Page 234 - ACCCN's Critical Care Nursing

Cardiovascular Assessment and Monitoring 211

Case study, Continued
● bibasal creps ● a pulmonary artery catheter was inserted and the following
● hepatomegaly – (non-tender) 16 cm values noted:
● bowel sounds active – CVP 18 mmHg
● urinalysis showed protein +++ and large amount of blood – PA pressures 51/31 mmHg
● intravenous fluids were commenced and the patient was trans- – PAWP 22 mmHg
ferred to a medical ward – CI 1.9 l L/min/m 2
– SVRI 2956 dynes/sec/cm −5
Differential diagnosis: Acute infection, possible urinary tract infec-
tion, acute hepatitis, renal impairment secondary to dehydration – BP 90/57 mmHg
– A dobutamine infusion was commenced @ 5 mcg/kg/min
Key events during hospitalisation A transthoracic echocardiography (TOE) was performed with the
Day 1 following hospital admission: following findings:
● the patient remained febrile (temperature up to 39°C) ● moderate/severe global dysfunction
● at 2100 hr BP noted in charts to be 90/50 with HR 120 bpm ● LVEF 25–30%
● RV severe hypokinesis
Day 2 post admission: ● valves structurally normal
● 0935 hr ● PA pressures ∼40 mmHg (mean)
● SaO 2 97–99% with non-rebreathing mask at 10 L/min ● no pleural effusion visible
overnight
● Patient became disorientated and pulling off mask: SaO 2 Discussion
81% on room air This case study illustrates the complexities of critical illness in the
● patient pale, tachypnoea RR 40 per minute presence of several risk factors and comorbidities. Initial non-
● mottled appearance on legs and abdomen invasive assessments following admission focused on treatment
● audible crackles right base and management of an acute infection and restoration of intravas-
● ECG taken: new T wave changes noted in lead III cular fluid volumes. When the patient was unresponsive to initial
● indwelling urinary catheter inserted: dark urine minimal treatment strategies, following admission to the intensive care
amount drained unit, invasive monitoring was required to guide patient manage-
● awaiting ICU medical assessment and transfer ment. Continuous invasive arterial monitoring aided titration of
● 1130 hr vasoconstrictor therapy and insertion of a central venous line
● the patient became unresponsive and had increasingly aided with directing fluid therapy. It would have been easy to have
laboured respirations focused on treating the patient as a patient in septic shock at this
● an emergency team call was made by the RN point based on clinical trends but the value of invasive pulmonary
● patient was given a bolus of 2 L Hartmans and O 2 adminis- artery readings and a transthoracic echocardiography guided
tered via a non-rebreathing mask management direction with evidence of cardiogenic shock (as
● 1230 hr evident by low cardiac index, low left ventricular ejection fraction
● the patient was transferred to the ICU and elevated pulmonary pressures in the presence of ECG T wave
● hypotensive, unresponsive to fluids, hypoxic despite 100% changes) prompting the commencement of a dobutamine infu-
O 2 via non-rebreather mask (SaO 2 76%) sion directed at increasing cardiac contractility and decreasing
● temperature 39.3°C preload. For the critical care nurse at the bedside, this patient dem-
● arterial line and internal jugular venous line inserted onstrates the need to be able to synthesise all assessment findings,
● IV noradrenaline infusion commenced with the aim of main- invasive and non-invasive, and titrate prescribed therapies to
tain a MAP > 75 mmHg achieve optimal tissue perfusion while providing holistic nursing
● heart rate 140 bpm sinus care in a complex and changing environment. Without invasive
● chest X-ray showed bilateral pulmonary infiltrates monitoring, management of this patient would have been techni-
● the patient was sedated, intubated and ventilation therapy cally challenging and required a trial and error approach until a
commenced successful treatment plan was accomplished. This patient did ulti-
● urine output 52 mL since IDC inserted (3 hours) mately get discharged from ICU on day 6 to the medical ward
● peripheries cool and dark/mottled in appearance, cap return and was eventually discharged back home after five weeks
>5 secs hospitalisation.