1 / 22

Progressive hypoxia in a patient with cirrhosis

Progressive hypoxia in a patient with cirrhosis. Scott Mead, M.D. Sept. 26, 2007. Case. 55 year-old woman Transferred to UW hospital after 2 week stay at OSH for hepatic encephalopathy, DVT, and cellulitis PMH: cirrhosis from EtOH/HCV with hx encephalopathy, varices, ascites

chelsi
Download Presentation

Progressive hypoxia in a patient with cirrhosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Progressive hypoxia in a patient with cirrhosis Scott Mead, M.D. Sept. 26, 2007

  2. Case • 55 year-old woman • Transferred to UW hospital after 2 week stay at OSH for hepatic encephalopathy, DVT, and cellulitis • PMH: cirrhosis from EtOH/HCV with hx encephalopathy, varices, ascites • Meds: lactulose, MVI, thiamine, folate, esomeprazole, Mg, gabapentin, nystatin, spironolactone, ceftriaxone, coumadin

  3. Case • Exam • Thin, ill-appearing female • 97.0, 98, 97/46, 22, 96% RA • HEENT – thrush, o/w normal • CV - normal • Pulm - normal • GI – ascites, o/w normal • Skin – spider nevi, scattered ecchymoses • Neuro – nonfocal, A&Ox3, no asterixis • Ext – 2+ edema LLE

  4. Case • Admit Labs: • WBC 5.1, Hct 26, Plt 113 • Na 131, K 5.7, Cr 4.1 • Tbili 3.8, Alk Phos 152, ALT 45, NH3 51 • INR 1.9 • UA with full field RBCs, 2-5 WBCs, o/w wnl

  5. Admission CXR

  6. Hospital Course • Days 1-2 • Worsening renal failure • Increasing delirium • Worsening LFTs • Day 3 • Worsening oxygenation requiring 3-4 liters per nasal cannula

  7. Day 3 CXR

  8. Day 4 Chest CT

  9. Day 4 Chest CT

  10. Hospital Course – days 5-6 • TTE with normal size and function • Blood cultures negative • Pulmonary consult • Empiric antibiotics for hospital acquired pneumonia • Increasing O2 requirements • ABG 7.21/45/68/17.4 on 100% O2

  11. Day 6 AM CXR

  12. Day 6 PM CXR

  13. Hospital Course • Transferred to TLC • CVVHD initiated • Intubated, mechanical ventilation with high O2 requirements • Clinically consistent with ARDS and MODS

  14. Acute Respiratory Distress Syndrome (ARDS) • 1967 • Approx 200,000 cases/year in U.S. • Mortality 40-60% (decreasing?) • Pathophysiology: • Endothelial injury • Epithelial injury – type I and type II cells • Cytokines • Fibrosis (some cases) N Engl J Med. 2000 May 4;342(18): 1334-49

  15. ARDS - definition PaO2/FiO2 = 68/1 = 68 N Engl J Med. 2000 May 4;342(18): 1334-49

  16. ARDS - causes N Engl J Med. 2000 May 4;342(18): 1334-49

  17. ARDS – treatment? • Yes • Treat underlying cause • Supportive care • Lower Vt (6 ml/kg) • No • Routine use of high PEEP • Ketoconazole • Pulmonary artery catheter (versus central line) • Maybe/Not yet • Conservative fluid management • Prone ventilation (though ↑O2 and ↓VAP, adverse effects) • Glucocorticoids • Surfactant • Partial liquid ventilation • Nitric oxide Cleve Clin J Med. 2006 Mar;73(3):217-9, 223-5, 229

  18. Hospital Course • Underwent bronchoscopy with BAL

  19. ARDS and Blastomyces? • Overwhelming Pulmonary Blastomycosis Associated with the Adult Respiratory Distress Syndrome • Keith C. Meyer, Edward J. McManus, and Dennis G. Maki • N Engl J Med. 1993 Oct 21;329(17): 1231-6

  20. ARDS and Blastomyces? N Engl J Med. 1993 Oct 21;329(17): 1231-6

  21. Hospital Course • Hypotension requiring pressor support • Amphotericin started • Progressive liver failure • Transitioned to comfort care on hospital day 11

  22. Questions?

More Related