A patient visited the emergency department because of two syncopes on that day. During the examination, he became unconsciousness because of ventricular fibrillation. After short resuscitation with ROSC after 10 minutes, he was transferred to ICU.
Patient´s history is remarkable of Parkinson disease, chronic lower limb ischemia, liver cirrhosis, alcohol addiction, smoking and chronic heart failure. Weight of approximately 75 kg.
The patient received mechanical ventilation and analgosedation. Ventilation without any problems (by emphysema) (BiPAP, PEEP 7, FiO2 0.5, Ti:e 1:2, Pmax 18, tidal volume around 450 ml, spontaneous ventilation was partially preserved with 4 supportive breaths/minute). Circulation support by the administration of noradrenaline 1.2 mg/h. Sinus rhythm with heart rate 80 bpm.
Lab results: troponin-T during admission 48 ng/ml, next value 220 ng/ml (approximately 12 hours ago). Consultation with a cardiologist – PCI will be done on the next day.
PiCCO monitoring was initiated with these values: cardiac output 4 l/min, cardiac index 2.2 l/min/m2, stroke volume variation 21%, dPmax 1460 mmHg/s, stroke volume 50 ml, systemic vascular resistance 934, EVLWI 12.3, GEDVI 1061, PVPI 1.7. Invasive blood pressure measurement gives BP of 104/62/47 mmHg.
You come to the nightshift and find out that noradrenalien dose was continuously increased over the day (0.3 mg/h in the morning, 1.2 mg/h at the moment). Peripheral perfusion is well preserved as well as diuresis, serum lactate level normal. Auscultation reveals very silent breathing sounds (in the right upper ventral region inaudible).
The ultrasonographic machine was at hand: