Because this patient seemed to have a variant of cancer-associated thrombosis and embolism (Trousseau’s syndrome), warfarin therapy was eschewed in favor of long-term low-molecular-weight heparin therapy. Her oxygen requirement gradually improved over 2–3 days of heparinization. Heparin therapy was initiated, and a mechanical filter was placed in the inferior vena cava just below the level of the renal veins after her Doppler study revealed DVT involving distal and proximal veins in bilateral lower extremities. 1 and 2), confirming huge emboli in the proximal tree with multiple smaller emboli in the more distal branches. The interventional radiologists performed an emergency pulmonary arteriogram ( figs. A pulmonary artery catheter was inserted and confirmed these findings. This suggested dilatation of right atrium and ventricle with pulmonary artery pressures of 46/20 mmHg with a relatively underfilled left heart. The patient became oliguric despite increasing central venous pressures, prompting us to obtain a transthoracic echocardiogram to assess better her cardiac function. The chest radiograph did not show evidence of pulmonary edema or any infiltrates suggesting aspiration. In the surgical intensive care unit, she was hemodynamically stable on minimal doses of dopamine infusion but still had an unexplained requirement of relatively high fraction of inspired oxygen (0.6–0.7 atm) and positive end-expiratory pressure of 7.5–10 cm H 2O, to maintain an arterial oxygen partial pressure of 65–70 mmHg. When the operation concluded, she remained intubated and mechanically ventilated and was transferred to the surgical intensive care unit. Desaturation was initially attributed to an unobserved aspiration. An arterial blood gas in the operating room later revealed p H of 7.25, carbon dioxide partial pressure of 55, oxygen partial pressure of 83, and HCO 3of 25 on 1.0 fraction of inspired oxygen, and positive end-expiratory pressure of 10 cm H 2O. She also was noted to have high peak airway pressures (> 40 cm H 2O), a low end-tidal carbon dioxide level (approximately 22 mmHg), and Sp O 2around 95%. Prompt intubation, ventilation with oxygen at a fraction of inspired oxygen of 1.0 atm, and confirmation of tube placement, both by auscultation as well as by positive end-tidal carbon dioxide, did not succeed in restoring her Sp O 2to the preanesthesia level. Her systolic blood pressure also decreased to 90 mmHg from a preanesthesia value of 130/70 mmHg. After injection of induction agents but before insertion of an endotracheal tube, the pulse oximeter reported a near instantaneous decrease from 100% to approximately 75% (despite the administration of 100% oxygen). The medications included thiopental and succinylcholine. General anesthesia was induced using a rapid-sequence technique. The sequential device was turned on just before the induction of anesthesia with inflation pressures around 45 mmHg. A sequential compression device with long sleeves (Sequel model 6325 Kendall Company, Mansfield, MA) was applied to both legs as part of routine practice for any surgery lasting over 3 h. After fluid resuscitation and administration of antibiotics, the patient was taken to the operating room, where her initial vital signs and oxygen saturation (Sp O 2) were within normal limits.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |