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

• Meds: lactulose, MVI, thiamine, folate, esomeprazole, Mg, gabapentin, nystatin, spironolactone, ceftriaxone, coumadin

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

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

Admission CXR

Hospital Course

• Days 1-2– Worsening renal failure– Increasing delirium– Worsening LFTs

• Day 3– Worsening oxygenation requiring 3-4 liters per

nasal cannula

Day 3 CXR

Day 4 Chest CT

Day 4 Chest CT

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

Day 6 AM CXR

Day 6 PM CXR

Hospital Course

• Transferred to TLC

• CVVHD initiated

• Intubated, mechanical ventilation with high O2 requirements

• Clinically consistent with ARDS and MODS

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

ARDS - definition

PaO2/FiO2 = 68/1 = 68

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

ARDS - causes

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

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

Hospital Course

• Underwent bronchoscopy with BAL

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

ARDS and Blastomyces?

N Engl J Med. 1993 Oct 21;329(17): 1231-6

Hospital Course

• Hypotension requiring pressor support

• Amphotericin started

• Progressive liver failure

• Transitioned to comfort care on hospital day 11

Questions?