CPC 12/12/02 Dr. Taft Bhuket

CC: Difficult to wean patient from the ventilator

HPI: LH is a 51 YOAA male who underwent an emergent CABG after suffering an anterior wall myocardial infarction. This was due to an occlusion of an LAD stent. The cross-clamp time was 49 minutes. The cardiopulmonary by-pass time was 80 minutes.
On post-op day one, the attempt to wean him from the ventilator failed due to rapid shallow respirations while on SIMV. At the time, his BP was 130/70, pulse 100, temperature 102.6. His cardiac output was 5.o and his PA pressure was 26/13. The patient was sedated, but responsive. The CXR is on the first screen.
The differential diagnoses at this time included atelectasis, pneumonia, or post pericardotomy syndrome on top of underlying COPD. He was started on Piperacillin/Tazobactam and aggressive pulmonary toilet. A sedimentation rate was drawn and was 97. Steroids were not instituted.
On post-op day 5, the CXR is shown on the 2°d screen. The patient was extubated, but required re-intubation due to rapid shallow respirations (the RR was recorded to be 45-55 bpm). He was placed back on the ventilator at assist control of 6, TV of 1000 and FIO2 of 30%.

PMH: Inferior Wall MI 1 month PTA (6/02) Hypertension Hyperlipidemia

PSH: Cardiac Catheterization with Coronary stent placement to LAD and RCA 6/02 Cardiac Catheterization with attempt to open LAD stent thrombosis 1 day Prior to CABG

Medications:
Enoxaparin 30 mg sc bid
Metoclopromine 5 mg ivpb q 8 hours
Pantoparazole 40 mg ivpb q 12 hours
Piperacillin/Tazobactam 3.375 grams iv q 6 hours
Propofol
Norepinephrine as needed for BP control

Allergies: None

Social History: 37.5 pack year history of smoking, no ETOH, drugs, or high risk sexual behaviors.

Family History: N/C

ROS: Unobtainable

Physical Exam:
BP 110/60 Pulse 90 Temperature 101 degrees 02 saturation -99% PA pressure- 30/15 weight- 70Kg
WDWN AA male on the ventilator, responding to name Heart- RRR S 1 S2, no rub
Chest incision- clean, dry and healing
Lungs- Bilateral basilar rhonchi
Abdomen- soft, BS active
Extremities-well healing vein graft donar sites
Neuorological: Awake, but lethargic, follows commands, Cranial nerves 2-12 intact, motor - bilateral diffuse upper and lower extremity weakness. Barely able to raise against gravity, DTR's depressed thoughout. Plantars- down going.

Current Ventilator Settings and Pulmonary Physiology
AC - 6 bpm, TV- 1000cc, F102- 30%
Total respirations - 11 bpm Minute volume- 8-12 Liters Peak pressure- 30 cm H2O PEEP- 5 cm H2O
ABG- 7.45/31.9/88/22.6 (A-a gradient pending) FVC-500cc
MIP- 14 cmH2O

Chemistry
Repeat ESR - 134
CBC- normal except for a HgB of 9.7 SMA7- normal
Calcium- 7.6
Albumin-2.5
Magnesium-2.0
P04- 3.7

A diagnostic Procedure was done.