Shock Solution 2

     
   

 

     
     

A 74 year old female was admitted to intensive care on Friday evening, following a laporotomy for bowel obstruction. There was a small amount of fecal soiling intra operatively, but the patient remained reasonably stable. The patient has a 40 pack year history of smoking, type II diabetes, two previous myocardial infarctions, a permanent pacemaker, and had a right carotid endarterectomy four years ago. During the night following the operation, she became hypotensive, blood pressure 80/56, heart rate 70. The resident on call commenced treatment with dobutamine, titrated against blood pressure response to a mean arterial pressure of 70.
When you come into work on Monday morning, the patient is still in the intensive care, extubated, apparently well, and still on dobutamine at 5 mic/kg/min, blood pressure 110/70, heart rate 70. You need the bed for the day’s admissions, but the patient cannot go out to the floor on inotropes, which the weekend staff were unable to wean.

       
     

  • Is this genuine hypotension? Yes

  • Is the heart rate appropriate for the blood pressure?

  • What is the patient’s volume status (cardiac filling)? Normal

  • Does the heart contract normally? Unknown

  • Is the patient abnormally vasodilated?

       
      Solution        
     

The perioperative process almost certainly stirred up some inflammatory mediators, leading to peripheral vasodilatation. This woman was unable to compensate for reduced peripheral resistance by increasing her cardiac output, because this is essentially fixed – by her pacemaker.
The patient’s pacemaker rate was reset at 90 beats/minute, and the patients no longer required dobutamine one hour later.

Dx: cardiogenic-septic shock due to inappropriate heart rate.