Please review the handout "Hemodynamic Monitoring and Inotropes" prior to this case

A 57 year-old male presents to the Emergency Room with a thirty-six hour history of fever and
abdominal pain. Abdominal films reveal free air and he is scheduled for emergency exploratory
laparotomy to repair a ruptured sigmoid diverticulum. Past medical history is significant for an
idiopathic cardiomyopathy with a baseline left ventricular ejection fraction of 15%.

Physical examination reveals a thin, pale, diaphoretic male with a depressed level of
consciousness. BP is 65/40 by cuff. HR is 120, temp 38.6°.

Differential diagnosis of this patient's hypotension includes:

a) Acute myocardial infarction

b) Chronic myocardial dysfunction

c) Sepsis

d) Hypovolemia

e) All of the above

To differentiate the etiology of his hypotension you place a radial arterial line, central venous
line, and pulmonary artery catheter.

Complications of right internal jugular catheterization include all of the following except:

a) Carotid artery puncture

b) Infection

c) Pneumothorax

d) Thoracic duct injury

e) Brachial plexus injury

All of the following are true about pulmonary artery rupture except:

a) May result from prolonged "wedging" of a PA catheter

b) Often presents as sudden bleeding from the endotracheal tube

c) Occurs with increased frequency in the presence of hypothermia and
anticoagulation

d) Occurs with increased frequency in patients with elevated pulmonary
artery pressure

e) Frequently responds to conservative management with a good clinical
outcome

Following placement of the invasive monitors the following data are obtained:

BP 70/40

CVP 4

PA 17/9

CO 1.9

SVR 1800

Your initial impression is:

a) The hemodynamic profile is compatible with sepsis alone

b) The hypotension is entirely due to an acute myocardial infarction

c) The clinical picture is explained by a worsening of his baseline myocardial
dysfunction

d) The patient is relatively hypovolemic and intravenous fluid is indicated

e) Additional volume is contraindicated because of the risk of pulmonary
edema secondary to cardiac dysfunction

The patient receives 2 liters of crystalloid over the next thirty minutes, resulting in:

BP 80/45

CVP 22

PA 35/17

CO 2.1

SVR 1400

Your impression of these data is:

a) An alpha agonist should be administered to increase blood pressure

b) An additional two liters of fluid should be administered over the next thirty
minutes

c) A septic picture is appearing more likely

d) There is increasing evidence of myocardial dysfunction

e) The patient is dangerously volume overloaded and should be diuresed
immediately

In view of his modest response to fluid administration you decide to begin inotropic support.

Which of the following statements is true regarding catecholamines?

a) ß1 agonists and phosphodiesterase inhibitors share a common mechanism
involving increases in intracellular cyclic AMP

b) Catecholamines must be administered in a loading dose followed by a
continuous infusion because of the long half-life of the drugs

c) Clinical effects of catecholamines are not affected by changes in end organ
receptor density (up- or down- regulation)

d) Catecholamines display selective positive inotropic effects without
affecting heart rate

e) Catecholamines decrease myocardial oxygen consumption by improving
diastollic relaxation

Suitable inotropes in this acute clinical situation include all of the following except:

a) Digoxin

b) Dopamine

c) Dobutamine

d) Epinephrine

e) Milrinone

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