Pt CRRT lines after it clogged off. LDH was 8600. And, no th | Figure 1

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Pt CRRT lines after it clogged off

LDH was 8600. And, no they weren't on propofol.

Resolved Rare

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Case Details

#HFrEF/CRRT/Swan-Ganz/

This is the case of a 60+ year old gentleman who has been told that he needed an LVAD for ischemic cardiomyopathy within the last 6 months. However, the patient refused it; since refusing LVAD, his condition has deteriorated with increased SOB affecting ADLs, mild CP, and bilateral LE edema +2. The patient states he wanted medical management instead of LVAD and recently stopped taking his meds because he felt better.

• PMH: HFrEF, CAD, HTN, DM, Hypothyroidism, Afib.
• Meds: Coreg/ASA/Entresto/Metformin/Synthroid/Amiodarone/Eliquis
• C/C: SOB x weeks with progressing bilateral LE edema. Admission labs show a Cr of 1.4, K 5.0, Mg 1.7, AST 234, ALT 198, WBC 11, Hg 11.5, Plt 234, lactic 2.0, INR 1.5, PT 15.
• Admission Vitals: BP 110/90, HR 120, RR 26, SpO2 on 4L 94%, Temp 99.7, rhythm Afib.
• Hospital Course: Initially admitted to the floor for diuresis and management of his HF. As his UO dropped and renal/hepatic function worsened, he was treated in ICU for advanced hemodynamic monitoring. Swan-Ganz was inserted, PA 50’s, CVP 15-18, CO 3.0-3.5, CI 1.8, echo EF < 20%, moderate TR, mild-moderate MR, MVG 50%. Primacor was started.

In ICU, renal/hepatic function continued to decline. Due to his low EF, a decision for CRRT instead of IHD was made. The patient underwent HD catheter placement as shown in the picture, CRRT started right after. LFT reached the 1000 range; he was hypotensive for a short time the day prior; U/S renal showed possible renal infarcts.

Clinical Questions

1. CRRT venous return alarms went off; all typical troubleshooting steps were done, but the alarm still went on. What could be going on? (Look at the picture; could it provide a clue?)
2. If all of your drips were being infused through the side port of the Swan introducer, would you expect the dose of your drips to increase given the proximity to the CRRT catheter, or would there be no effect at all?
3. How reliable is thermodilution CO in the setting of TR? Is there a better method of measuring CO? 3.1. Primacor vs Dobutamine for renal patients— which is better? What should you remember?
4. What could explain the worsening in his renal/hepatic decline including the sudden increase in LFT with possible renal infarcts?

Additional Cases

Case of 60 y/o F

60 y/o F c/o dizziness, nausea, syncope with +LOC, weakness, and RLQ abdominal pain. The patient is CAOx4, mentating appropriately, unsure if she hit her head. Exam reveals minor edema in lower extremities, stroke scale negative, pupils pearl, rales noted in bases.

• Vitals: BP: 84/56, RR: 14 unlabored, regular rhythm, HR: 84, SpO2: 93%, Temp: 98.2F.

Case of 80y M

80y M at home syncope, apnea, spontaneous recovery; emergency called, paramedics saw later asystole on monitor, but he again spontaneously recovered. ECGs showed: rhythmic, HF: 45-50/Min, QRS: 100-120msec, no P-wave.

• RR: 100/80 with Dobutamine-Perfusion 45mg/h.
• Labs: no CK/Trop but K: 7.9 mmol/l, Crea: 4.9.

Summary of Notable Cases

• Case of 52-year-old man: Presented with a 20-minute history of chest pain radiating to the left shoulder and neck associated with dyspnea and diaphoresis.
• Case of 28-year-old woman: Presented with a 3-day history of intense pruritus over the lower back following care for rescue dogs.