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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

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Progressive hypoxia in a patient with cirrhosis

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  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?

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