progressive hypoxia in a patient with cirrhosis
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Progressive hypoxia in a patient with cirrhosis
Scott Mead, M.D.
Sept. 26, 2007
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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
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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
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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
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Admission CXR
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Hospital Course
• Days 1-2– Worsening renal failure– Increasing delirium– Worsening LFTs
• Day 3– Worsening oxygenation requiring 3-4 liters per
nasal cannula
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Day 3 CXR
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Day 4 Chest CT
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Day 4 Chest CT
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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
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Day 6 AM CXR
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Day 6 PM CXR
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Hospital Course
• Transferred to TLC
• CVVHD initiated
• Intubated, mechanical ventilation with high O2 requirements
• Clinically consistent with ARDS and MODS
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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
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ARDS - definition
PaO2/FiO2 = 68/1 = 68
N Engl J Med. 2000 May 4;342(18): 1334-49
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ARDS - causes
N Engl J Med. 2000 May 4;342(18): 1334-49
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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
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Hospital Course
• Underwent bronchoscopy with BAL
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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
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ARDS and Blastomyces?
N Engl J Med. 1993 Oct 21;329(17): 1231-6
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Hospital Course
• Hypotension requiring pressor support
• Amphotericin started
• Progressive liver failure
• Transitioned to comfort care on hospital day 11
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Questions?