Cardiac Cardiac assessment at the assessment at the

cutting edgecutting edgeJoanne SmithJoanne Smith

Nurse PractitionerNurse PractitionerMaureen CoombsMaureen Coombs

Consultant Nurse in Critical Consultant Nurse in Critical CareCare

Southampton University Southampton University Hospitals TrustHospitals Trust

Case study 1Case study 1

67 year old female67 year old femaleAttended pre-assessment clinic for Attended pre-assessment clinic for

mitral valve surgery for mitral mitral valve surgery for mitral regurgitationregurgitation

Past Medical HistoryPast Medical History Diabetic - Type 2 on InsulinDiabetic - Type 2 on Insulin HypertensionHypertension Renal impairmentRenal impairment R & L Varicose Veins Stripped 1990R & L Varicose Veins Stripped 1990 R cataract surgery 1998R cataract surgery 1998

History of Presenting History of Presenting ComplaintComplaint

Diagnosed with ‘murmur’ in 1998, Diagnosed with ‘murmur’ in 1998, during admission for cataract surgeryduring admission for cataract surgery

Referred to Cardiologist – for Echo Referred to Cardiologist – for Echo Complains of breathlessness when Complains of breathlessness when

doing housework and climbing stairsdoing housework and climbing stairs Intermittent chest pains on exertion, Intermittent chest pains on exertion,

radiation to L breastradiation to L breast Reviewed 6/12 in outpatientsReviewed 6/12 in outpatients

Recent History of IllnessRecent History of Illness

Breathlessness on minimal exertionBreathlessness on minimal exertion Feeling tired and lethargicFeeling tired and lethargic Chest discomfort occurring at any Chest discomfort occurring at any

time time Coronary angiogram – October 2005 Coronary angiogram – October 2005

– normal coronary arteries– normal coronary arteries Referred for Elective MVRReferred for Elective MVR

Pre-assessment Pre-assessment

Short of breath on arrival at clinicShort of breath on arrival at clinic Evidence of weight loss – ill fitting Evidence of weight loss – ill fitting

clothesclothes Generalized pallorGeneralized pallor ECG – RBBB, HR 59bpmECG – RBBB, HR 59bpm BP – 155/70, RR 16 min, OBP – 155/70, RR 16 min, O22 Sats 95% Sats 95%

airair States 3 episodes of collapse in previous States 3 episodes of collapse in previous

6 months6 months

Review of SystemsReview of Systems

RespiratoryRespiratory RR 16 min, equal lung expansion, bi-basal crackles, RR 16 min, equal lung expansion, bi-basal crackles,

resonantresonant

CardiovascularCardiovascular Apyrexial, pitting oedema to ankles, heaving apex, Apyrexial, pitting oedema to ankles, heaving apex,

thrill present throughout. Loud bilateral carotid thrill present throughout. Loud bilateral carotid bruits. Loud systolic murmur in aortic region (grade bruits. Loud systolic murmur in aortic region (grade 4). Loud pansystolic murmur radiating to axilla 4). Loud pansystolic murmur radiating to axilla (grade 3 in mitral region), bilateral femoral bruits. (grade 3 in mitral region), bilateral femoral bruits.

Hb 98g/L, JVP 5cm at 45 degreesHb 98g/L, JVP 5cm at 45 degrees

Review of SystemsReview of Systems RenalRenal Urea 17.8, Creat 181 (Under c/o Nephrologist)Urea 17.8, Creat 181 (Under c/o Nephrologist)

Neurological Neurological Evidence of peripheral neuropathy, secondary to Evidence of peripheral neuropathy, secondary to

diabetesdiabetes

GI GI Generalized tenderness over whole abdomen, recent Generalized tenderness over whole abdomen, recent

unintentional weight loss (10 Kg in 2 months), loss of unintentional weight loss (10 Kg in 2 months), loss of appetite, states recent episodes of fresh blood whilst appetite, states recent episodes of fresh blood whilst having bowels open,having bowels open,

BMI < 20BMI < 20

Review of SystemsReview of Systems

Social Social Lives with husband and 2 daughters in Lives with husband and 2 daughters in

Portsmouth. Portsmouth. Usually independent with activities of daily livingUsually independent with activities of daily living

Drugs Drugs Bisporolol Bisporolol RamiprilRamipril AmlodipineAmlodipine

No known allergiesNo known allergies

Clinical Investigations and Clinical Investigations and OutcomesOutcomes

Admitted to unit for further Admitted to unit for further investigationsinvestigations

Repeat transthoracic echo Repeat transthoracic echo – – Moderate / severe aortic stenosisModerate / severe aortic stenosis

CXR CXR – – Evidence of cardiomegaly, pulmonary Evidence of cardiomegaly, pulmonary

oedema, no major lung pathologyoedema, no major lung pathology Abdominal USS Abdominal USS

- ? Lower abdominal mass / referred for - ? Lower abdominal mass / referred for colonoscopycolonoscopy

Case study 2Case study 2 63 yr old male63 yr old male Married with 2 sons and a daughterMarried with 2 sons and a daughter Lives in Spain and on south coastLives in Spain and on south coast

E/A from renal unit for cardiac E/A from renal unit for cardiac surgerysurgery

Intubated, ventilated, sedated and Intubated, ventilated, sedated and on inotropic supporton inotropic support

Recent history of current Recent history of current illnessillness

Aug 2006Aug 2006 Diarrhoea – 3 weeksDiarrhoea – 3 weeks Sept 2006Sept 2006 ICU admission for E. coli ICU admission for E. coli

sepsissepsis

6 day hospital stay6 day hospital stay Oct 2006Oct 2006 SOB, anaemia, renal SOB, anaemia, renal

failurefailure

(BE -7.4, HCO(BE -7.4, HCO33 18.7) 18.7) Nov 2006Nov 2006 Re-admitted with Re-admitted with

pulmonary pulmonary oedema, metabolic oedema, metabolic acidosis, acidosis, haemofilteredhaemofiltered

Cardiac investigationsCardiac investigations

PMHPMH Adult polycystic kidney disease Adult polycystic kidney disease

normally good u/o, creat. 300normally good u/o, creat. 300 HypertensionHypertension Intracerebral haemorrhage (1995) – Intracerebral haemorrhage (1995) –

full recoveryfull recovery GoutGout Active and independent until Aug Active and independent until Aug

20062006

Review of systemsReview of systems RSRS

Intubated and ventilated. Pressure Controlled Intubated and ventilated. Pressure Controlled Ventilation 500 x 15. FIOVentilation 500 x 15. FIO2 2 0.6%, PEEP 5. PaO 0.6%, PEEP 5. PaO22 6.92. Air entry all zones. 6.92. Air entry all zones. Bi-basal cracklesBi-basal crackles

CVSCVSSR 105/min, B/P 105/46 (MAP 70) on Noradr. 13, SR 105/min, B/P 105/46 (MAP 70) on Noradr. 13,

Dopamine 6. RA 14. Electrolytes within range. Dopamine 6. RA 14. Electrolytes within range. Lactate 1. Cool peripheries. Apyrexial. WCC 8.9. Lactate 1. Cool peripheries. Apyrexial. WCC 8.9. CRP 66. Nil on blood cultures. Clotting NAD. CRP 66. Nil on blood cultures. Clotting NAD. Splinters left hand. Bounding short carotid pulses. Splinters left hand. Bounding short carotid pulses. Heaving Apex. Diastolic murmur 2/6 Aorta and SM Heaving Apex. Diastolic murmur 2/6 Aorta and SM 3/6 Apex and LSB3/6 Apex and LSB

CXR on admissionCXR on admission

Review of systemsReview of systems RenalRenal

CVVH via Lt. femoral vascath. Last filtered 24 CVVH via Lt. femoral vascath. Last filtered 24 hours ago hours ago u/o 10mls/hour. Achieving 100 mls/hr off filtre u/o 10mls/hour. Achieving 100 mls/hr off filtre Negative 2L bal achieved. Ur 13.3, Creat. 442Negative 2L bal achieved. Ur 13.3, Creat. 442

NeuroNeuroPERL size 4, Sedated Alfentanil and PropofolPERL size 4, Sedated Alfentanil and Propofol

GI GI Abdo soft. Massive ballottable kidneys. 3-4cms Abdo soft. Massive ballottable kidneys. 3-4cms smooth liver edge. Bowel sounds present. smooth liver edge. Bowel sounds present. LFTs NAD. Albumin 23. BM 6.8 on Insulin LFTs NAD. Albumin 23. BM 6.8 on Insulin sliding scalesliding scale

Review of systemsReview of systems

HygieneHygieneAll areas intact. Eyes/mouth clean and All areas intact. Eyes/mouth clean and moist. All lines clean and dry. No obvious moist. All lines clean and dry. No obvious inflamed jointsinflamed joints

SocialSocialWife and family aware of t/f and plan for Wife and family aware of t/f and plan for surgery Consent to be obtainedsurgery Consent to be obtained

DrugsDrugsOn Ben-pen QDS IV for suspected IEOn Ben-pen QDS IV for suspected IE

Clinical Intervention and Clinical Intervention and OutcomesOutcomes

AVR (Bovine Pericardial bioprosthesis)AVR (Bovine Pericardial bioprosthesis) Valve triscuspid, structurally normalValve triscuspid, structurally normal

Slow recovery requiring respiratory, cardiac and Slow recovery requiring respiratory, cardiac and renal therapy support. Tracheostomy day 10renal therapy support. Tracheostomy day 10

Haemofiltration d/c day 20, u/o with diuretic Haemofiltration d/c day 20, u/o with diuretic supportsupport

Slow wean onto CPAP and trachy maskSlow wean onto CPAP and trachy mask Discharged from CICU day 29. Discharged home Discharged from CICU day 29. Discharged home

day 42 day 42

In conclusion, In conclusion, have we achieved have we achieved what we set out what we set out

to?to?