*الواقعة:(83- 87)*

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

n

N O

Objectives

Introduction Case Discussio

nConclusio

n

N O

Objectives

Introduction Case Discussio

nConclusio

n

N O

Objectives

Introduction Case Discussio

nConclusio

n

N O

Objectives

Introduction Case Discussio

nConclusio

n

N O

Objectives

Introduction Case Discussio

nConclusio

n

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

n

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

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Effect of iNO on myocardial infarct size. representative midventricular slice from a mouse breathing room air without iNO

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

Serial changes in %baseline of slope of LV end-systolic

pressure-volume relationship. †P<0.05 vs. baseline.

Objectives

Introduction Case Discussio

nConclusio

n

Objectives

Introduction Case Discussio

nConclusio

n

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

n

Preoperative medications included atenolol

and nitrates.

Baseline cardiac troponin I (cTnI) was 0.04

µg/L.

History

Objectives

Introduction Case Discussio

nConclusio

n

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

n

Cardiac catheterization showed two-vessel

disease (LAD and RCA) with good global

LV function.

Cardiac Cath.

Objectives

Introduction Case Discussio

nConclusio

n

Standardized balanced propofol, sufentanil,

and cisatracurium anesthesia was used with

the maintenance of stable hemodynamics.

Anesthesia

Objectives

Introduction Case Discussio

nConclusio

n

Two vessels were grafted; internal mammary

artery to the LAD and saphenous vein to the

RCA.

Surgery

Objectives

Introduction Case Discussio

nConclusio

n

The cross-clamp time was 100 min and the

CPB time was 160 min.

Surgery

Objectives

Introduction Case Discussio

nConclusio

n

Discontinuation of CPB was accomplished

with with epinephrine (4 µg/min).

Surgery

Objectives

Introduction Case Discussio

nConclusio

n

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,.