Chapter 17, Patient Assessment: Cardiovascular System

Case Study/Short-Answer Questions and Discussion Points

Mr. T. is a 69-year-old male, 61, 97.6 kg (BSA 2.22) whose medical history revealed
questionable hypertension with noncompliant use of medication and absent regular
medical treatment.
Mr. T. arrived at the emergency department with complaints of increasingly
severe abdominal pains. The abdomen was tender upon palpation and distended. Initial
vital signs were: blood pressure 190/104 mm Hg, heart rate 86 beats/min, normal sinus
rhythm, respiratory rate 22 breaths/min, and SpO 2 96%.
Laboratory results showed Hgb 11 g/dL, Hct 33%, white blood cell (WBC) 9,840,
and lactate 2.2 mmol/L.
A preliminary differential diagnosis of acute appendicitis versus abdominal aortic
aneurysm was made. The physical examination and laboratory test findings were
inconclusive so a computed axial tomography scan was performed. Results of the scan
showed a 9-cm abdominal aortic aneurysm.
Mr. T.s condition worsens rapidly after the scan with complaints of increased
abdominal pain, severe respiratory distress with an SpO 2 value decreasing to 89%, and
a sudden decrease in his blood pressure to 108/64 mm Hg. Respiratory rate increased
to a rate of 36 and he exhibited shallow breathing. Heart rate remained in a sinus
rhythm, however it increased to 98.
Due to Mr. T.s worsening respiratory status and blood pressure, he was
intubated and placed on controlled mechanical ventilation. To assist with ventilation

synchronization management, he was sedated. Mr. T. was subsequently admitted to the

intensive care unit (ICU) for stabilization and additional monitoring.
Upon admission to the ICU an arterial line was placed and he was attached to a
less invasive CO monitoring device to measure and monitor CO and other dynamic
variables, such as stroke volume variation (SVV). In addition, to provide ready access to
his central circulation, a central line was placed in his right internal jugular vein. The
specific catheter used was one that monitors continuous central venous oxygen
saturation values to provide an assessment of his overall oxygenation balance status.
Additional hemodynamic and oxygenation values obtained in the ICU were:
cardiac index 2.8 mL/min/m2, SV variation 13%, and ScvO 2 72%. All of these variables
are within the normal value range. Care included continued monitoring of Mr. T.s status.
About an hour after admission to the ICU Mr. T.s condition continued to
deteriorate. His reprofiled parameters were: blood pressure 98/48 mm Hg, HR 126
beats/min, CI 2.1 L/min/m2, SVV 24% and ScvO2 54%.
The profile Mr. T. now presents can be one of acute hypovolemia, hemorrhage,
or potentially both. The cardiac fl ow indices are low. With a cardiac index of 2.1 and a
heart rate of 126, the SV is only 37. These are significant changes from the earlier set of
parameters that showed a SV of 63. The ScvO 2 value in addition decreased from 72%
to 54%, again a clinically significant change. Factors to assess when the ScvO 2 value
changes are those conditions that alter either oxygen delivery; arterial oxygen
saturation, hemoglobin, or CO, and those that affect oxygen consumption; metabolic
demand, pain, shivering, and fever. SVV as a dynamic indicator of fluid responsiveness

suggested that since Mr. T. is on controlled mechanical venation, he would respond

favorably to fluid.
A repeat laboratory hemoglobin and hematocrit sample showed Mr. T.s blood
count to have dropped from Hgb 11/Hct 33 to Hgb 9/Hct 27. This significant drop along
with the indicators of a hypovolemic state resulting from potential bleeding from the
aortic aneurysm led the surgical team to perform an emergent abdominal aortic
aneurysm repair.
The remaining course of hospitalization was unremarkable and Mr. T. did well.
Discharge was within 5 days.
1. What were the symptoms that caused concern on initial assessment?
Answers to consider

Abdominal pain upon palpation

Pain increasing in severity

Differential diagnosis leads to diametrically different interventions.

2. How did the additional parameters, CI, SVV, and ScvO 2, assist in the
identification of the clinical problem?
Answers to consider

ScvO2 is an indicator of the adequacy of oxygen delivery to meet the tissues

needs.

Cardiac index is a determinant of flow. With low value, oxygen delivery may not

be sufficient to meet the tissue needs.

SVV is a dynamic variable that is sensitive and specific for predicting the

patients ability to respond to fluid.

Mr. T.s values were indicating that flow was low and global needs were not being

met. The SVV reflected that preload was not optimal.

3. What would be a course of action for improving CO, ScvO 2, and SVV?
Answers to consider

Preload would be a good first choice to optimize flow.

If SV was low with an SVV in normal range, assessing and optimizing afterload,

then contractility would be a good strategy.

If ScvO2 remains low despite the optimization of oxygen delivery, then demand

facts for the patient need to be assessed and decreased.