Reference no: EM133395243

John Doe is a 73 y/o gentleman 5'9," weighing 274lbs. that has just returned from surgery following a left femoral popliteal bypass. The patient has a known history of obesity, hypertension, adult onset diabetes, coronary artery disease (CAD), myocardial infarction (MI) with stents to the right coronary artery (RCA) and the left anterior descending artery (LAD), deep vein thrombosis (DVT's) bilaterally and peripheral vascular disease. The physician states that the patient tolerated surgery well with an estimated blood loss of 330ml. One hour following surgery the patient was drinking a clear liquid diet. Three hours postoperatively the patient complained of severe chest stabbing chest pain, became nauseated, and vomited. The physician was called and following a 12 lead ECG the patient was rushed to the heart catheterization lab. A coronary angioplasty was attempted; however the left main coronary artery could not be opened up with the balloon. On retracting the catheter the patient again became nauseated and severely bradycardic in the 30's and hypotensive at 60/40; 0.5 mg of atropine was given intravenously (IV), the patient was started on a dopamine infusion, was intubated and ventilated, and transferred directly to the operating room for a coronary artery bypass grafting (CABG).

The patient has returned from bypass surgery to the ICU. The patient had a CABG X 3. The patient is orally intubated with a pulmonary artery (PA) catheter 60cm @ the hub. Vital signs and labs are as follows:

Hypotensive: 80-90s systolic

Tachycardic 110-120 beats per minute.

Frequent multifocal PVCs seen

Mediastinal chest tubes with moderate sanguineous output of 100ml/hr

Right atrial (RA) central venous pressure (CVP) of 3mm/hg off of PA catheter, CI = 2.0, SVRI 3200 dyn/s/cm^-5

Echocardiogram shows cardiomegaly and an ejections fraction of 33%

Respiratory: Course crackles heard in lower lobes, SaO₂=96% on FiO₂= 40%.

Urine output 25ml/hr dark and concentrated

Skin cool 

WBC 22, HCT 29, HGB 11.0, PLT 250, INR 2.1

1. Given the above information how would you define John's preload? (increased, decreased, or normal)
2. What indications of an altered preload do you see in the above information?
3. Identify treatment of choice for preload and give rationale (and doses, if a medication).
4. Identify reasons why this patient may have an altered preload. What symptoms might the patient have?
5. What other data from the PA catheter parameters could assist you to determine the volume status of your patient?
6. What orders do you anticipate based on your assessment of the patient's preload?
7. How will your initial treatment affect afterload?