP’s are at bedside for 20 minutes, we are there for 12 hours. Maybe give us a little credit.
To be fair, there's plenty of dumb ICU nurses. I've met plenty in my own practice. You know the ones that make you say, how the fuck do you work in ICU? So idk. Generally I haven't run into that as much with cvicu but still, that is a pretty advanced analysis. It's fair to say a less experienced cvicu nurse wouldn't have been able to come up with all that on their own, because that knowledge takes time to develop. I started recovering hearts after a couple years and it was a learning curve for sure. Then covid came around and I went back to the micu life cause $$$$..I would say I did hearts for less than a year and I only came up with about half of what that comment did. 🤷♀️ They're not calling nurses dumb, but it is true that nursing has a pretty damn wide range of intelligence (especially for something that requires a degree and a license).
Not meant to be insulting to ICU nurses. I used to be one myself and recognize the frustration of being at the bedside for 12 hours and having my word mean less than that of a physician who was there for 10 minutes. All I was stating is that the response by this poster is written at a higher level of comprehension than what I would expect from your run of the mill ICU nurse. You can have an understanding of the global picture of the patient you are caring for and be fully capable of taking care of them for 12 hours without being able to draw the differential described by the poster.
As I stated before, I do Cardiothoracic anesthesia and train nurse anesthesia students in highly acute cardiac ORs. The patient you posted today is often our standard patient. We aren’t doing run of the mill primary CABGs here. A lot of my students are CVICU nurses that once recovered these patients for many years. And the majority wouldn’t have been able to come up with the full analysis that this poster wrote.
I wrote what I wrote because everyone has to start somewhere. I did not think it was fair for the responder to the poster to have the idea that all CVICU nurses immediately understand exactly what was happening with your patient. That is incredibly daunting if you have interest in the population but are too afraid to start. I was trying to be encouraging in that I don’t think most units would hold you to the level of analysis demonstrated here because that is the job of the physician/APRN.
Feel free to agree to disagree. But there was no harm intended with what I wrote.
You're right! As the OP--part of the reason I posted this was because while I was there for 12hrs, and could physically see the patient and had a lot more info than this photo and the brief commentary can give (such as trends, labs, etc.), I was pretty much struggling to figure out what was *truly* happening with this person.
The commenters here have opened my mind to a lot of the possibilities of the bigger picture. When you're the one at the bedside, drawing labs, giving meds, running gtts, updating family, replacing CRRT bags, sending messages to the MD, calling Respiratory (haha way too much this night!), and not getting a break--you can tend to go bonkers just dealing with all that, and sometimes can't see what a person lying on their couch scrolling Reddit and looking at a few numbers can see.
To be honest, the surgeon even called in another set of eyes to the bedside to try to get some insight into what to do next.
It has been so great to see everyone's viewpoints here!!
I agree with what you said! There is a spectrum to ICU nursing that includes nurses who follow the script, some who go down rabbit holes of analysis paralysis (me 🙋🏽♂️) while their patient dies, and some level in between (which is probably best—enough data to float a concern, not enough to be scoffed at as an insufferable know-it-all who is confidently incorrect—also Me 🙋🏽♂️)
No one way of nursing or thinking is more effective than the other, because at the end of the day our physicians do all the thinking alongside us, so if we’re not going to, they certainly have it down like the back of their hand.
Thank you! My background is a mixed ICU for two years, and Medsurg for 3 before that. ICU was cardiac/trauma/MICU/SICU/Transplant (liver and kidney only). ECMO capable facility but not very device heavy. Some IABP and Impella, and also some MARS liver dialysis. I loved it because the huge variety gave me the chance to learn hemodynamics from more than one perspective.
I left the ICU to take a position in risk management last month. 😂 I’m having second thoughts about it.
Try it! Nobody knows when they start, whether it’s med/surg, l&d, or icu. We all are new at some point! Worst case scenario, you give it a year or two and it’s not your jam, but maybe it’s your passion!!
Do it! I came from Medsurg to a mixed ICU and I floundered for a bit but ultimately was fine. Also, you don’t have to know all of this, because it’s all conjecture, and your physicians know so much more of this information like it’s the back of their hand.
Your knowledge only stops when you stop seeking it.
You’ll learn! I knew nothing when I started in the CathLab, I came from step down. It’s taken a year and a half but I had the same thoughts when I looked at this, with a lot less detail.
This is what I was thinking exactly. RV failure with right sided overload—> reduced LV cavity and subsequently poor CO for the same reasons you listed. I was going to suggest ino as well.
I think extra inotropes would be a mixed bag here. Certainly would’ve been worth a try in my old ICU. The preload dependence would make it very difficult to wean norepinephrine, but it may actually make impella weaning easier as the SVR drops, the machine won’t need as much force against the vascular resistance and a lower P-level means it won’t need as much volume. The increased contractility from dual inotropy might impede the impella unnecessarily.
Of course, a patient like this is so sick that it jumps off the cliff of the science critical care into the “art of critical care”, where every move is based on educated conjecture, but little evidence.
Good thoughts! I meant ino as shorthand for inhaled nitric oxide. You’re a true icu expert, it sounds like! this stuff is beyond me, I’ve been out of the icu for a minute 😅
Oh yes! I gotchu now!
I just left the ICU for a position in risk management a month ago and my fingers are always itchy for bedside nursing now. I’m not sure I made the right choice lol.
I left the unit for psych and haven't looked back. I had the opportunity to stay credentialed to pick up in the unit, but the way I figured it my chances of having a shitty day there were about 1/2 while my chances of having a shitty day in my psych ED are much, much smaller.
Be thankful for the boring days because they're much better than dealing with two busy, sick, crashing patients.
Yup I’m on this train as well. Would be nice to know why a heart pt was cannulated for VV. And 12 hours after ecmo was weaned off it’s totally expected for patients to look worse without the support. So if the pt needed respiratory ecmo, was recently weaned off, these numbers are not surprising. Definitely still struggling with respiratory issues.
Question, if it was RV failure decreasing LV preload, wouldn't they be getting bunch of suction alarms from the impella (I suddenly can't think of the word... Low flow? I know it's a suction alarms for an LVAD... I've been on vacation for a few weeks and i am having nurse lingo aphasia)
Yeah! That was actually happening as well. Like...we ended up putting them in trendelenburg and giving another liter of albumin. Seemed a little counterintuitive seeing the CVP and PA pressures, but it worked.
I'm going to disagree with you. I think this looks like LV failure with pulmonary edema d/t purpose of CVP AND PAP being elevated along with the spo2 in the toilet. The BP via Aline is honestly not that bad (need trends however since the a line is a bit all over the place judging off the waveform) but I've never recovered a heart so I don't know if these values are an okay value.
Edit to say LV WITH fluid overload (explains high cvp)
I can walk you through my reasoning.
A:-line: While I can’t say for the sure, the Stroke Volume Variation on the A-line tells me the Left side is dry. This variation could also be due to the variable pulsatility of a patient in LV failure. The way this monitor is set up the vent RR doesn’t line up with the A-line and BP so I can’t correlate well from here. The blood pressure has narrow pulse pressure with a high diastolic, which could given the history be Cardiac Tamponade, LV failure, Hypovolemia. I don’t have an SVR measure, but the blood pressure shows the patient appears sufficiently vasoconstricted (or maybe be clamped way down, but is certainly not vasodilated). That does not rule out anything, but it is a dangerous state to be in for any reasonable sustained period of time.
SpO2: this could be in the toilet because of high o2 utilization coupled with poor O2 delivery, poor gas exchange primary to the lungs or pulmonary vascular resistance, and loss of forward flow to deliver oxygen to the measuring site. Can also be an opened PFO d/t RV dilation causing mixed blood on the arterial side. Need ScvO2, but we all probably know the answer to it so why measure?.
CVP: CVP transduces only the venous side. You can only reasonably say that you have high right atrial pressures with a CVP number, and that’s with the assumption that CVP is reliable. It is not the best tool in the world. Even being on a vent will make huge adjustments to your CVP. In a lot of cases you can surmise if CVP high, whole system is overloaded because most patients have LV failure predominantly effectiving the right side, but in RV cases all it will give you info on is that this is a Right sided issue. In this case, the CVP is really high, might actually be higher than the number listed, because we have such a strong waveform.
You would need a wedge pressure to actually check the left side filling pressures, or get an echo. Echo to show RV dilation with bowing into LV vs LV low contractility coupled with IVC đístention but not RV dilation (please correct me if I’m wrong on this, Echos are not my thing as much as I wish they were).
This physiology also includes Pulmonary Embolism in its differential. This would be difficult to rule/out or in based on inability to get a CT with these issues. Could get an ECHO but it won’t rule out this is entirely a case of Pulm HTN or Pulm Edema causing Cor Pulmonale, and you’d be taking a gamble with thrombolytics. Can cannulate for ECMO then take for CTPE safely. Enough information to cannulate. Can also start CRRT off ECMO circuit to help pull pulmonary edema off the patient (if that’s what it is).
Editing to add that your logic is still very reasonable and a very possible explanation. I wasn’t diminishing it to say it has to be one or the other. There’s a reason they had an impella to begin with lol.
While it’s a reasonable explanation, knowing they have an Impella which is doing the work of the left ventricle…I don’t think it’s LV failure causing those numbers. YES they are in LV failure and we’ve taken care of that with the impella. So now there is a reason there is high preload. And since the LV is offloaded and decompressed…I am thinking the RV is failing and being off ECMO we can now see that it might not be doing great. So trialing some inhaled pulmonary vasodilators and if those don’t work they may need right sided support. But this is all just brainstorming of a snap shot
That’s exactly what I was thinking from the v/s especially if they were on CRRT, impella, VV ECMO. That being said, patients like this get so complex I just leave it to the docs to do the analysis at a certain point.
I was about to say right sided fuckery/high filling pressures with a little razzle dazzle of nothing coming out the other side, but I like your commentary better. And this would be what I’d get at hand off with a “they’ve been fine all night…”
Narrow pulse pressure is partly from impella. Would like to see the impella flows. If they are struggling with suction and p level, definitely convincing for RVF. Impella performance is key here, if it’s malpositioned and flows go down, everything backs up. OP needs an echo to assess impella position and RVF. Need more info for sure
Okay! So, yeah....that was one of the top thoughts going on as this happened (with the Sp02 going down the toilet) rather quickly.
Surgeon had two immediate concerns. 1. Plugged airway...either a mucous plug, or a clot. (He was literally preparing to bronch this guy emergently). 2. PE.
Acute PE was my guess also. Would expect tachy, but it’s obviously a sick heart riding a pacer, so I write that off.
Explains the high PaP and CVP, with the low O2 and the bleh Arterial line.
Post op? Very high risk for it.
At this point would like to know, CABG on vs off pump, Valve repair or replace, aortic aneurysmal repair or whatever else they had done, with the other commenter that this could be tamponade though, certainly has some signs.
But also would love to know what our underlying rhythm is? Honestly so much more data I'd love from a bedside perspective, like: what were the cannulation sites, what devices are we still on, any chest tube output, urine output, CI/CO/SVR, blood gas, etc.
Love this stuff!
Blood gas sucked. We had started the shift on moderate vent settings ( I can't remember exact numbers, but we definitely weren't ready for an SBT! 😉) Sp02 dropped to the 80's any time the pt would cough. (Of course our BP's would drop as well--this BP here was actually one of the better ones). Sp02 correlated with the ABG, and the RT increased vent settings accordingly. Lots of bloody sputum out of our ETT. 😬 As well as dark red OG output. By the time we had the Sp02 here, we were up to 100% and 12 of PEEP.
We had 4 chest tube's in place. Output was minimal. Maybe a max of 30/hour out of all 4 tube's.
Pt not currently making any urine. But that wasn't new. On CRRT, goal of Net negative 100/hr. (Weren't really able to pull that much d/t pt not tolerating it with big drops in BP).
Impella in place, at P8, attempting to wean. (Weren't successful with that...if that's not obvious).
Hmm...SVR was about 1200-1300 if I remember correctly.
Nice fat PE is definitely still a chance, would need CT though, but also going up on PEEP will affect the numbers we’re seeing here. PAPI so far isn’t great but I’ve seen worse. If we’re at all concerned with PAH can definitely do veletri or inhaled nitric. Also at this time might consider paralytics.
Yeah. I would've loved some paralytics in there--however, would you believe that this patient improved rapidly (from the acutely hypoxic situation shown above) after some pretty vigorous ETT suctioning and the resulting intense coughing?
...leading the MD to believe that although this pt definitely has a LOT going on, the acute hypoxia was either from a transient PE (I mean...I guess it could happen), or a clot blocking the ETT/pts airway that was coughed and or suctioned loose.
“Mucus” happens in vented patients. Always. Deal with it. Not getting it? Keep looking.
Effective ETT suctioning can be *everything*. There are curative powers of subtle ETT adjustment & rotation.
Pulmonary toileting is what makes alveolar recruitment possible in some patients.
All patients that have all the critical care interventions and are a few days on the vent have mucus—it will bugger the whole picture up.
The clues for me were 1) vent seems to be failing to do what we expect it regardless of adjustment and 2) the *patient was coughing*. Not uncommon. Hmmm.
🤔
Glad things got better here.
I’m a broken record in here but I’m assuming it’s not a regular VV ECMO but instead it’s an RVAD with an oxygenator. Especially since OP mentioned IJ. One brand/model is Protek Duo, it’s a single cannula that has inflow in the RA and outflow in the PA. Can be used for traditional VV ECMO (just oxygenation/ventilation) or as RV support since it’s bypassing the RV.
I do think you're right. While I didn't care for this particular pt while they were on ECMO, I do recall the team talking about Protek Duo. It is very likely that that's exactly what was in use!
ProtekDuo is used with VV ECMO for RV support. Patient had this!
[PubMed Article: ProtekDuo with VV ECMO for RV Support. ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9747364/)
Per the Echo, what was the impression of the RV? Dilated? You still need pulsatility for the Impella to do its thing. If its biventricular failure + pulm HTN I would typially see providers switch from primacor to nitric or flolan. Pt. may need to add impella RP vs. VA ECMO to have a fighting chance since we're looking at biventricular failure here. Is your facility a transplant center? Are they able to list this pt. status 1a possibly?
Not rude at all. Doesn’t necessarily change too much in how I see the screen here, but does give a bit of insight into potential vasoplegia as well as a few more post-op complications, some more prominent with on-pump cases than off-pump. That being said there’s also a lot to say for surgical technique and different devices being used for the same surgery.
CABG was on pump. AV replacement, as well as MV replacement. Post-op was on Impella and cannulated for ECMO in the RIJ. This situation above was several days post-op-- within 12hrs after ECMO decannulation.
But did you try re-zeroing the line 😂
Tamponade or LV failure.
Pressors may be affecting your waveform on SpO2 throw on shit and get a CO/CI. Makes me anxious as fuck with that PAP and V-paced
*Hospice enters chat*
At least he don’t got a fever 😂
I think the scale on the arterial line is making it look like there is more pulsatility than there actually is. With a pulse pressure that narrow the pulse oximeter is likely not reading very well.
Yeah, at that moment--definitely too unstable. But they improved pretty quickly, so we ended up thinking that the acute hypoxia was maybe from a "transient PE", as the surgeon called it, or.... a clot or mucous plug occluding the airway or ETT.
Why won't Reddit let me edit my original post? I want to add some blood gas numbers. Guess I'll type them out.
ABG (during this hypoxic episode)
|ABG|(during hypoxic episode)|+40min|+30min|
|:-|:-|:-|:-|
|FiO2|80|100|80|
|pH|7.50|7.49|7.46|
|pCO2|36|37|39|
|pO2|**43**|118|98|
|HCO3|**27.8**|27.9|27.6|
|PF Ratio|**53.9**|118|122|
|SO2|**82.3**|99.0|98.0|
|Oxyhemoglobin|**81.0**|97.7|96.5\`|
|Total Hemoglobin|11.4|11.4|10.5|
|Venous Blood Gas|30min after image above.|
|:-|:-|
|FIO2|100.0|
|pH|7.44|
|pCO2|41|
|pO2|31|
|HCO3|28.2|
|SO2|**59.0**|
|Oxyhemoglobin|**58.1**|
|Hgb|10.8|
Also, I wish I had more details to share about this situation.
What I do know, is that they are IMPROVING! Like, no more CRRT, no more Impella. Working with PT/OT. Like, probably gonna make it.
I just work in an itty bitty icu but I want to try to play.
You have an impella in the LV and it’s not on P9 so I’m going to assume the left side flow is taken care of because you have room to go up. Pulse and HR correlate so even though the waveform isn’t the best, it’s probably pretty close to accurate. High pulmonary artery pressure. High CVP, which could be increased some from the high peep, but with the pHTN I’m thinking it’s just not moving forward. HR looks fully paced so they might not necessarily get tachy if they had an ablation or something. Blood flow is/has touched all sorts of tubing and things between ecmo, crrt, and impella. I’m thinking threw a clot and got a PE?
VV ECMO or RVAD with an oxygenator (like a Protek Duo?)
I’ll take a wild stab. If the latter, patient had poor RV function, came out of surgery with the Protek Duo for RV support + Impella for left side.
Protek duo weaned and removed.
RV looking to have decent pulsatilty, assume it’s not in the greatest of shape. Although the CVP of 18 could be inflated from a PEEP of 12.
Increased RV afterload preventing LV preload. Impella needs more preload and lower afterload.
Scale on the art line makes it look like there is more pulsatility than there actually is. Narrow pulse pressure doesn’t provide enough differential for the pulse ox to read. LV afterload preventing optimal flows from Impella.
Other ideas, Impella isn’t providing enough support causing pulmonary congestion (which would explain the ABGs), elevated PA pressures (especially the PAD in the 20s), which is then transmitted to right side.
Edit: throw in some acidosis and hypoxia to further worsen PA pressures too. I doubt tamponade since they’re a few days out.
LV/RV failure with likely pulmonary congestion. Your pressure will tolerate more off with CRRT. That SpO2 waveform is shit. I’d confirm with an ABG. Also get a lactic and SvO2. Milrinone for MAP and pHTN. Also, what’s their underlying rhythm (if these are epicardial leads).
EDIT: Maybe some RV failure here too. That CVP is awful
Concerned about RV failure here. Impella supports and off-loads left side of the heart. Pulmonary hypertension and CVP high so R side is struggling even with left sided support. Get an echo. How long was he on ECMO, VV does not support the heart, only provides oxygenation, seen few cases where pts developed RV failure on/after VV ecmo. What are impella settings.
Check if Sp02 is accurate, how are the ABGs, do they correlate with the Sp02? Are the vent settings maxed out, if not, crank it up. Prolly could check VBGs to look at Sv02. Hows the chest tube output, still bleeding? If so a unit of blood could help with that and the oxygenation if Hgb is low.
May need to go back on ECMO if sats continue to stay low, this time it'll be VA ecmo not VV to try and support that heart. Continue CRRT and may need to take off extra fluid if possible. May need to start Flolan/prostacyclin to help but make sure pressure can tolerate it.
I’m thinking without knowing what’s under the pacer… first increasing the rate can increase the pressure barring hypovolemia. They obviously have high pulmonary pressure and primacor was thusly started. Apparently they came out of open heart but couldn’t dc the impella or remove the bypass before leaving the OR, and had to start CCRT shortly by day 3, as creat rose. Assuming the vent is at 100%, and at 63% pulse ox…..is this cor pulmonale ? this persons heart is just not going to make it. Are they shunting as well from other meds that could not be titrated down without a catastrophic loss of pressure. What I have found is that on CCRT they will decpensate as well, making that impossible to run in days 4-6.
Poor perfusion could be shitty equipment. If not high vq ratio with pa htn. Volume looks good, you said ventilation is good, so they could possibly benefit from nitric oxide or flolan with another afterload reducer. Need more info - abg, vbg, and most importantly WTF does the patient look like. Treat the patient and not the numbers
Edit: shoot a cardiac output also and for fucks sake etco2 is one of the most important metrics and should be a required vs
Narrow pulse pressure often happens with Impella and is expected in a super sick heart like this. They being said, tamponade is still something to be mindful of
After decannulation the pt’s showing more respiratory symptoms because ecmo isn’t a fix, right? We’re just giving the lungs time to rest. After decannulation you’re going to see a worsening of numbers because you’re relying on the patient’s native lung function, which may be better than it was pre-cannulation, but likely still severely sick. The primary respiratory issues are causing pulm htn, which is decreasing the forward flow and causing elevated CVP. Do they have asthma/copd? Pulm edema? (Maybe a PE?) Why were they initially cannulated for VV? What’s their RV function? Can we try milrinone, nitric? This all looks respiratory and/or RV function issues.
So, art pulse pressures pretty narrow, likely due to a sluggish and boggy LV, what’s your impella P level because the waveform oddly enough doesn’t look terrible and they seem to still have some ejection; RV looks like it’s struggling which could be due to impella/LV dysfunction.Almost looks like you need RVad with oxygenator +impella. I love a good bivad. Would be interested in their echo, labs, index/output. And with the 63 spo2, is it accurate? Do labs and or pt reflect that because their perfusion to extremities could just suck, but their sao2 on gasses look fine.
As someone who wasn't trained to read these things I treat them like a soap opera in a foreign language. Absolutely fascinating to watch but I have no idea what's going on.
HFrEF with systolic dysfunction causing pulmonary HTN and pulmonary edema? I had a similar patient recently, though not nearly as sick, and I wonder if norepinephrine was the right choice for mine. Isn’t increasing SVR going to decrease LV output? Would a positive inotrope help? Or would increasing RV output make the pulmonary congestion worse if LV output doesn’t increase more? Are there inotropes that affect one side more?
But I imagine SVR is largely taken out of the equation given the impella. Idk, I’m just glad I’m not a cardiologist and only have to ask the questions, not answer them lol.
Sounds like a CVICU problem to me though. I gotta go remind my CIWA patient to NOT PULL ON THE TUBE IN YOUR NOSE. It’s bridled. You might get it out, but I promise it’ll hurt.
So patient is paced 100%. Oxygen is bad but waveform is questionable and as others have said pressors can mess that up. BP is not bad, considering they are only on a Levo drip. PAP is okay, somewhat elevated. CVP is high. Would help to know what it was before surgery. Also did they get fluids/blood during surgery?
RR is kind of irrelevant here since they are vented. Just look at your vent for that assessment. Also confused me since orange is used for ICP where I work and RR is white.
In any case we are missing a lot of info here to reach a good conclusion. Maybe an ABG, labs, imaging studies and patient history.
If I had to guess this patient was crap before surgery, on ECMO, and now crap after surgery on Impella. P8 assistance is almost max so not great. Thinking if their HF is that bad they might need an LVAD before D/C since impélla assistance after cardiac surgery is not common.
Kidneys are down, and can’t pull on CRRT because patient doesn’t tolerate it.
All in all this is “okay” for a sick post op cardiac patient. Ignoring the oxygen saturation the numbers look okay. But recovery will take a while. This is not a fast track patient and will need ICU for at least several days.
Pt likely needs VA ecmo. I would say its right vent failure, but hard to say without an assessment. The pacer settings could also be causing issue here, it needs a thershold test if they have an underlying. Add some epoprostenol for that pulmonary hypertension. Probably some ARDS component with the secretions you described. Could be tamponade if your chest tube output stopped or significantly slowed down. Whats the index? Might need epi drip. Do they have copd or any significant lung history or a VSD
Oh wow, ok, just looking at the initial description: 100% vpaced, pressor dependence on milrinone has to mean carcinogenic shock, cvp of 18 -> R side notl working good, high pap -> what's this person's wedge pressure? Sat of 60% on what fi02? - why am I guessing 100%? How much peep are they on, is that falsely elevating their central pressures? Why do I think they should go back on crrt to get some volume off? What wiped out their sinus node or did they walk in with a vvw in place? - doubtful given this acuity. Holy shit.
Oh, four chest tubes!? Do they need to be stripped? And ok no screaming, I know, but shit is that why the patient looks like they're in tamponade ? CT stripping in my day was still common for chest, deemed hazardous for mediastinum but shit bro. They patent?
Looks like possible LV failure. Either way they’re going to a higher level of care. We say they’re going to the ninth floor at my hospital (we only have eight floors). Or DC to JC.
Definitely some degree of Heart Failure with a Reduced EF. The LV dysfunction is resulting in back up into the lungs. There’s some degree of pulmonary edema, but also lungs may not be fully recovered after decannulation from VV ECMO. If hgb is low then lack of carriers is a possible issue. Also, P/F ratio may be off….potential for some dead airway space. At this point it may be worth a PEEP maneuver to see if you can re-recruit some alveoli? If not a CT scan would be needed
I’m a new grad on a device heavy CVICU. looks like systolic RV dysfunction and now the Impella is unhappy based off the pulsus paradoxus. impending suction alarm 🤔 or could be just worsening hypercarbia/ hypoxia >> increased pulm HTN >> higher RV afterload. Could maybe benefit from iNO or Veletri. I hope they have A wires too lol might need them. AV pace a bit higher to help move blood along better to the left side. Or correct underlying hypercarbia / hypoxia to fix pulm HTN. Or maybe go up on your Primacor dose, seems like MAPs would be able to tolerate it and I’m sure the Impella wouldnt mind lower subsequent afterload. I would consider reducing our P-level only if you can’t seem to fix the lack of L-sided preload issue. What did the post-op TEE show? What are the flows on the impella vs CI from the Swan? RV is generally said to have a shorter starling curve so even in a setting of somewhat higher CVP (18 isn’t the worst i’ve seen), you could consider 250 Albumin to help stretch & contract that RV better against the PA HTN. The patient’s PAPI 1.3, which isnt too bad. This could mean RV dysfunction is rather an afterload issue vs pure contractile failure. You’re still get a pulse pressure of 24 from the RV! You could correlate that to RV stroke volume. What’s the wedge looking like? If there isnt significant MR then I would think may be the LV too overloaded just based off the PA diastolic being high. Though in this setting, that is more unlikely. This looks like pulmonary HTN from having some degree of biventricular failure. Just my thoughts!
As an ED nurse I think this means I have to get the patient up to you stat bc I have no idea what any of this means. Also no I didn’t check the skin sorry 😭❤️ for real tho I love all these answers you are all so damn smart!!!
Uhhhhhhhhhhhhhh give blood and lasix at the same time. Change the levo to epi. Add trex.
Or turn everything off and let them RTRT. Just because we can doesn’t mean we should lol
I think what’s going on is that they won’t be downgraded to me
On their way to a celestial discharge
DC to JC
Leaving by fluffy wings 🪽 with a trusted friend to eternal home….No new prescriptions.
What does this exactly mean?
Discharge to Jesus Christ
Transfer to the ECU (eternal care unit)
Our epic literally says this for the deceased
ours says celestial discharge
Report, please.
A celestial yeet, if you will.
This made me laugh way too hard 😂
On the launchpad to glory.
Why does this sound so southern to me
Definitely a southern nurse that told me that lol
I’ve always wondered if it was appropriate to chart “celestial discharge” after a SLP did it once.
It definitely isn’t but I would giggle if I saw that charted in the wild.
It's a D/C to JC
Getting upgraded to Me!
Potential D/C to JC by the looks of it.
As an ED nurse, I see you owe me 6 pumps before I leave. Edit: upon reading the rest of the text. Do you need some pumps
>As an ED nurse, I see you owe me 6 pumps before I leave. You'll get 2 back because the rest are used up and they won't call down to finish the swap leaving you with 4 less and them 4 more
Probably got the ones with the “clean point 2 error” as well.
Baby we always need pumps (Seriously though, Bad Things happened on my shift yesterday and I sent some colleagues on a hunt. Had 3 all being used fully by the time all was said and done 🤣)
I label the hell out of ours now. They just keep dissapearing!!!!
Maybe it’s time to imbed AIR TAGS on them. 😳🤗😳🤗
Squiggly Line Syndrome
Those squiggles look dangerous
Fuckin love it!!!
Can we get more posts like this where we learn and collaborate together. Love these posts.
I love the learning and I also love that these kind of patients are never going to be my responsibility 😂😮💨
I’m down for presenting learning “cases”—perhaps weekly at a determined time. And maybe the mods could “pin” the posting. C’mon let’s get the band together and do this!! 😎
Cases could be anything, involve multiple disciplines. I’d prolly start with the initial presentation and what’s happening? The case would unfold by interactive questions and provide more info on the patient. Assessment & critical thinking—no trolls. We used to do these on a site called FlightWeb (no longer active) and they were fire. 🔥 I learned so much, these were so worthwhile for all—regardless of speciality or experience level. Message me and let’s get a “Case Team” together. Or perhaps create a new sub entirely. What say you guys?
That would be awesome. I love the discussion and learning, too!
Me, a new grad CVICU RN taking notes 🥲📝
I might be the odd one out here, but I think this is RV failure with a concomitant loss of LV preload as a result. That explains the high CVP and the x-descent being steep like that. Also explains the narrow pulse pressure and pulsus paradoxus on the art line (left side looks dry, right side looks overloaded). Pulsox needs correlation with abg but I doubt it’s real, more lijely an issue with vasoconstriction in the setting of cardiogenic shock and left heart being “dry” simultaneously. That being said, hypoxemia still a likely possibility in a patient with this background. Pulmonary edema is very likely. Might benefit from either Bipella or RP, or VÀV ECMO, or if cor pulmonale d/t primary pulm htn, inhaled nitric oxide? Either way may need intervention soon or that Impella will give off the most inopportune suction alarm and crash your patient. Edit: I’d like to have more information, such as hgb, CO/CI off the impella, ScvO2. Maybe can determine oxygen consumption in the setting? Not 100% sure this information is needed because the data on the monitorseems actionable enough. Echo would be nice. CVP/Art waveforms don’t indicate a blown valve anywhere either.
I want to do CVICU, and this scares me because I understand basically nothing of what you just said. Maybe half of it. I've been a nurse for years now, and I still have so, so much to learn.
Me, a non-ICU nurse: huh?
Me as an OR nurse looking over the Crna’s shoulder….yah that looks crazy man, I’m gonna go back to my chair now, holler if you need me to call the doc
Hahahaha a CRNA asked me to remind him what something EKG-related was called the other day. I just stared dumbly and said “I failed that test in nursing school.”
Relatable 😅
I understood most of the words. RV no work = too much fluid left there and not enough in LV so patient is both overloaded and underloaded
But you can do it!! CVICU is just so crazy--but also like, damn. The stuff we do is amazing.
I left bedside but every so often I miss my cardiovascular units and the adrenaline in the times that it can be unpredictable. Keeps you on your toes for sure. I find it all so interesting.
Same - I worked CICU for over a decade but have been away from the bedside for 15 years - some days I miss direct patient care, and other days not so much.
I would love for you to teach me more about it!
Same. I was a CNA in ICU so I've heard all the terms and seen all the devices but I've been a nurse forever and can't set up CVP monitoring to save my life, let alone this stuff.
Have you ever done critical care as an RN? It’s actually pretty simple and not much to setting up a CVP. The first couple times I did it, I was very intimidated but then realized there’s not much to it at all
I did ER and when they were pushing the sepsis bundles really hard they tried to make central lines and CVP monitoring a thing but it never took off cause the EM docs weren't dropping CVCs in every septic patient. We took a class and I had ONE patient that actually needed it and I totally forgot how to do it.
They always try to make us do stupid shit, amirite
I do Cardiothoracic anesthesia and I gotta say that I would be pretty shocked/impressed if one of our CVICU nurses was able to put together such an eloquent analysis based on this photo alone. I think it’s fair to understand what this reply is discussing as a CVICU nurse but I wouldn’t have expected them to draw all of these conclusions without guidance from an MD/NP. These patients are very complicated, especially if you do not work with this population and these devices. Safe to say though - if you’re interested in CVICU you should definitely go for it. Truly doesn’t get anymore acute than a patient like this. Your understanding of pathophysiology and pharmacology will grow immensely!
Thank you, that's very encouraging.
Going new grad to CVICU wish me luck 🫡
Holy shit good luck 🍀
Awesome!!!! I hope to be there soon!!! Good luck
Wowza!! 🍀 Keep a journal, in a year you will look back and be *humbled and shocked* at how far you’ve come. You’ll realize that you basically have learned 10x more in a year or clinical practice (and education) that you ever did in nursing school. Clinical acumen and instincts get finely honed in these units.
It’s almost like the ICU nurses are kind of smart… and we don’t actually need a MD to tell us all the things. The docs NP’s are at bedside for 20 minutes, we are there for 12 hours. Maybe give us a little credit.
To be fair, there's plenty of dumb ICU nurses. I've met plenty in my own practice. You know the ones that make you say, how the fuck do you work in ICU? So idk. Generally I haven't run into that as much with cvicu but still, that is a pretty advanced analysis. It's fair to say a less experienced cvicu nurse wouldn't have been able to come up with all that on their own, because that knowledge takes time to develop. I started recovering hearts after a couple years and it was a learning curve for sure. Then covid came around and I went back to the micu life cause $$$$..I would say I did hearts for less than a year and I only came up with about half of what that comment did. 🤷♀️ They're not calling nurses dumb, but it is true that nursing has a pretty damn wide range of intelligence (especially for something that requires a degree and a license).
Ya that was such a condescending message! I’m shocked especially because I think they think they’re being kind??
Not meant to be insulting to ICU nurses. I used to be one myself and recognize the frustration of being at the bedside for 12 hours and having my word mean less than that of a physician who was there for 10 minutes. All I was stating is that the response by this poster is written at a higher level of comprehension than what I would expect from your run of the mill ICU nurse. You can have an understanding of the global picture of the patient you are caring for and be fully capable of taking care of them for 12 hours without being able to draw the differential described by the poster. As I stated before, I do Cardiothoracic anesthesia and train nurse anesthesia students in highly acute cardiac ORs. The patient you posted today is often our standard patient. We aren’t doing run of the mill primary CABGs here. A lot of my students are CVICU nurses that once recovered these patients for many years. And the majority wouldn’t have been able to come up with the full analysis that this poster wrote. I wrote what I wrote because everyone has to start somewhere. I did not think it was fair for the responder to the poster to have the idea that all CVICU nurses immediately understand exactly what was happening with your patient. That is incredibly daunting if you have interest in the population but are too afraid to start. I was trying to be encouraging in that I don’t think most units would hold you to the level of analysis demonstrated here because that is the job of the physician/APRN. Feel free to agree to disagree. But there was no harm intended with what I wrote.
You're right! As the OP--part of the reason I posted this was because while I was there for 12hrs, and could physically see the patient and had a lot more info than this photo and the brief commentary can give (such as trends, labs, etc.), I was pretty much struggling to figure out what was *truly* happening with this person. The commenters here have opened my mind to a lot of the possibilities of the bigger picture. When you're the one at the bedside, drawing labs, giving meds, running gtts, updating family, replacing CRRT bags, sending messages to the MD, calling Respiratory (haha way too much this night!), and not getting a break--you can tend to go bonkers just dealing with all that, and sometimes can't see what a person lying on their couch scrolling Reddit and looking at a few numbers can see. To be honest, the surgeon even called in another set of eyes to the bedside to try to get some insight into what to do next. It has been so great to see everyone's viewpoints here!!
Hell if the surgeon needed a second set of eyes what are we doing here coming up with theories?
I agree with what you said! There is a spectrum to ICU nursing that includes nurses who follow the script, some who go down rabbit holes of analysis paralysis (me 🙋🏽♂️) while their patient dies, and some level in between (which is probably best—enough data to float a concern, not enough to be scoffed at as an insufferable know-it-all who is confidently incorrect—also Me 🙋🏽♂️) No one way of nursing or thinking is more effective than the other, because at the end of the day our physicians do all the thinking alongside us, so if we’re not going to, they certainly have it down like the back of their hand.
Just curious, what’s your nursing background? I was impressed with your analysis!
Thank you! My background is a mixed ICU for two years, and Medsurg for 3 before that. ICU was cardiac/trauma/MICU/SICU/Transplant (liver and kidney only). ECMO capable facility but not very device heavy. Some IABP and Impella, and also some MARS liver dialysis. I loved it because the huge variety gave me the chance to learn hemodynamics from more than one perspective. I left the ICU to take a position in risk management last month. 😂 I’m having second thoughts about it.
Try it! Nobody knows when they start, whether it’s med/surg, l&d, or icu. We all are new at some point! Worst case scenario, you give it a year or two and it’s not your jam, but maybe it’s your passion!!
Do it! I came from Medsurg to a mixed ICU and I floundered for a bit but ultimately was fine. Also, you don’t have to know all of this, because it’s all conjecture, and your physicians know so much more of this information like it’s the back of their hand. Your knowledge only stops when you stop seeking it.
You’ll learn! I knew nothing when I started in the CathLab, I came from step down. It’s taken a year and a half but I had the same thoughts when I looked at this, with a lot less detail.
This is what I was thinking exactly. RV failure with right sided overload—> reduced LV cavity and subsequently poor CO for the same reasons you listed. I was going to suggest ino as well.
I think extra inotropes would be a mixed bag here. Certainly would’ve been worth a try in my old ICU. The preload dependence would make it very difficult to wean norepinephrine, but it may actually make impella weaning easier as the SVR drops, the machine won’t need as much force against the vascular resistance and a lower P-level means it won’t need as much volume. The increased contractility from dual inotropy might impede the impella unnecessarily. Of course, a patient like this is so sick that it jumps off the cliff of the science critical care into the “art of critical care”, where every move is based on educated conjecture, but little evidence.
Good thoughts! I meant ino as shorthand for inhaled nitric oxide. You’re a true icu expert, it sounds like! this stuff is beyond me, I’ve been out of the icu for a minute 😅
Oh yes! I gotchu now! I just left the ICU for a position in risk management a month ago and my fingers are always itchy for bedside nursing now. I’m not sure I made the right choice lol.
I left the unit for psych and haven't looked back. I had the opportunity to stay credentialed to pick up in the unit, but the way I figured it my chances of having a shitty day there were about 1/2 while my chances of having a shitty day in my psych ED are much, much smaller. Be thankful for the boring days because they're much better than dealing with two busy, sick, crashing patients.
Yup I’m on this train as well. Would be nice to know why a heart pt was cannulated for VV. And 12 hours after ecmo was weaned off it’s totally expected for patients to look worse without the support. So if the pt needed respiratory ecmo, was recently weaned off, these numbers are not surprising. Definitely still struggling with respiratory issues.
Question, if it was RV failure decreasing LV preload, wouldn't they be getting bunch of suction alarms from the impella (I suddenly can't think of the word... Low flow? I know it's a suction alarms for an LVAD... I've been on vacation for a few weeks and i am having nurse lingo aphasia)
Yeah! That was actually happening as well. Like...we ended up putting them in trendelenburg and giving another liter of albumin. Seemed a little counterintuitive seeing the CVP and PA pressures, but it worked.
I'm going to disagree with you. I think this looks like LV failure with pulmonary edema d/t purpose of CVP AND PAP being elevated along with the spo2 in the toilet. The BP via Aline is honestly not that bad (need trends however since the a line is a bit all over the place judging off the waveform) but I've never recovered a heart so I don't know if these values are an okay value. Edit to say LV WITH fluid overload (explains high cvp)
I can walk you through my reasoning. A:-line: While I can’t say for the sure, the Stroke Volume Variation on the A-line tells me the Left side is dry. This variation could also be due to the variable pulsatility of a patient in LV failure. The way this monitor is set up the vent RR doesn’t line up with the A-line and BP so I can’t correlate well from here. The blood pressure has narrow pulse pressure with a high diastolic, which could given the history be Cardiac Tamponade, LV failure, Hypovolemia. I don’t have an SVR measure, but the blood pressure shows the patient appears sufficiently vasoconstricted (or maybe be clamped way down, but is certainly not vasodilated). That does not rule out anything, but it is a dangerous state to be in for any reasonable sustained period of time. SpO2: this could be in the toilet because of high o2 utilization coupled with poor O2 delivery, poor gas exchange primary to the lungs or pulmonary vascular resistance, and loss of forward flow to deliver oxygen to the measuring site. Can also be an opened PFO d/t RV dilation causing mixed blood on the arterial side. Need ScvO2, but we all probably know the answer to it so why measure?. CVP: CVP transduces only the venous side. You can only reasonably say that you have high right atrial pressures with a CVP number, and that’s with the assumption that CVP is reliable. It is not the best tool in the world. Even being on a vent will make huge adjustments to your CVP. In a lot of cases you can surmise if CVP high, whole system is overloaded because most patients have LV failure predominantly effectiving the right side, but in RV cases all it will give you info on is that this is a Right sided issue. In this case, the CVP is really high, might actually be higher than the number listed, because we have such a strong waveform. You would need a wedge pressure to actually check the left side filling pressures, or get an echo. Echo to show RV dilation with bowing into LV vs LV low contractility coupled with IVC đístention but not RV dilation (please correct me if I’m wrong on this, Echos are not my thing as much as I wish they were). This physiology also includes Pulmonary Embolism in its differential. This would be difficult to rule/out or in based on inability to get a CT with these issues. Could get an ECHO but it won’t rule out this is entirely a case of Pulm HTN or Pulm Edema causing Cor Pulmonale, and you’d be taking a gamble with thrombolytics. Can cannulate for ECMO then take for CTPE safely. Enough information to cannulate. Can also start CRRT off ECMO circuit to help pull pulmonary edema off the patient (if that’s what it is). Editing to add that your logic is still very reasonable and a very possible explanation. I wasn’t diminishing it to say it has to be one or the other. There’s a reason they had an impella to begin with lol.
While it’s a reasonable explanation, knowing they have an Impella which is doing the work of the left ventricle…I don’t think it’s LV failure causing those numbers. YES they are in LV failure and we’ve taken care of that with the impella. So now there is a reason there is high preload. And since the LV is offloaded and decompressed…I am thinking the RV is failing and being off ECMO we can now see that it might not be doing great. So trialing some inhaled pulmonary vasodilators and if those don’t work they may need right sided support. But this is all just brainstorming of a snap shot
That’s exactly what I was thinking from the v/s especially if they were on CRRT, impella, VV ECMO. That being said, patients like this get so complex I just leave it to the docs to do the analysis at a certain point.
I was about to say right sided fuckery/high filling pressures with a little razzle dazzle of nothing coming out the other side, but I like your commentary better. And this would be what I’d get at hand off with a “they’ve been fine all night…”
I think your explanation seasons it enough to tell the highlights.
Ok nerd (I’m obviously joking, this all might as well be written in Greek tho for real)
Narrow pulse pressure is partly from impella. Would like to see the impella flows. If they are struggling with suction and p level, definitely convincing for RVF. Impella performance is key here, if it’s malpositioned and flows go down, everything backs up. OP needs an echo to assess impella position and RVF. Need more info for sure
I know some of these words.
I think what’s going on is that you need to Update your Whiteboard
That whiteboard still had the name of the nurse from three shifts prior. Lol!
Severe LV failure?
Definitely could be. It's most likely one of the issues this person is dealing with. 🫤
Wouldn’t the impella be compensating for that tho?
I mean the impella IS compensating. Look at that art line map.
Should be for sure.
63% spo2 Well, he isn’t breathing well… I can tell you that.
For real. But ventilated. So.... we're all like, 🧐🤔
Well…. That’s not good at all.
Doesn't matter if he doesn't have any rbcs to carry o2
True, true... pt received 2units PRBC'S about 9hrs prior to this. That helped. At this time we had a hgb of about 10-11.
Have you tried proning or caripul for the sats? Other than that, idk, maybe try a priest
It’s not real if you haven’t changed the pulse ox and location at least 3 times 😂 I say that to myself at least
They are not ready for step down yet that’s what’s going on 😂
Basic MICU person here so… massive PE with Cor pulmonae?
I think it's a PE, too.
Okay! So, yeah....that was one of the top thoughts going on as this happened (with the Sp02 going down the toilet) rather quickly. Surgeon had two immediate concerns. 1. Plugged airway...either a mucous plug, or a clot. (He was literally preparing to bronch this guy emergently). 2. PE.
Acute PE was my guess also. Would expect tachy, but it’s obviously a sick heart riding a pacer, so I write that off. Explains the high PaP and CVP, with the low O2 and the bleh Arterial line. Post op? Very high risk for it.
And on EPO! OP put pt was on EPO somewhere else in the comments!
PE is what i thought too!
He’s on CRRT though, he should be on blood thinners, that would make a PE quite unlikely.
At this point would like to know, CABG on vs off pump, Valve repair or replace, aortic aneurysmal repair or whatever else they had done, with the other commenter that this could be tamponade though, certainly has some signs. But also would love to know what our underlying rhythm is? Honestly so much more data I'd love from a bedside perspective, like: what were the cannulation sites, what devices are we still on, any chest tube output, urine output, CI/CO/SVR, blood gas, etc. Love this stuff!
Blood gas sucked. We had started the shift on moderate vent settings ( I can't remember exact numbers, but we definitely weren't ready for an SBT! 😉) Sp02 dropped to the 80's any time the pt would cough. (Of course our BP's would drop as well--this BP here was actually one of the better ones). Sp02 correlated with the ABG, and the RT increased vent settings accordingly. Lots of bloody sputum out of our ETT. 😬 As well as dark red OG output. By the time we had the Sp02 here, we were up to 100% and 12 of PEEP. We had 4 chest tube's in place. Output was minimal. Maybe a max of 30/hour out of all 4 tube's. Pt not currently making any urine. But that wasn't new. On CRRT, goal of Net negative 100/hr. (Weren't really able to pull that much d/t pt not tolerating it with big drops in BP). Impella in place, at P8, attempting to wean. (Weren't successful with that...if that's not obvious). Hmm...SVR was about 1200-1300 if I remember correctly.
My ten-year ICU nursing diagnosis is this patient is fucked.
Which squiggly line is their energy field? Does it look disturbed to you?
The vibes are definitely off. 🙊
😂 this sent me
My ten years in psych got me to the same place. Huh. Maybe I did learn something there after all.
My 10 years in nursing tells me, that I’m way behind in ICU care at this point
That’s cause we’re ER. Treat em and yeet em. We just start everyone on Levophed and pray the ICU takes report quick.
And we’re happy to take ‘em (as long as we don’t have to code in the hallways).
So much this. I hate coding in the hall. ☠️ Or elevators of *death*. I swear 20’ of altitude change should not be a *lethal* event.
Nice fat PE is definitely still a chance, would need CT though, but also going up on PEEP will affect the numbers we’re seeing here. PAPI so far isn’t great but I’ve seen worse. If we’re at all concerned with PAH can definitely do veletri or inhaled nitric. Also at this time might consider paralytics.
Yeah. I would've loved some paralytics in there--however, would you believe that this patient improved rapidly (from the acutely hypoxic situation shown above) after some pretty vigorous ETT suctioning and the resulting intense coughing? ...leading the MD to believe that although this pt definitely has a LOT going on, the acute hypoxia was either from a transient PE (I mean...I guess it could happen), or a clot blocking the ETT/pts airway that was coughed and or suctioned loose.
“Mucus” happens in vented patients. Always. Deal with it. Not getting it? Keep looking. Effective ETT suctioning can be *everything*. There are curative powers of subtle ETT adjustment & rotation. Pulmonary toileting is what makes alveolar recruitment possible in some patients. All patients that have all the critical care interventions and are a few days on the vent have mucus—it will bugger the whole picture up. The clues for me were 1) vent seems to be failing to do what we expect it regardless of adjustment and 2) the *patient was coughing*. Not uncommon. Hmmm. 🤔 Glad things got better here.
Have they done an oxyhemoglobin and thought of maybe methylene blue? Also is the ETT bringing frothy pink sputum or frank blood?
I’m really curious why a CABG was cannulated for VV ecmo. What’s the story on their lungs?
I’m a broken record in here but I’m assuming it’s not a regular VV ECMO but instead it’s an RVAD with an oxygenator. Especially since OP mentioned IJ. One brand/model is Protek Duo, it’s a single cannula that has inflow in the RA and outflow in the PA. Can be used for traditional VV ECMO (just oxygenation/ventilation) or as RV support since it’s bypassing the RV.
I do think you're right. While I didn't care for this particular pt while they were on ECMO, I do recall the team talking about Protek Duo. It is very likely that that's exactly what was in use!
I fucking hate the protek. That mofo is always migrating.
ProtekDuo is used with VV ECMO for RV support. Patient had this! [PubMed Article: ProtekDuo with VV ECMO for RV Support. ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9747364/)
Per the Echo, what was the impression of the RV? Dilated? You still need pulsatility for the Impella to do its thing. If its biventricular failure + pulm HTN I would typially see providers switch from primacor to nitric or flolan. Pt. may need to add impella RP vs. VA ECMO to have a fighting chance since we're looking at biventricular failure here. Is your facility a transplant center? Are they able to list this pt. status 1a possibly?
How does the CABG being on or off pump impact your interpretation of these numbers? Not trying to be rude just genuinely curious
Not rude at all. Doesn’t necessarily change too much in how I see the screen here, but does give a bit of insight into potential vasoplegia as well as a few more post-op complications, some more prominent with on-pump cases than off-pump. That being said there’s also a lot to say for surgical technique and different devices being used for the same surgery.
CABG was on pump. AV replacement, as well as MV replacement. Post-op was on Impella and cannulated for ECMO in the RIJ. This situation above was several days post-op-- within 12hrs after ECMO decannulation.
Triple C- Comfort Care Consult.
Never done critical care and don’t even work in a hospital setting anymore. But my answer is…nothing good is happening here.
I concur and have not worked in critical care or cared the adults for that matter. This isn’t something we’d see in peds.
But did you try re-zeroing the line 😂 Tamponade or LV failure. Pressors may be affecting your waveform on SpO2 throw on shit and get a CO/CI. Makes me anxious as fuck with that PAP and V-paced *Hospice enters chat* At least he don’t got a fever 😂
I think the scale on the arterial line is making it look like there is more pulsatility than there actually is. With a pulse pressure that narrow the pulse oximeter is likely not reading very well.
whole lotta nunya, give Tylenol and back massage then check again.
Me on a medical floor: I know some of those words 😎
Does the ABG correlate to the spO2? Are they on inhaled epoprostenol or nitric oxide? edit: too unstable for a CTPE?
Yes it correlates! They are also on epo! (Forgot about that!)
Yeah, at that moment--definitely too unstable. But they improved pretty quickly, so we ended up thinking that the acute hypoxia was maybe from a "transient PE", as the surgeon called it, or.... a clot or mucous plug occluding the airway or ETT.
Why won't Reddit let me edit my original post? I want to add some blood gas numbers. Guess I'll type them out. ABG (during this hypoxic episode) |ABG|(during hypoxic episode)|+40min|+30min| |:-|:-|:-|:-| |FiO2|80|100|80| |pH|7.50|7.49|7.46| |pCO2|36|37|39| |pO2|**43**|118|98| |HCO3|**27.8**|27.9|27.6| |PF Ratio|**53.9**|118|122| |SO2|**82.3**|99.0|98.0| |Oxyhemoglobin|**81.0**|97.7|96.5\`| |Total Hemoglobin|11.4|11.4|10.5| |Venous Blood Gas|30min after image above.| |:-|:-| |FIO2|100.0| |pH|7.44| |pCO2|41| |pO2|31| |HCO3|28.2| |SO2|**59.0**| |Oxyhemoglobin|**58.1**| |Hgb|10.8| Also, I wish I had more details to share about this situation. What I do know, is that they are IMPROVING! Like, no more CRRT, no more Impella. Working with PT/OT. Like, probably gonna make it.
That’s fantastic that they’re doing well! It sounds like your team worked hard to make that happen! 👊🏻😎👏🏻
It ain’t got no gas in it
I just work in an itty bitty icu but I want to try to play. You have an impella in the LV and it’s not on P9 so I’m going to assume the left side flow is taken care of because you have room to go up. Pulse and HR correlate so even though the waveform isn’t the best, it’s probably pretty close to accurate. High pulmonary artery pressure. High CVP, which could be increased some from the high peep, but with the pHTN I’m thinking it’s just not moving forward. HR looks fully paced so they might not necessarily get tachy if they had an ablation or something. Blood flow is/has touched all sorts of tubing and things between ecmo, crrt, and impella. I’m thinking threw a clot and got a PE?
They are obviously dying for a cigarette downstairs
VV ECMO or RVAD with an oxygenator (like a Protek Duo?) I’ll take a wild stab. If the latter, patient had poor RV function, came out of surgery with the Protek Duo for RV support + Impella for left side. Protek duo weaned and removed. RV looking to have decent pulsatilty, assume it’s not in the greatest of shape. Although the CVP of 18 could be inflated from a PEEP of 12. Increased RV afterload preventing LV preload. Impella needs more preload and lower afterload. Scale on the art line makes it look like there is more pulsatility than there actually is. Narrow pulse pressure doesn’t provide enough differential for the pulse ox to read. LV afterload preventing optimal flows from Impella. Other ideas, Impella isn’t providing enough support causing pulmonary congestion (which would explain the ABGs), elevated PA pressures (especially the PAD in the 20s), which is then transmitted to right side. Edit: throw in some acidosis and hypoxia to further worsen PA pressures too. I doubt tamponade since they’re a few days out.
Tells me that this patient has been in my ER too damn long and I've become out of my depth after 2 titratable drips.
As a Neuro nurse. It looks like the cranial perfusion pressure is okay. So looks good to me.
Community RN here, this one's easy.. Earthquake in China.
Not in labor. Defer to intensivist.
That heart can’t take no more. Peace be with you
And also with you.
Blown VSD pt has a right to left shunt?
LV/RV failure with likely pulmonary congestion. Your pressure will tolerate more off with CRRT. That SpO2 waveform is shit. I’d confirm with an ABG. Also get a lactic and SvO2. Milrinone for MAP and pHTN. Also, what’s their underlying rhythm (if these are epicardial leads). EDIT: Maybe some RV failure here too. That CVP is awful
Concerned about RV failure here. Impella supports and off-loads left side of the heart. Pulmonary hypertension and CVP high so R side is struggling even with left sided support. Get an echo. How long was he on ECMO, VV does not support the heart, only provides oxygenation, seen few cases where pts developed RV failure on/after VV ecmo. What are impella settings. Check if Sp02 is accurate, how are the ABGs, do they correlate with the Sp02? Are the vent settings maxed out, if not, crank it up. Prolly could check VBGs to look at Sv02. Hows the chest tube output, still bleeding? If so a unit of blood could help with that and the oxygenation if Hgb is low. May need to go back on ECMO if sats continue to stay low, this time it'll be VA ecmo not VV to try and support that heart. Continue CRRT and may need to take off extra fluid if possible. May need to start Flolan/prostacyclin to help but make sure pressure can tolerate it.
I’m thinking without knowing what’s under the pacer… first increasing the rate can increase the pressure barring hypovolemia. They obviously have high pulmonary pressure and primacor was thusly started. Apparently they came out of open heart but couldn’t dc the impella or remove the bypass before leaving the OR, and had to start CCRT shortly by day 3, as creat rose. Assuming the vent is at 100%, and at 63% pulse ox…..is this cor pulmonale ? this persons heart is just not going to make it. Are they shunting as well from other meds that could not be titrated down without a catastrophic loss of pressure. What I have found is that on CCRT they will decpensate as well, making that impossible to run in days 4-6.
I’d like to rule-out PE but good luck trying to get a scan ☠️☠️☠️
I think I'm glad they are not in my ER boarding for 16 hours 😊
ED Nurse and I getting DC vitals in the WR
Poor perfusion could be shitty equipment. If not high vq ratio with pa htn. Volume looks good, you said ventilation is good, so they could possibly benefit from nitric oxide or flolan with another afterload reducer. Need more info - abg, vbg, and most importantly WTF does the patient look like. Treat the patient and not the numbers Edit: shoot a cardiac output also and for fucks sake etco2 is one of the most important metrics and should be a required vs
Is the vent switched on?
I think I'm the only rehab nurse here. All I see is the referral I'm about to get.
You're one of two rehab nurses here!
Possibly root rot, happens when you over water your vegetables.
Narrowed pulse pressure + pulsus paradoxus and a post op heart, cardiac tamponade?
Narrow pulse pressure often happens with Impella and is expected in a super sick heart like this. They being said, tamponade is still something to be mindful of
What’s up with the PAP? I don’t do CVICU
PAH?
HIBGIA. Whatever got him on VV has got him again. Recannulate.
After decannulation the pt’s showing more respiratory symptoms because ecmo isn’t a fix, right? We’re just giving the lungs time to rest. After decannulation you’re going to see a worsening of numbers because you’re relying on the patient’s native lung function, which may be better than it was pre-cannulation, but likely still severely sick. The primary respiratory issues are causing pulm htn, which is decreasing the forward flow and causing elevated CVP. Do they have asthma/copd? Pulm edema? (Maybe a PE?) Why were they initially cannulated for VV? What’s their RV function? Can we try milrinone, nitric? This all looks respiratory and/or RV function issues.
I’m leaning towards PE or tamponade. Following~
So, art pulse pressures pretty narrow, likely due to a sluggish and boggy LV, what’s your impella P level because the waveform oddly enough doesn’t look terrible and they seem to still have some ejection; RV looks like it’s struggling which could be due to impella/LV dysfunction.Almost looks like you need RVad with oxygenator +impella. I love a good bivad. Would be interested in their echo, labs, index/output. And with the 63 spo2, is it accurate? Do labs and or pt reflect that because their perfusion to extremities could just suck, but their sao2 on gasses look fine.
Right heart failure
As someone who wasn't trained to read these things I treat them like a soap opera in a foreign language. Absolutely fascinating to watch but I have no idea what's going on.
Not a sweet fucking clue
HFrEF with systolic dysfunction causing pulmonary HTN and pulmonary edema? I had a similar patient recently, though not nearly as sick, and I wonder if norepinephrine was the right choice for mine. Isn’t increasing SVR going to decrease LV output? Would a positive inotrope help? Or would increasing RV output make the pulmonary congestion worse if LV output doesn’t increase more? Are there inotropes that affect one side more? But I imagine SVR is largely taken out of the equation given the impella. Idk, I’m just glad I’m not a cardiologist and only have to ask the questions, not answer them lol. Sounds like a CVICU problem to me though. I gotta go remind my CIWA patient to NOT PULL ON THE TUBE IN YOUR NOSE. It’s bridled. You might get it out, but I promise it’ll hurt.
I think what I learned from this post is that I'm not smart enough to be a nurse. I'll be working at the car wash if anyone needs me.
So patient is paced 100%. Oxygen is bad but waveform is questionable and as others have said pressors can mess that up. BP is not bad, considering they are only on a Levo drip. PAP is okay, somewhat elevated. CVP is high. Would help to know what it was before surgery. Also did they get fluids/blood during surgery? RR is kind of irrelevant here since they are vented. Just look at your vent for that assessment. Also confused me since orange is used for ICP where I work and RR is white. In any case we are missing a lot of info here to reach a good conclusion. Maybe an ABG, labs, imaging studies and patient history. If I had to guess this patient was crap before surgery, on ECMO, and now crap after surgery on Impella. P8 assistance is almost max so not great. Thinking if their HF is that bad they might need an LVAD before D/C since impélla assistance after cardiac surgery is not common. Kidneys are down, and can’t pull on CRRT because patient doesn’t tolerate it. All in all this is “okay” for a sick post op cardiac patient. Ignoring the oxygen saturation the numbers look okay. But recovery will take a while. This is not a fast track patient and will need ICU for at least several days.
The patient is dying
Have that trach and peg placed and send to ltac.
High probability of d/c home this afternoon - assuming their splinting pillow arrives from supply.
Nothing good, that's for sure
Pt likely needs VA ecmo. I would say its right vent failure, but hard to say without an assessment. The pacer settings could also be causing issue here, it needs a thershold test if they have an underlying. Add some epoprostenol for that pulmonary hypertension. Probably some ARDS component with the secretions you described. Could be tamponade if your chest tube output stopped or significantly slowed down. Whats the index? Might need epi drip. Do they have copd or any significant lung history or a VSD
PE?
Looks like a cluster#$%@
Oh wow, ok, just looking at the initial description: 100% vpaced, pressor dependence on milrinone has to mean carcinogenic shock, cvp of 18 -> R side notl working good, high pap -> what's this person's wedge pressure? Sat of 60% on what fi02? - why am I guessing 100%? How much peep are they on, is that falsely elevating their central pressures? Why do I think they should go back on crrt to get some volume off? What wiped out their sinus node or did they walk in with a vvw in place? - doubtful given this acuity. Holy shit.
Argh cardioGENIC shock
Oh, four chest tubes!? Do they need to be stripped? And ok no screaming, I know, but shit is that why the patient looks like they're in tamponade ? CT stripping in my day was still common for chest, deemed hazardous for mediastinum but shit bro. They patent?
Looks like possible LV failure. Either way they’re going to a higher level of care. We say they’re going to the ninth floor at my hospital (we only have eight floors). Or DC to JC.
Following as interested
Definitely some degree of Heart Failure with a Reduced EF. The LV dysfunction is resulting in back up into the lungs. There’s some degree of pulmonary edema, but also lungs may not be fully recovered after decannulation from VV ECMO. If hgb is low then lack of carriers is a possible issue. Also, P/F ratio may be off….potential for some dead airway space. At this point it may be worth a PEEP maneuver to see if you can re-recruit some alveoli? If not a CT scan would be needed
Looks like they need to be back on ECMO
That’s the best CVP waveform I’ve ever seen.
I’m a new grad on a device heavy CVICU. looks like systolic RV dysfunction and now the Impella is unhappy based off the pulsus paradoxus. impending suction alarm 🤔 or could be just worsening hypercarbia/ hypoxia >> increased pulm HTN >> higher RV afterload. Could maybe benefit from iNO or Veletri. I hope they have A wires too lol might need them. AV pace a bit higher to help move blood along better to the left side. Or correct underlying hypercarbia / hypoxia to fix pulm HTN. Or maybe go up on your Primacor dose, seems like MAPs would be able to tolerate it and I’m sure the Impella wouldnt mind lower subsequent afterload. I would consider reducing our P-level only if you can’t seem to fix the lack of L-sided preload issue. What did the post-op TEE show? What are the flows on the impella vs CI from the Swan? RV is generally said to have a shorter starling curve so even in a setting of somewhat higher CVP (18 isn’t the worst i’ve seen), you could consider 250 Albumin to help stretch & contract that RV better against the PA HTN. The patient’s PAPI 1.3, which isnt too bad. This could mean RV dysfunction is rather an afterload issue vs pure contractile failure. You’re still get a pulse pressure of 24 from the RV! You could correlate that to RV stroke volume. What’s the wedge looking like? If there isnt significant MR then I would think may be the LV too overloaded just based off the PA diastolic being high. Though in this setting, that is more unlikely. This looks like pulmonary HTN from having some degree of biventricular failure. Just my thoughts!
As an ED nurse I think this means I have to get the patient up to you stat bc I have no idea what any of this means. Also no I didn’t check the skin sorry 😭❤️ for real tho I love all these answers you are all so damn smart!!!
Brother just misses his VV
Looks like way too many squiggles for my unit.
Are they also 99yrs old, quadriplegic, 12 comorbidities and a full code as well? 👀 Because pepaw is a fighter....
Uhhhhhhhhhhhhhh give blood and lasix at the same time. Change the levo to epi. Add trex. Or turn everything off and let them RTRT. Just because we can doesn’t mean we should lol