1 / 22

Persistent post-op hypoxia

This case study explores a patient with persistent post-operative hypoxia in the ICU, ultimately diagnosed with hepatopulmonary syndrome. Symptoms included platypnea and orthodeoxia, and the patient required long-term oxygen therapy.

jessiehall
Download Presentation

Persistent post-op hypoxia

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. Persistent post-op hypoxia ICU, Pamela Youde Nethersole Eastern Hospital Dr Emily Cheung & Dr Arthur CW Lau 24 Sep 2010

  2. Case • M/69, ADLI • Ex smoker, drinker • PMH: • eAg negative chronic hep B • Ulcerative colitis on mesalazine • HT

  3. Newly diagnosed HCC over right lobe • ‘C’ adm for open right hemi-hepatectomy • Uneventful operation • Intra-op finding: • Large tumor at seg V of liver • Liver not cirrhotic macroscopically

  4. Post op extubated and transferred to ICU for monitoring • Post op on 6L O2, gradually tail down O2 requirement • On 2L O2 without SOB on discharge • Discharge from ICU on D1

  5. Developed abdominal distension with post-op ileus on D3 • Increasing O2 requirement and desaturation noted in general ward • Readmitted ICU on D4 • Required 12 L O2 on admission to ICU • ABG on O2: unremarkable

  6. CT – lung window

  7. CXR and CT reviewed • suggestive of some atelectasis in dependent part of both lower lobes • Probably contributed by bowel distension • No evidence of PE or chest infection

  8. Progress • NIV given for a short period of time, but not very responsive • Chest physio with lung expansion by incentive spirometry started • However, still noticed occasional desaturation • ? Causes for persistent hypoxaemia

  9. Detailed history taking • Complaints of discomfort on sitting up while watching TV, feels better if lying down • Symptoms present for 2 years • P/E: • No Stigmata of chronic liver disease • No clubbing, spider naevi • No gynecomastia

  10. Patient complaints SOB while sitting up, relieved by lying Platypea • More than three repeated trials of SpO2 measurement on 3L O2 Orthodeoxia • Lying: SaO2 > 93% • Sitting: Desaturated with SaO2 down to 81%, not fully correctable by increasing FiO2

  11. Bedside Echo with contrast by ICU Team • Chamber sizes relatively normal • Presence of intrapulmonary shunt, as indicated by bubbles on left side after 3rd beat • Ddx: • Intrapulmonary/Intracardiac shunt • More likely intrapulmonary shunt because bubbles did not occur immediately on L side post-bubble contrast injection • Discharged from ICU on D8 • Reviewed by medical team

  12. Progress • Inpatient Echo repeated by Cardiac team on D14 • mild pul hypertension • Bubbles contrast was seen in LA and LV after injection, suggested the presence of right to left shunt • no definite intra-cardiac shunt was detected • Ddx: intra-cardiac/intrapulmonary AV shunt • Patient refused TEE

  13. Impression of the causes of hypoxemia • Hepatopulmonary syndrome, and • Atelectasis due to bowel distension

  14. Hepatopulmonary syndrome • Characterized by a defect in arterial oxygenation induced by pulmonary vascular dilatation in the setting of liver disease • Trial of • Liver disease • Pulmonary vascular dilatation • Defect in oxygenation

  15. Source: Roberto Rodríguez-Roisin, M.D., and Michael J. Krowka, M.DHepatopulmonary Syndrome — A Liver-Induced Lung Vascular Disorder. NEJM, Volume 358:2378-2387 May 29, 2008 Number 22

  16. Clinical features • 18% asymptomatic • Platypnea : • Dyspnea improves when lying flat • Orthodexoia: • Hypoxemia worsens upon sitting up and improves when lying flat • pO2 decreased by > 5% or > 0.5 kPa

  17. Opacification of right atrium and right ventricule with microbubbles and delayed opacification of the LA and LV

  18. Pathobiology • Gross dilatation of the pulomonary precapillary and capillary vessels • Absolute increase in no of dilated vessels • Pleural and pulmonary AV communications and portopulomonary venous anastomoses

  19. Dilated capillaries  not uniform blood flow • Venous blood passed rapidly or directly thro intrapulmonaryshunt to pulmonary veins • VQ mismatch

  20. Treatment • No effective medical therapies • Liver transplantation is the only successful treatment • pO2 < 60 mmHg is considered to be an indication for liver transplantation • Long term oxygen therapy • For symptomatic patients with severe hypoxaemia

  21. THE END

More Related