*الواقعة:(83- 87)*
DESCRIPTION
" فَلَوْلَا إِذَا بَلَغَتِ الْحُلْقُومَ (83) وَأَنْتُمْ حِينَئِذٍ تَنْظُرُونَ (84) وَنَحْنُ أَقْرَبُ إِلَيْهِ مِنْكُمْ ولكن لَا تُبْصِرُونَ (85) فَلَوْلَا إِنْ كُنْتُمْ غَيْرَ مَدِينِينَ (86) تَرْجِعُونَهَا إِنْ كُنْتُمْ صَادِقِينَ (87)". صدق الله العظيم. *الواقعة:(83- 87)*. - PowerPoint PPT PresentationTRANSCRIPT
الحلقوم" ) بلغت إذا تنظرون( 83فلوال حينئذ وأنتمتبصرون( )84) ولكنال منكم إليه أقرب ( 85ونحن
مدينين ) غير كنتم إن كنتم( 86فلوال إن ترجعونها("87صادقين )
(: (*87- 83الواقعة*
ا4ل4ع4ظ4ي4م ا4ل4ل4ه4 ص4د4ق4
Egypt, Sunset
Mohamed R. El-Tahan, M.D. Assistant Professor of Anaesthesia & Surgical ICU, University of Dammam, Dammam, Saudi Arabia,
Member of the Association of Cardiothoracic Anaesthetists of UK,Member of the European Association of Cardio-Thoracic Anesthetists,
Member of the Association of Anaesthetists of Great Britain and Ireland,Associate Professor of Cardiothoracic Anaesthesia & Surgical ICU,
Mansoura University, Mansoura, Egypt,Instructor for ALS & EPLS, European Resuscitation Council.
NO and APRV for the Treatment of Myocardial Stunning Complicated
with ARDS after Cardiac Surgery: Case Report &
Review of Literature
Objectives
Introduction Case Discussio
nConclusio
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N O
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nConclusio
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N O
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nConclusio
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N O
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Introduction Case Discussio
nConclusio
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N O
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Introduction Case Discussio
nConclusio
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N O
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Introduction Case Discussio
nConclusio
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Myocardial stunning is an uncommon post-
ischemic reversible contractile dysfunction
after cardiac surgery.
Myocardial stunning often defined as the
need for prolonged inotropic therapy or
IABP, which is frequently observed 4-6 hrs.
after the use of CPB for CABG surgery.
Objectives
Introduction Case Discussio
nConclusio
n
Myocardial stunning usually resolves
around 24 hrs. postoperatively.
Objectives
Introduction Case Discussio
nConclusio
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Nitric oxide (NO) inhalation may represent a
novel therapy for myocardial stunning by
improving LV function after ischemia and
reperfusion.
Objectives
Introduction Case Discussio
nConclusio
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nConclusio
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nConclusio
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Effect of iNO on myocardial infarct size. representative midventricular slice from a mouse breathing room air without iNO
Objectives
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nConclusio
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Objectives
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nConclusio
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nConclusio
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nConclusio
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Serial changes in %baseline of slope of LV end-systolic
pressure-volume relationship. †P<0.05 vs. baseline.
Objectives
Introduction Case Discussio
nConclusio
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Objectives
Introduction Case Discussio
nConclusio
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A 49-yrs-old (56 kg, 156 cm) gentleman
with a history of hypertension, diabetes and
coronary artery disease, presented for
bypass grafting for the left-anterior
descending (LAD) and right coronary (RCA)
arteries.
History
Objectives
Introduction Case Discussio
nConclusio
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Preoperative medications included atenolol
and nitrates.
Baseline cardiac troponin I (cTnI) was 0.04
µg/L.
History
Objectives
Introduction Case Discussio
nConclusio
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TTE findings showed an EF of 58%, apical-
inferior wall hypokinesia, trivial mitral and
tricuspid regurgitation, MPAP of 24 mm Hg,
and normal RV diameters.
TTE
Objectives
Introduction Case Discussio
nConclusio
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Cardiac catheterization showed two-vessel
disease (LAD and RCA) with good global
LV function.
Cardiac Cath.
Objectives
Introduction Case Discussio
nConclusio
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Standardized balanced propofol, sufentanil,
and cisatracurium anesthesia was used with
the maintenance of stable hemodynamics.
Anesthesia
Objectives
Introduction Case Discussio
nConclusio
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Two vessels were grafted; internal mammary
artery to the LAD and saphenous vein to the
RCA.
Surgery
Objectives
Introduction Case Discussio
nConclusio
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The cross-clamp time was 100 min and the
CPB time was 160 min.
Surgery
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nConclusio
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Discontinuation of CPB was accomplished
with with epinephrine (4 µg/min).
Surgery
Objectives
Introduction Case Discussio
nConclusio
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The patient was shifted to the ICU while he
was sedated and ventilated using SIMV/PSV
mode with a FiO2 of 0.45, VT of 450 mL,
frequency of 12/min, I: E ratio of 1:2,
PEEP of 5 cm H2O and PSV of 20 cm H2O.
Postoperative Management
Objectives
Introduction Case Discussio
nConclusio
n
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
Excessive mediastinal bleeding (900 mL) was noted
throughout the first 2 postoperative hours.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
Hemoglobin was 5.5 g/dL.
PT was 29.0 s.
INR was 2.3.
aPTT was 98.5 s.
Platelet count was 15 103/mL.
Fibrinogen was 72 mg/dL.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
5 U PRBCs, 4 U FFP, 8 U cryoprecipitate was
transfused, protamine sulfate (1 mg/kg) was given,
metabolic acidosis was corrected and normothermia was
optimized. Unfortunately, hemorrhage persisted through
the drainage tubes.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
TEE showed EF of 55%, normal RV diameters and
wall motions, and ruled out of the pericardial
collection.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
The use of recombinant activated factor VII in a dose
of 20 μg/kg succeeded in controlling of bleeding.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
On the POD 2, ECG excluded new ischemia and cTnI
was 5.7 µg/L.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs. 81 125/63 7 14 24/15 2.8 1923 11524 hrs. 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
Epinephrine infusion and ventilatory support were
successfully discontinued.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
Tracheal extubation was performed uneventfully.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
The patient had developed cardiogenic pulmonary
edema with rising cTnI to 84 µg/L.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
ECG excluded new onset myocardial ischemia.
TEE showed EF of 32%, diffuse LV hypokinesis, normal
RV function and absence of pericardial collection.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
The patient was re-intubated and ventilated using
SIMV/PSV mode using a FiO2 of 1.0, VT of 330 mL,
frequency of 16/min, I: E ratio of 1:2, PEEP of 5
cmH2O and PSV of 20 cmH2O.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
For circulatory support, epinephrine (14 µg/min),
dopamine (15 µg/kg/min) and IABP were necessary.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
Coronary angiography confirmed the patency of the
two bypass grafts and revealed global LV hypokinesis.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
After 6 hrs. the patient developed progressive
tachypnea > 40/min, Paw ≥ 42 cm H2O and refractory
hypoxemia despite of increasing the levels of PEEP to
15 cm H2O.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
PCV mode was used using FiO2 of 1.0, pressure level
of 25-35 cmH2O, I:E ratio of 1:1.5 and increasing
PEEP up to 15cmH2O without significant improvement.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
APRV was initiated with FiO2 of 1.0, P-high of 35 cmH2O, P-
low of 15 cmH2O, T-high of 4 s, T-low of 0.8 s, release rate of
13/min and automatic tube compensation of 100%.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
After 4 hours, modest improvement in oxygenation was
noted
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
cTnI increased to 183 µg/L.
TEE revealed EF of 30% without significant changes in the RV
diameters.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative ManagementPAOP was 30-33 mm Hg, TEE showed EF of 23%, preserved RVF.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management pH SaO2 SvO2 PaO2 PvO2 Pa/Fi PaCO2
After ICU admission0 hr 7.33 99 79 198 63 440 3812 hrs 7.41 100 80 178 71 445 4124 hrs 7.38 100 85 186 75 531 43
After extubation0 hr 7.42 99 79 173 67 433 406 hrs 7.39 100 84 183 69 457 3912 hrs 7.40 99 82 153 72 510 3716 hrs 7.16 72 43 59 29 84 48
SIMV/PSV* 7.20 76 48 62 32 62 45PCV* 7.20 75 44 60 32 60 47APRV
1 hr* 7.32 80 58 75 33 75 414 hrs* 7.34 82 61 78 35 78 37
iNO12 hrs* 7.39 92 77 112 63 224 3624 hrs 7.39 94 81 122 76 242 3448 hrs 7.42 96 87 136 82 272 33
POD 6 7.39 96 80 138 77 307 40POD 7 7.37 96 81 122 73 305 39
Trials of the use of increasing inhaled NO up to 20 ppm
was followed with improvement of hemodynamic and
oxygenation parameters over the following 12 hrs.
which allowed decrease of FiO2 to 0.5.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
Trials of the use of increasing inhaled NO up to 20 ppm
was followed with improvement of hemodynamic and
oxygenation parameters over the following 12 hrs.
which allowed decrease of FiO2 to 0.5.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
On the POD 4, TEE examination documented
improved EF up to 50%, cTnI decreased to 38 µg/L,
and circulatory support was gradually discontinued.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative ManagementChest infiltrates were gradually improved
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative ManagementChest infiltrates were gradually improved
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
iNO was gradually discontinued by the POD 5.
cTnI was 7 µg/L.
Objectives
Introduction Case Discussio
nConclusio
n
Postoperative Management HR BP CVP PAOP PAP CI SVRI PVRIAfter ICU admission
0 hr 97 108/56 4 11 19/11 2.6 2123 12312 hrs 81 125/63 7 14 24/15 2.8 1923 11524 hrs 76 134/74 6 12 28/14 2.9 2427 193
After extubation 0 hr 85 127/83 5 10 24/11 2.9 2565 1626 hrs 80 139/89 7 12 29/13 2.5 3168 16012 hrs 91 121/74 8 11 31/12 2.4 2733 13316 hrs 125 78/33 10 35 54/37 1.45 1920 586
SIMV/PSV* 131 81/37 9 32 48/35 1.5 2150 350PCV* 119 82/39 9 30 45/32 1.5 2250 350APRV
1 hr* 114 81/36 7 31 47/33 1.7 2070 3294 hrs* 116 83/38 9 33 49/35 1.6 2210 337
iNO12 hrs* 104 118/68 7 13 23/14 2.6 2400 12324 hrs 90 139/88 6 10 21/11 3.5 2262 11548 hrs 88 143/85 7 11 24/12 3.6 2156 111
POD 6 88 123/80 5 8 25/10 3.7 2182 125POD 7 88 133/89 5 9 23/11 3.5 2299 135
APRV was discontinued and the patient was extubated
uneventfully.
On the POD 9, the patient developed
mediastinitis (secondary to staphylococcus
aureus) and worsening septic shock.
Postoperative Management
Objectives
Introduction Case Discussio
nConclusio
n
He was treated with intravenous antibiotics,
sternal debridement, vacuum-assisted
wound closure, fluid and vasopressor
therapy.
Postoperative Management
Objectives
Introduction Case Discussio
nConclusio
n
He developed progressive rhabdomyolysis
and he passed away on the POD 13.
Postoperative Management
Objectives
Introduction Case Discussio
nConclusio
n
Objectives
Introduction Case Discussio
nConclusio
n
Objectives
Introduction Case Discussio
nConclusio
n
Objectives
Introduction Case Discussio
nConclusio
n
Drugs like milrinone or levosimendan may
be helpful in the management of refractory
myocardial stunning in the presented case.
Objectives
Introduction Case Discussio
nConclusio
n
The use of veno-arterial ECMO would be a
pretty choice in the present case, 1. Upper-body hypoxemia (LV dysfunction and
impaired lung function).
2. It was unavailabile at our center.
Objectives
Introduction Case Discussio
nConclusio
n
The improved LV function might be
attributed to: Improved oxygenation.
Decreased PAP.
Attenuation of possible delayed myocardial
reperfusion injury after excessive mediastinal
bleeding.
Objectives
Introduction Case Discussio
nConclusio
n
It is unlikely that patient had reperfusion
injury too late like 2 or 3 days after
reperfusion.
Limitation to the Reported Case
Objectives
Introduction Case Discussio
nConclusio
n
To show the evidence of reperfusion
myocardial injury, we demonstrated:A. Marked rising in cardiac troponin levels.
B. Diffuse LV hypokinesis.
C. Patent grafted vessels.
Limitation to the Reported Case
Objectives
Introduction Case Discussio
nConclusio
n
However, we could not exclude the
detrimental effect of severe anemia or
worsening hypoxemia on the LV functions.
Limitation to the Reported Case
Objectives
Introduction Case Discussio
nConclusio
n
A more likely explanation is that the patient
had not only myocardial dysfunction, but
also acute lung injury from massive
transfusion.
Limitation to the Reported Case
Objectives
Introduction Case Discussio
nConclusio
n
The combined use of NO inhalation and
APRV may be a safe and effective treatment
modality for the refractory myocardial
stunning and ARDS after cardiac surgery.
Thank you for your listening
The Nubian museum in Aswan, Egypt,.