Interesting Situation (Thoughts?)

Same thing you did. Additionally, I might have talked to the docs about Dobutamine, which has a far shorter half life. Or you could have treated the SVR directly. But that CVP was pretty high -- had he been diuresed?

Patient seemed pretty euvolemic - despite the CVP.

What we ended up doing was giving 250 of 5% Albumin and restarting the Nicardipine gtt.

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Someone had mentioned giving albumin right off the bat before even touching the Milrinone. Would still love to hear peoples thoughts and opinions on the situation.

Hard titration numbers are tough to work with. When I titrate off drips quickly (milrinone's half life notwithstanding) I cut in half whatever the patient is on at the time. So, as goofy as it may sound, I would have gone from 0.125 to 0.0625.

I hate milrinone and it needs to be given great consideration before it is chosen because once it is, you're married to it for a while. My opinion. Better combinations are available that aren't such a big commitment.

My inclination likely would have been to diurese unless i see real signs of hypovolemia, at least after the first attempt to titrate milrinone off failed. For whatever its worth, its been a while since i took care of post cabg patients.

Im wondering what exactly you mean when you say the patient seemed euvolemic despite the cvp.

After a while, CVP is not a good indicator of intravascular fluid status (some would argue it never is but that's another issue). In this situation, I would have had someone throw a bedside echo probe on the heart to see what's happening (overfilled, underfilled, no output due to high SVR or due poor inotropy?). PA caths are nice but not always the best. Correlate it with a Fick equation cardiac output? Correlate clinically (py making pee with warm extremities and peripheral pulses?). If pt looks bad, is prob restart Milrinone right away and then maybe switch to dobutamine after talking to provider. Some providers love one or the other but the bottom line is that every heart reacts to drugs differently and the dobutamine may be better for that pt at that moment. Def wouldn't diurese someone with that bad of a CI unless the echo showed major overfilling.

After a while, CVP is not a good indicator of intravascular fluid status (some would argue it never is but that's another issue). In QUOTE]

Agree with your post...I'm one of those that actually believe CVP has a role in determining, not volume status, but cardiac function in select patients. It's nuanced, but I very much am able to put to use what I see in CVP.

Agree completely. Blindly resuscitating to a CVP of x or y (just like using any other single parameter) is misguided. However I am also not of the opinion that CVP should be banned from the unit or OR (as it is in some places). Used correctly and correlated clinically it can add useful information (especially when regarding fluid tolerance vs. fluid responsiveness). Also good for helping to diagnose changes in pt status (tamponade, decreased ventricular function, etc). I think an ultrasound probe on the heart gives you better info, but it may be changes in the CVP that clue you in that you need to go grab the ultrasound.

Curious about any other infusions and uop?

Same thing you did. Additionally, I might have talked to the docs about Dobutamine, which has a far shorter half life. Or you could have treated the SVR directly. But that CVP was pretty high -- had he been diuresed?

I am confused about "treat the SVR directly". CO and SVR are inversely related. If CO is down, then SVR has to be high....correct? It is my understanding that the SVR is a calculated number, not a measured number.

I can see your rationale behind not using CVP alone, but all of your other hemodynamic parameters seem to indicate that he was definitely fluid up as he was hypertensive, extremely high PA pressures with a high CVP. If it was just one outlier, I can see not blindly treating CVP, but all three point in the direction of being fluid up. The amount of time the patient was on bypass will directly affect kidney function and almost always causes some sort of acute kidney injury that usually presents 2 or 3 days post op. I would have definitely suggested diuretics, if not some push-pull with diuretics and concentrated albumin to improve those hemodynamic parameters. His SVR is high enough that he is indicating he's clamped down, and could use some albumin but has a lot of fluid to give. A SPB of 140 is way too high for a CABG, so nicard was a good choice for sure. I think lasix, lasix, lasix (depending on kidney function) maybe some diamox and nicardipine, and restarting the milrinone wean once he is a little more fluid negative and can tolerate it.