Roberto

Roberto is a 66yo male former smoker with a history of HTN, Type II DM and a previous inferior MI 12 years ago for which he had placement of several stents. He recently presented with exertional angina and underwent a cardiac catheterization which demonstrated 3 vessel CAD with an LV EF of 25%. He underwent preoperative pulmonary screening in which he had a pO2 of over 300 on low level O2. He had an IABP placed preoperatively because of concerns over his decreased LV function. The next morning he underwent a successful 4 vessel CABG with significantly improved LV function (EF 50%) and weaned easily from CPB on only Milrinone support, and his IABP was removed in the OR. However, after coming off bypass he began having a slow but continued downward drift of his oxygen saturation, even with escalation of his FiO2 to 100%. His heart function and blood pressure remained excellent with a cardiac index of 3.6, and without any additional inotropic support. A CXR was obtained in the OR that was essentially normal, and his lactate on the ABG was 1.6. Because of concerns of his saturation in the low 70’s, despite no obvious etiology, he was urgently transferred across town to your center for possible ECMO support. He was evaluated by the critical care team on arrival with updated data for your review.

Ventilator - RR 14, TV 450, PEEP 8, 100% FiO2

ABG - 7.38, pCO2 31, pO2 43, O2Sat 78%. Lactate 1.1.

Pertinent Labs - Hgb 9.3, WBC 8.4, Plts 187,000, Normal electrolytes. Bicarb 24, BUN/Cr 15/1.6

Swan-Ganz - Cardiac Index 4.1, MVO2 Sat 55%, PAP 41/17

iNO trial 40ppm - No improvement in saturation, in fact over 20 minutes the saturation fell slightly into the low to mid 70’s, and the iNO was D/C’ed.