PE and R. to L. atrial shunt

LindaMarie76 · Mar 21, 2005

No intelligent response from me. Thanks for sharing.

Linda

I had an interesting patient yesterday. A 47 y.o. otherwise healthy female had a lumbar laminectomy the day before and she was getting out of bed for the first time with physical therapy and her shell back brace. She passed out and luckily the neurosurgeon was near the room and facilitated the code. She had a pulse and was breathing, but her oxygen saturation was in the 50's. STAT CT scan showed a massive PE blocking practically her entire right lung. She was intubated in the ICU and started on Diprivan and Heparin. She was still only saturating in the 70's even with peep added because she was suspected to have also aspirated. Chest x-ray confirmed proper tube placement. Patient was then whisked off the radiology to have the PE embolized. She had a one minute seizure while on the radiology table and never saturated above 60%, even after the procedure. The pulmonologist tried norcuron which didn't seem to help either, although she was not resisting the ventilator. An ECHO with Bubble Study (new thing for me) confirmed a right to left shunt. I read up about it a little on-line last night and found that it can sometimes be caused by the pressure from the PE. The cardiologist mentioned that maybe the embolectomy was performed incorrectly. The patient was given 1L NS bolus and then 200cc's /hr. Also, she was going to be getting TPA 100mg over 24 hours. She arrived to our unit at 1015 am and I left around 8pm and she never saturated above 80%. I fear for her prognosis.

Any thoughts or experiences with right to left shunts in adults?

lifeLONGstudent · Apr 4, 2005

It's been 2 weeks. Can you tell us more: what happened, what did you all discover,etc.

thanks for sharing/teaching

lifeLONGstudent

heartICU · Apr 4, 2005

I have had a patient who has had a R-to-L shunt purposely placed to alleviate strain on the right heart. I know this isn't what you are looking for, but it's kind of interesting anyway. She had severe pulm hypertension, so they did an atrial septotomy...basically just punched a hole between her right and left atrium. That allowed some of the blood to go directly to the left side without traveling through her lungs. Didn't improve her oxygenation, but did slow down the cor pulmonale she was developing.

Edited to add: Ok, I just reread the original post. The R-to-L shunt could have been caused by the pressure from the PE, just like the above scenario with my patient. Your patient would have had to have an ASD...but they are not all that uncommon. I remember reading somewhere that up to 30% of all people have a probe-patient ASD upon autopsy. The PE would have caused severe pulmonary hypertension (depending on where in the lung it is), so it could have ended up just like my patient. Any word on how she did?

-Emma- · Apr 5, 2005

Unfortunately the patient did not survive. She was off of the sedation the next day and didn't wake up. EEG confirmed no electrical activity. Family was refusing a cerebral blood flow study until a week later. Family was having a hard time accepting, of course. The next of kin was a 22 y.o. daughter, so all decisions landed on her. They finally agreed to the cerebral blood flow study (which was the first I went to and was interesting to watch) which confirmed no blood flow and brain death. To my pleasant surprise, the family agreed to organ donation. So then Gift of Life took over and had me draw the most blood I have EVER drawn on a patient. I'd bet there were about 40 tubes to draw. Within 3 hours of getting started with Gift of Life, there was a candidate for the liver transplant.

This was an unfortunate case for the neurosurgeons who did her laminectomy, but I think they did an excellent job with the family and breaking the news to them and not giving false hope from the beginning.

Dinith88 · Apr 5, 2005

She had severe pulm hypertension, so they did an atrial septotomy...

How cool is that! Have you ever heard of or seen this procedure being done since? It must be a drastic last-ditch thing or some newer/experimental procedure? Thats really far out...

heartICU · Apr 5, 2005

I had actually taken care of another person who had it also. She had extremely severe heart failure...she had all three valves done multiple times, and had the worst pulmonary hypertension I had ever seen...the difference between her PAS and SBP was about 5-10... By the time she came to my hospital, she had the atrial septotomy, and a MVR (second time redo), AVR (third time redo), and TVR (first time).

About two months after surgery, she ended up passing away, ironically not because of her cardiac function. She tripped and fell while on the RNF, and suffered a severe SAH. (She was on a heparin gtt). They took her to neurosurg emergently, but didn't help. She was one sick lady!

How cool is that! Have you ever heard of or seen this procedure being done since? It must be a drastic last-ditch thing or some newer/experimental procedure? Thats really far out...

heartICU · Apr 5, 2005

So then Gift of Life took over and had me draw the most blood I have EVER drawn on a patient. I'd bet there were about 40 tubes to draw.

When I was in ICU, I prepped heart and lung transplant patients....we have to draw a TON of blood on them too...30-40 tubes is about right! You feel like you are sucking them dry!

diddoms · Apr 5, 2005

I used to work in a hyperbaric facility where we treated amoungst other things scuba divers with the Bends or decompression illness( DCI). Every once and a while we would get some one who had relatively severe symptoms given the nitrogen load they were exposed to. We would send them off dor testing and usually they still had a patent forame ovale, which is supposed to close over after birth. Sometimes the opening occurs with straining( valsalva manoever). Small bubbles of nitrogen return to the pulmonary circulation and are usually filtered by the lungs, but when a R>L shunyt occurs the bubble are free to move out into the circulaton where they cause all the problems.