As the ICU attending you are cruising through the unit about 5 pm on your way to dinner when you notice a crowd of people headed by the CCM fellow at the bedside of a very cyanotic person. Lines are being placed and intubation is occurring. The patient's distal extremities are the color of a (blue) scrub suit.
Quick history given you: This is a 48 y/o female who was on coumadin for manifestations of Lupus Anticoagulant related phlebitis, but otherwise well. She had a recent history of Listeria meningitis that had been fully treated with no sequellae. The evening prior to admission she had been out to an uneventful dinner with her husband. On the day of admission, she was persuaded to come to the ED by her husband after she complained of some nausea and malaise, thought to be food intolerance. In the ED, her vitals were normal but she had a 103 degree temp elevation, a white count of 12K but with 47 bands. Otherwise her labs and x-rays were all normal. She did not want to be admitted. Her attending physician persuaded her to be admitted for 24 hour observation solely on the basis of her temp elevation and history of atypical infections.
She was admitted to the ward for observation, cultured and given an IV of 100cc/hr of the usual IV fluids. She was stable until about 6 hours after admission when she complained of progressive malaise and then became progressively obtunded within 15 minutes of her last ability to follow commands. The floor resident took one look at her and personally wheeled her to the ICU....express. On arrival she was in respiratory failure and exhibited both central and peripheral cyanosis. She wasintubated and an arterial line was placed which revealed a systolic blood pressure of 50. Her Sa02 was not readable. Two big bore lines were placed and 6% Hetastarch was infused wide open. Dopamine was started at 20 mcg/kg/min. Her blood pressure progressively deteriorated and finally she became bradycardic and CPR was started.
CPR did not generate any meaningful blood pressure with CPR. Turning up the infusing volume and dopamine were not fruitful. Things are deteriorating fast. You order a thoracic tray and chest retractor, pour some quick betadyne on the left lateral chest and stand poised with the fruits of Dr. Bard and Dr. Parker's labor over the 5th interspace. Should you do it? If so, why? or why not?
I have added a personal indication for internal cardiac massage:
I elected to open this patients chest for the following reasons: I didn't have a good handle on what was going on. Not enough time to assess trends or figure out obvious pathology. Patient was progressively going out before my eyes and I couldn't stop it with any other aggressive therapy. Vital signs went away very rapidly and progressively but not in instantaneously as might be expected from a simple cardiac arrest from a malignant arrhythmia. She was relatively young, had no obvious chronic diseases such as advanced heard disease that would limit any kind of resuscitation. There was no time for the usual invasive monitoring procedures to assess hemodynamics.
I wanted to find out what was going on with this woman's heart and fix it if I could. Once in the chest, I found that her heart was totally empty. There was not two red corpuscles to rub together. This was unexpected because she had been 100/hr of IV fluids since admission and exhibited no other previous evidence of hypovolemia. We immediately attached the rapid infuser and dumped two liters of hespan into her in a couple of minutes. I could feel the heart fill during this process. Once the heart began to fill, I began internal cardiac massage that registered with a meaningful blood pressure on the arterial line. When the heart fully expanded, it began to beat spontaneously. On an epinepherine infusion I had a blood pressure of 130 within a few minutes. I did not cross clamp the aorta. I tend not to believe in this maneuver. It was sufficient for me to wait until the heart filled. There was a cardiac surgeon in the house and the patient was evaluated by her in the ICU, then taken to the OR for chest closure.
I would like to report that this was a major save. In fact, the lady later proceeded to deteriorate on the epinepherine infusion and ultimately went into progressive heart failure and died some time later. Autopsy was done which showed (preliminary report): Gram positive bacteria growing in all culture bottles. Bilateral hemorrhagic adrenals. Otherwise, no obvious gross damage. I think the tissue cuts will show overwhelming sepsis and accelerated multiple organ system failure. She probably died of "Jim Henson's Disease", accelerated gram positive sepsis, helped out by some kind of Lupus ameliorated immune deficiency.
Was it worth anything to open the chest? I guess it depends. In this case, I was able to assess the fluid volume status immediately just by feeling the heart. I do believe we would not have gained this information before clinical death otherwise. Clearly, internal massage generates a much better cardiac output than external compressions. I was able to get a much better augmented heart function in this manner while fluid repletion was happening. There was never really a suspicion of tampanade.
It is my bias that if (and a big if) the point of no return had not been reached (unknown to me) in the pathway of sepsis, we might have been able to save this woman because we were able to figure out a lot of things quicker and do something about them.