Cardiovascular SEEK

Question 1

VV ECMO - oxygenation issues

Answer 1

• check ECMO, patient and ventilator
• if PO2 levels are low and the same across the circuit…make sure oxygen source is okay
• if PO2 levels are low and pressure difference between pre/post >70…replace oxygenator
• If preoxygenator PO2 level is high and SaO2 is low on pulse ox…think recirculation (drainage cannulas are too close to each other). Fix by repositioning cannula and ruling out intrathoracic issues (tamponade, ptx). A/W cannula position and too high ECMO flow rates. Fix by repositioning, decrease flow rates or consider extra cannula

Question 2

Indications for CTS evaluation in right sided endocarditis

Answer 2

• failure of medical therapy (persistent +blood cx or enlarge veggie), large veggie (>1 cm), fungal endocarditis or heart failure due to acute TR
• always be worried about fungal endocarditis in IVDU

Question 3

Indications for CTS evaluation in left sided endocarditis

Answer 3

• failure of medical therapy, acute HF 2/2 valvular dysfunction, abscess, large vegetation (>1 cm) w/ evidence of embolic disease, fungal endocarditis, acute CVA

Question 4

hypotension in acute inferior MI

Answer 4

• r/o acute concomitant RV infarct
• RV stroke volume is preload dependent. Nitro will vasodilate and decrease right sided CO and compromise LV preload causing severe hypotension. Will see elevated right sided pressures.
• TX w/ fluids but be careful of RV overdistension. Can consider inotropes and MCS if no improvement.

Question 5

Prolonged QTC syndromes

Answer 5

• MC cause of acquired LQTS is low K+, low Mg++ and QTc prolonging meds.
• Three different types of congenital LQTCS.
• T1 is most common and usually triggered by activity…mutation in KCNQ1 gene…loss of fx in K+ channel. TX w/ B blocker.
• T2 is 2nd most common…mutation in KCNQ2 gene…also loss of fx in K+ channel. TX w/ aldactone.
• T3 is most rare…mutation in SNC5A gene…gain of function in Na+ channel. TX w/ mexiletine

Question 6

Things to improve hemodynamics in VA ECMO; how to decompress LV, what to watch out for in VA ECMO patients

Answer 6

• watch out for LV overdistension and subsequent stasis (LV not strong enough to overcome aortic pressure)
• can fix w/ inotropes
• IABP can help to decrease after load
• can decrease ECMO pump speed to decrease after load
• can increase PEEP to decrease after load

Question 7

Post CABG hypotension/shock

Answer 7

• DDX = LV dysfunction 2/2 preoperative MI, myocardial stunning from cardioplegia, decreased preload 2/2 bleeding (hemothorax, pericardial effusion) or venous tone and mechanical complications.
• low chest tube output + high cardiac pressures + low CI = r/o hemothorax. Contact CTS asap

Question 8

New onset afib in critically ill ICU patients

Answer 8

• possible genetic susceptibility
• thought to increase cost, ICU LOS, long term stroke risk/death.
• urgent systemic anticoagulation NOT recommended
• unstable = cardiovert
• stable = rate control>rhythm control in the ICU
• > 48 hours = increase stroke risk. CHAD2VASc not validated in the ICU. Generally AC risk>benefits in ICU patients if NOAF.
• Need to decide whether or not to AC prior to hospital discharge. Generally avoid in the ICU if NOAF.

Question 9

ETCO2 in CPR and proper CPR

Answer 9

• ET CO2<10 after 20 mins of CPR a/w very low likelihood of survival neurologically intact
• ET CO>35 = check for ROSC
• compression of at least 2”, at least 100/min, bag at 8/10 a minute with about 500 cc of volume

Question 10

inferior MI

Answer 10

• always be mindful of RV involvement. Will typically see hypotension JVD and clear lungs
• RV involvement = extremely preload dependent. Avoid vasodilators but also be careful with IV fluids (can over distend RV and compromise LV filling)

Question 11

Post MI arrhythmia

Answer 11

• PVCs, NSVT are relatively common. Sustained VT and VF are less common. Both can happen in first 48 hours s/p MI and thought to be 2/2 reperfusion.
• Late VT/VF after 48 hours s/p MI is a/w increased mortality

Question 12

how to calculate PVR

Answer 12

PVR = (mPAP - PCWP) / CO
mPAP = 0.33(PA systolic-PA diastolic) + PA diastolic

Question 13

hemoperricardium in the setting of acute STEMI

Answer 13

• will see multiple densities in pericardial fluid with evidence of tamponade
• can be either type A dissection to the RCA or ventricular wall rupture
• > 500 cc of fluid not likely to be beneficial in this case
• tx w/ CTS evaluation