a new paradigm of physiology oriented critical...

A New Paradigm of Physiology Oriented Critical Care

Case Scenarios (Hemodynamics)

Dr. Yasser Elsayed, MD, PhD

Associate Professor

Integrated Hemodynamics Program

International POCUSNEO

University of Manitoba

Case 1

• Premature 26+1 Wks. gestation , IUGR , born by emergency CS due to placental insufficiency

• Day 2 of life

• FIO2: 0.6

• On conventional ventilation, PEEP of 7 and VG of 4/kg

• Low blood pressure

• Lactic acid of 4.6 mmol/l

• Oliguria

Before

Before

Before

What would be your recommendation?

• A) Inhaled Nitric Oxide

• B) Sildenafil

• C) either Nitric oxide or sildenafil

• D) No Pulmonary vasodilator needed and escalate ventilation support

Physiological tips

What would be your recommendation?

• A) Inhaled Nitric Oxide

• B) Sildenafil

• C) either Nitric oxide or sildenafil

• D) No Pulmonary vasodilator needed and escalate ventilation support

Case 2

• 40 weeks with HIE

• Clinical pulmonary hypertension on iNO

• Lactic acid of 5 mmol/l

The best selective CV support (physiologic based )

• A) Fluids only

• B) Vasopressor (nor-epinephrine or vasopressin)

• C) Inotrope (Dobutamine)

• D) Dopamine

The best selective CV support

• A) Fluids only

• B) Vasopressor (nor-epinephrine or vasopressin)

• C) Inotrope (Dobutamine)

• D) Dopamine

Case 3 HIE on cooling , one day old

UOP 1 ml/kg, no acidosis

What is the physiologic intervention

• A) No intervention

• B) Dopamine

• C) Dobutamine

• D) Fluids

Case 3 HIE on cooling , one day old UOP 1 ml/kg, no acidosis

Dopamine of 5 mic

What is the physiologic intervention

• A) No intervention

• B) Dopamine

• C) Dobutamine

• D) Fluids

Case 4HIE out born missed to be on cooling

low UOPLactic acid of 6 mmol/l

• Low systole with narrow pulse pressure

• What is your recommendation?

Dobutamine

Intervention ?

• A) No intervention

• B) Dopamine

• C) Dobutamine

• D) Fluids

Lessons from cases 2-4

In HIE on cooling and with low BP:

• Vasopressin is a good option with low SVR and pulmonary hypertension

• Worsening of BP might happen with acidosis

• Dobutamine is a good option with low systole and narrow PP (normal diastole)

• Borderline blood pressure with maintained trend, NO acidosis and acceptable UOP needs just watching without intervention

Case 5

• A preterm male infant born at 25 weeks GA,birth weight 620 g, The clinical course wascomplicated by development of NEC stage IIIrequired ileal resection with ileostomy.

• He developed postoperative anuria withnormal blood pressure and significant edemadue to third space loses.

Intervention?

• A) No intervention

• B) Dopamine

• C) Lasix

• D) Fluids

Severe under filling

What is your impression?

Intervention?

• A) No intervention

• B) Dopamine

• C) Lasix

• D) Fluids

LVO ml kg -1min -1 105

MBP mmHg 34

DBP mmHg 26

SBP mmHg 37

SVR mmHg L-1 Kg-1 min-1 323

Lactic acid mmol dl -1 2.3

Formulated Medical Recommendation

• Fluid management with steroid to control loss of fluids to the third space

• No cardiovascular medication used

• Recovered in 48 hours