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• W2895639937 abstract "SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: We present a case of H1N1 ARDS with shock due to right ventricular dysfunction (RVD) evaluated early by point-of-care ultrasonography (POCUS). CASE PRESENTATION: Forty-one-year-old African American man with no past medical history was admitted to our hospital complaining of shortness of breath and fever. He was diagnosed with H1N1 influenza which progressed to ARDS. He was placed on mechanical ventilation with low tidal volumes, PEEP of 12, and FiO2 of 100%. His initial PaO2/FiO2 ratio was 80 and progressed to shock. Initial POCUS performed suggested no RVD and therefore received two liters of crystalloids. His shock worsened requiring vasoactive agents and progressed into multiorgan failure. Repeat POCUS showed a dilated right atrium (RA) and ventricle (RV) with paradoxical septal motion. Tricuspid annular plane systolic excursion (TAPSE) was measured 0.83 cm with RV systolic pressure (RVSP) estimated at 39.5 mmHg. Patient was placed on epinephrine and a repeat echocardiogram was performed with his RVSP at 60.7 mmHg. CT angiography of the chest was done, a small pulmonary embolism was found. Patient was started on inhaled epoprostenol at 0.05 ng/kg/min, heparin, and placed on continuous renal replacement therapy. Two liters were removed with improvement of hemodynamics. Repeat bedside echocardiography revealed a TAPSE to 1.40 cm and improvement of other parameters and eventual discontinuation of all vasoactive agents and inhaled epoprostenol. DISCUSSION: Severe right ventricular dysfunction (RVD) is associated with increasing mortality among ARDS patients and is identified in about 22% to 50% of these patients. TAPSE is an easily obtained parameter that correlates well with RV function. Therefore the role of bedside echocardiography becomes pivotal in identifying early RVD. Acute RV failure is a rapidly progressive syndrome with multiple systemic effects which can be confused with worsening septic shock and can spiral out of control if not evaluated early in the course of therapy. RVD is not only due to increased afterload but also decreased contractility. Patients with ARDS tend to have increased RV afterload which derives from pulmonary vasoconstriction from hypoxia, hypercapnia, and positive pressure ventilation, but also decreased RV contractility. Pulmonary embolisms not only adds mechanical obstruction but also release vasoactive and neurohumoral mediators. In our present case the addition of a PE on top of ARDS led to severe RVD and POCUS led to an appropriate diagnosis and treatment for our patient. CONCLUSIONS: The utilization of POCUS is a quick and effective method in identifying RVD and should prompt further investigations and rapid initiation of RV protective therapies such as, optimizing mechanical ventilation with low PEEP and tidal volume, correcting hypercapnia, adding pulmonary vasculature dilatory agents and inotropic agents to augment RV function. Reference #1: Zochios, V., Parhar K., Tunnicliffe W., et al. The Right Ventricle in ARDS. Chest. 2017; 152 (1): 181-193 Reference #2: Greyson, C.R. Pathophysiology of right ventricular failure. Crit Care Med. 2008; 36: S57–S65 Reference #3: Smulders Y.M. Pathophysiology and treatment of haemodynamic instability in acute pulmonary embolism: the pivotal role of pulmonary vasoconstriction. Cardiovasc Res. 2000; 48(1): 23-33. DISCLOSURES: No relevant relationships by Amit Chopra, source=Web Response No relevant relationships by Kurt Hu, source=Web Response No relevant relationships by Muhammad Imtiaz, source=Web Response No relevant relationships by Alireza Nathani, source=Web Response" @default.
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• W2895639937 date "2018-10-01" @default.
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• W2895639937 title "NOT ALL SHOCK IS THE SAME: A CASE OF RIGHT VENTRICULAR FAILURE IDENTIFIED BY POINT-OF-CARE ULTRASONOGRAPHY" @default.
• W2895639937 doi "https://doi.org/10.1016/j.chest.2018.08.293" @default.
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