This is my first case report here so be gentile ;-)

I'm todays float CRNA, so responsable for coffee brakes, trauma/codes and lending a hand in the holding or pacu if neseccairy. Over here in The Netherlands we have a MDA supervised system.

A 60 year old male for elective laparoscopic cholecystectomy. Non english or dutch speaking so he was screened with a family member who stated no previous medical history exept a RBBB, no allergies and no med's.

GA induced with propofol, rocuronium, sufentanil, tube+ sevo. Surgery went uneventfull, no blood loss, fluid 1000ml of crystalloids. Reversal with 100mg sugammadex, extubaton and PACU were all uneventfull. 15mg Piritramide and 1000mg acetaminophen before discharging to the ward. OR and surgeon started their next case.

Approx 45 minutes later as i'm chatting with the PACU nurses, they get a call from the ward stating they are returning the patient because of 'severe pain' and he's caughing up blood. PACU sighs and complain he probably needs more pain meds and the blood's probably from the ETT. Jeez, damn ward nurses!

I decided to help in the busy holding which is located opposit of the PACU.
About 30 minutes later I happened to see the patient. An anxious man, sweating profusely, pale with a shallow respiratory rate of 30, HF: 130 (RBBB), RR 146/90 and a SpO2 of 98% on 4l O2 nasal cannula. I talked to the student PACU nurse standing next to the patient: how's he doing?

'He got another 10mg of piritramide and a PCA pump and the other PACU nurse (her preceptor) wants to transfer the patient back to the ward, but I'm not too sure'.

I talked to the preceptor: ' he's fine, his RR is good and he got some more narcs so he can go back now!'

Not too sure of that, I called the MDA to come and take a look. This is a down-to-earth anesthetist who listens to what you've got to say and usually concurs with your interventions.

I try to communicate as best as I can with the patient who's still short of breath and complains of pain and holds his chest instead of his abdomen. The blood that was supposedly coughed up looks more like a reddish foam.

A chest X-ray and 12-lead are ordered. His condition is not stabile and sat's are 90%, so you switch to a non-rebreather mask 15l/min. Patient is lethargic, non invasive ETCO2 measures 75mmHg. Respirations are supported with the CPAP funtion of the PACU vent.

Our work diagnoses were either a massive MI or pulmonary edema. Nitroglycerin, morphine, dobutamine and lasix administered, as well as a second IV and arterial line. Cardiologist consult and the ECG showed st-elevation in all leads, and the X-ray a severely enlarged heart. Cardiologist recommended transfer to a Cardiothoracic hospital for PCI. Aspirin, heparin and clopidogrel, intubation and transfer.

We later heard that it was probably a acute decompensation And pulmonary edema caused by a combination of the IV fluids and a PAN ischemia. (So much for family history, huh)

Patient still in ICU, required multiple CABG's and IABP support