Chapter 12: Miscellaneous Devices

Case Presentation

A 75-year-old woman was brought to the emergency department (ED) with altered mental status and lethargy by her son. The patient’s son found her in bed with altered mental status for an unknown duration. At home, her vitals showed a pulse of 126 bpm, systolic blood pressure of 82/42 mmHg, and oxygen saturation of 89% on room air. Upon arrival at the ED, the patient received 1.5 L of normal saline and was placed on high-flow supplemental oxygen.

The patient’s past medical history includes nonischemic cardiomyopathy (left ventricular ejection fraction of 30%), hypertension, paroxysmal atrial fibrillation, and recurrent urinary tract infections. She is currently taking metoprolol succinate, spironolactone, lisinopril, apixaban, and nitrofurantoin.

Upon examination in the ED, the patient remained minimally responsive, with a temperature of 39.3°C, heart rate of 114 bpm, blood pressure of 86/50 mmHg, and oxygen saturation of 88% on high-flow oxygen. Her physical examination revealed a normal S1 and S2, no S3 or S4, and a grade 2/6 mid-peaking systolic murmur at the left sternal border. Jugular veins were difficult to assess due to her body habitus, and lung fields were clear anteriorly. The patient’s extremities were cool to the touch with sluggish capillary refill. The patient was intubated in the ED and received an additional 2 L of normal saline. She was subsequently transferred to the intensive care unit.

The patient’s initial laboratory values (with normal reference values shown in parentheses) are as follows:

• Leukocyte count: 18,000/µL (4500-11,000/µL)

• Hemoglobin, blood: 11 g/dL (11.9-14.8 g/dL)

• Sodium: 128 mEq/L (135-145 mEq/L)

• Potassium: 3.7 mEq/L (3.5-5.0 mEq/L)

• Blood urea nitrogen: 44 mg/dL (7-18 mg/dL)

• Creatinine: 1.6 mg/dL (0.6-1.2 mg/dL)

• Lactate: 4.7 mmol/L (0.5-2.2 mmol/L)

A pulmonary artery (PA) catheter was placed, and findings were as follows:

• Right atrial pressure, mean: 8 mmHg (1-5 mmHg)

• Right ventricular pressure: 50/20 mmHg (15-30 mmHg/4-12 mmHg)

• PA pressure: 50/15 mmHg (mean 28 mmHg)

• Pulmonary capillary wedge pressure, mean: 14 mmHg (4-12 mmHg)

• Oxygen saturation: 40%

She was then started on antibiotics and pressors, and mixed etiology of shock was considered.

KEY POINTS

• Environmental and biomedical equipment play an important role in care of cardiac critical care unit (CCU) patients, and knowledge of these devices can guide the treatment in an efficient manner.

• Troubleshooting the equipment in CCU on a day-to-day basis is a challenging process and can improve patient outcomes.

• This chapter describes several devices used in the care of critically ill patients in the CCU.