Critical Care Case Studies

Critical Care Case Studies-5
FIGURE 1: CT scan of the chest demonstrating pulmonary emboli in bilateral main pulmonary artery What distinguishes massive from submassive pulmonary embolism? Anticoagulation was initiated and the patient was transferred to the intensive care unit (ICU) for further management.Although in the past, peri-operative mortality was a high as 57%, some experienced centers now report peri-operative mortality of approximately 6% [33].

FIGURE 1: CT scan of the chest demonstrating pulmonary emboli in bilateral main pulmonary artery What distinguishes massive from submassive pulmonary embolism? Anticoagulation was initiated and the patient was transferred to the intensive care unit (ICU) for further management.Although in the past, peri-operative mortality was a high as 57%, some experienced centers now report peri-operative mortality of approximately 6% [33].

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In patients with less severe hypotension and more severe cardiac dysfunction, inotropic agents may be considered as an adjunct or alternative to norepinephrine [6-11].

Newer inotropic agents, such as amrinone, which act as both inotropic agent and pulmonary vasodilator have shown promise in animal studies and case reports [12,13].

She was brought to the emergency department, where vital signs were notable for temperature of 100.9ºF, HR=142/min, BP=90/60 mm Hg after intravenous fluids, with oxygen saturation of 99% while breathing 100% oxygen via non-rebreather mask.

Columbia University College of Physicians and Surgeons HISTORY:55-year-old female nursing home resident with past medical history of AIDS, dilated cardiomyopathy (estimated left ventricular ejection fraction 15% on a previous transthoracic echocardiogram), and prior deep venous thrombosis (DVT) was found to be hypotensive and in respiratory distress while at her skilled nursing facility.

Rotatable pigtail catheter [20]: The pigtail tip of this catheter (Cook Europe; Bjaeverskov, Denmark) is rotated either by hand or by an attachable low-speed electric catheter to disrupt the intrapulmonary clot into smaller fragments which then migrate into the distal pulmonary circulation.

The catheter can be advanced into peripheral pulmonary branches and manually rotated to further clot fragmentation.

One study in humans [14], however, suggested that a 500 ml fluid load may initially improve cardiac output among patients with massive PE, although the long-term effects of fluid administration on cardiac function and hemodynamics are unclear.

Most authors would agree that intravenous fluids must be used with caution in patients with massive PE [15-17].

HOSPITAL COURSEAfter admission to the ICU, the patient received an intravenous infusion of unfractionated heparin drip and an intravenous infusion of norepinephrine at 5 micrograms/minute for hemodynamic support.

A Foley catheter was placed with urine output remaining 2g/d L hemoglobin drop­) developed.

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