909: Shock and Volume Responsiveness With Hepatic Metastases: Case Suggestive of Ivc Compression Syndrome

Introduction: Inferior vena cava syndrome (IVCS) is a rare but critical condition, often due to external compression from intra-abdominal malignancies. It leads to impaired venous return, preload depletion, and hemodynamic instability. Diagnosis is typically clinical, supported by imaging and point of care ultrasound (POCUS), and is often underrecognized in critically ill patients. Description: 57 year old woman with diabetes and recurrent pyelonephritis presented with hypotension, encephalopathy, jaundice, hepatomegaly, bilateral lower extremity edema after recent hospitalization in Ghana. Labs showed leukocytosis, elevated liver enzymes, Acute kidney injury, lactic acidosis. CT and MRI revealed massive hepatomegaly with innumerable hepatic lesions, a large ovarian teratoma, and mass effect on the portal vein. POCUS showed a collapsed IVC and hyperdynamic LV. She remained fluid responsive but vasopressor dependent. Blood cultures were negative, but urine grew ESBL E. coli. Despite broad-spectrum antibiotics, she deteriorated with respiratory failure and died from multiorgan failure. Discussion: This case shows the clinical impact of IVC compression from hepatic metastases. Her persistent hypotension, fluid dependence, and ultrasound findings (collapsed IVC, kissing ventricles) suggested impaired venous return despite no cardiac or obstructive etiology. Imaging supported extrinsic mass effect on vascular structures. IVC stenting was deferred due to instability. In advanced malignancy, mechanical venous obstruction may worsen septic or hypovolemic shock. Recognition of preload dependence via bedside ultrasound can guide management, even when definitive intervention isn’t feasible.