ICU stories: Starting a night shift and knowing very little about the pt, I walked in the room (eldelrly, POD #2 "heart surgery", on the vent + on HD) and I saw this on the monitor. What did I do not like in the waveforms (pt had femoral aline and RIJ Swan)? No quiz coming...
Arterial line waveform was very spikey with 2-3 spikes. It flushed well and then returned to this weird configuration. I have seen it in pts with extreme vasoconstriction (patient was on levophed 0.3 mcg/kg/min and cardiac index was 1.2 with SvO2 40%).
The non-compliant arteries do not stretch in response to the systolic pressure, and thus the rapid rise of SBP results in a steep systolic upstroke. See also how weird the downslope segment was; it looked like there was a 2nd systolic upstroke and no clear dicrotic notch
Also the CVP waveform seemed to have fused c+v waves with obliteration of x descent. We see this in tricuspid regurgitation.Also notice that CVP is read as 19 but the fused cv wave reached >25 and this is the pressure that liver/kidneys face during large part of the cardiac cycle
Patient had undergone aortic valve replacement + debridement of mitral annular calcification with mitral valve replacement + LVOT resection + tricuspid valve repair
TTE/TEE next am (no clips available, sorry...) showed hyperdynamic LV with LVOT (explaining 2 systolic strokes) and severe TR (explaining the fused cv wave). Valves were well seated. The patient died the next day
Take home messages:
1. A great LVEF (this patient had > 70%) does not exclude poor cardiac output
2. Always check the a-line and CVP waveforms. Even though we have fancier tools (Swan, echo) it is fun to demystify them
Thanks for reading!
1. A great LVEF (this patient had > 70%) does not exclude poor cardiac output
2. Always check the a-line and CVP waveforms. Even though we have fancier tools (Swan, echo) it is fun to demystify them
Thanks for reading!
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