Abstract Case 82 Y/o Female with a history of hypertension and Atrial fibrillation initially presented with metabolic encephalopathy in the setting of urinary tract infection, managed conservatively with antibiotics. On admission day 2, the patient had a syncopal episode with hypotension, Mean Arterial Pressure (MAP) 50-55mmHg. On evaluation, she was unable to protect her airway and was immediately intubated. No Point-of-Care Ultrasound (POCUS) at the time of intubation, given urgency and lack of availability of ultrasound. Patient persistently hypotensive after intubation, requiring escalation of vasopressor support with Levophed 30mcg/min and Vasopressin 0.4 Units/min. Noted to have intermittent episodes of MAPs to 60-65mmHg with a pulse pressure ot 18-20mmhg. Taken for CT-Chest, which was negative for acute PE but did show a severely dilated pulmonary artery (Fig. a). Transferred to the ICU, an arterial line was placed, and the patient continued to have intermittent hypotension. Given persistent shock started on phenylephrine, but continued to have intermittent hypotension. Bedside POCUS showed diffuse Left Ventricular (LV) hypertrophy and possible LV apical cavity collapse (Fig. B, C). 2D Echocardiography noted to have dilation of the bilateral atria and right ventricle with appropriate LV function (Fig. D). Also reported to have Severe Tricuspid Regurgitation (TR) and a dilated IVC, collapsibility 20% (Fig. D/E). Significant improvement in blood pressure and cardiogenic shock with serial boluses of 250ml Lactated Ringer’s solution. The patient was weaned off pressors over the next 8 hours. Discussion This case highlights three key aspects of managing complex cardiopulmonary physiology. First, the utility of immediate goal-directed echocardiography before intubation in optimizing patient hemodynamics. While difficult in a rapid response setting, understanding her RV dilation and possible pulmonary hypertension before intubation might aid with her persistent shock post-intubation. Secondly, the utility of serial POCUS in identifying complex physiology and dictating management. Phenylephrine was initially used to assist with blood pressure support. However, given complex cardiogenic shock with severe TR and intermittent LV apical collapse, it was realized that it would benefit from fluid resuscitation. Lastly, this case highlights the utility of highly monitored fluid resuscitation in certain complex cardiac physiologies involving TR. This is aimed at improving RV ventricular function by increasing preload, as well as enhancing LV preload and function. This abstract is funded by: None
Ahmed et al. (Fri,) studied this question.