a new paradigm of physiology oriented critical...
TRANSCRIPT
A New Paradigm of Physiology Oriented Critical Care
Case Scenarios (Hemodynamics)
Dr. Yasser Elsayed, MD, PhD
Associate Professor
Integrated Hemodynamics Program
International POCUSNEO
University of Manitoba
Case 1
• Premature 26+1 Wks. gestation , IUGR , born by emergency CS due to placental insufficiency
• Day 2 of life
• FIO2: 0.6
• On conventional ventilation, PEEP of 7 and VG of 4/kg
• Low blood pressure
• Lactic acid of 4.6 mmol/l
• Oliguria
Before
Before
Before
What would be your recommendation?
• A) Inhaled Nitric Oxide
• B) Sildenafil
• C) either Nitric oxide or sildenafil
• D) No Pulmonary vasodilator needed and escalate ventilation support
Physiological tips
What would be your recommendation?
• A) Inhaled Nitric Oxide
• B) Sildenafil
• C) either Nitric oxide or sildenafil
• D) No Pulmonary vasodilator needed and escalate ventilation support
Case 2
• 40 weeks with HIE
• Clinical pulmonary hypertension on iNO
• Lactic acid of 5 mmol/l
The best selective CV support (physiologic based )
• A) Fluids only
• B) Vasopressor (nor-epinephrine or vasopressin)
• C) Inotrope (Dobutamine)
• D) Dopamine
The best selective CV support
• A) Fluids only
• B) Vasopressor (nor-epinephrine or vasopressin)
• C) Inotrope (Dobutamine)
• D) Dopamine
Case 3 HIE on cooling , one day old
UOP 1 ml/kg, no acidosis
What is the physiologic intervention
• A) No intervention
• B) Dopamine
• C) Dobutamine
• D) Fluids
Case 3 HIE on cooling , one day old UOP 1 ml/kg, no acidosis
Dopamine of 5 mic
What is the physiologic intervention
• A) No intervention
• B) Dopamine
• C) Dobutamine
• D) Fluids
Case 4HIE out born missed to be on cooling
low UOPLactic acid of 6 mmol/l
• Low systole with narrow pulse pressure
• What is your recommendation?
Dobutamine
Intervention ?
• A) No intervention
• B) Dopamine
• C) Dobutamine
• D) Fluids
Lessons from cases 2-4
In HIE on cooling and with low BP:
• Vasopressin is a good option with low SVR and pulmonary hypertension
• Worsening of BP might happen with acidosis
• Dobutamine is a good option with low systole and narrow PP (normal diastole)
• Borderline blood pressure with maintained trend, NO acidosis and acceptable UOP needs just watching without intervention
Case 5
• A preterm male infant born at 25 weeks GA,birth weight 620 g, The clinical course wascomplicated by development of NEC stage IIIrequired ileal resection with ileostomy.
• He developed postoperative anuria withnormal blood pressure and significant edemadue to third space loses.
Intervention?
• A) No intervention
• B) Dopamine
• C) Lasix
• D) Fluids
Severe under filling
What is your impression?
Intervention?
• A) No intervention
• B) Dopamine
• C) Lasix
• D) Fluids
LVO ml kg -1min -1 105
MBP mmHg 34
DBP mmHg 26
SBP mmHg 37
SVR mmHg L-1 Kg-1 min-1 323
Lactic acid mmol dl -1 2.3
Formulated Medical Recommendation
• Fluid management with steroid to control loss of fluids to the third space
• No cardiovascular medication used
• Recovered in 48 hours