CHEST Guidelines-A-59-Year-Old-Man-in-Refractory-Shock

A-59-Year-Old-Man-in-Refractory-Shock_chest

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A 59-year-old man with advanced pancreatic cancer, complicated by hepatic vein thrombosis and bilateral pulmonary embolism, was treated in critical care for four weeks and then transferred to a general ward. He was later readmitted to the ICU for shock and hypoxemia due to new-onset colitis and aspiration, manifesting as refractory shock and sinus tachycardia. Despite aggressive treatment with fluids, vasopressors, and other medications, his condition remained critical. <br /><br />Bedside ultrasound and limited transthoracic echocardiography (LiTTE) were used, revealing large left pleural effusion and suggesting obstructive shock due to dynamic left ventricular outflow tract obstruction (DLVOTO). Doppler ultrasound, both pulsed-wave (PWD) and continuous-wave (CWD), revealed a peak pressure gradient of 127 mm Hg across the LVOT, confirming DLVOTO.<br /><br />DLVOTO, an often underestimated cause of refractory shock, involves the anterior mitral valve leaflet obstructing the LVOT. It's exacerbated by conditions like septic shock, leading to a hyperdynamic left ventricle and contributing to the patient's ongoing hemodynamic instability. Proper diagnosis is crucial as it impacts treatment and mortality rates in critical settings.<br /><br />The patient was treated with 5% albumin to increase preload, intravenous metoprolol to reduce heart rate, and phenylephrine bolus for afterload, which improved his condition by reducing the LVOT gradient to 9 mm Hg. The case underscores the importance of timely diagnosis and intervention using LiTTE, illustrating that increased peak velocities in the LVOT can demonstrate DLVOTO and guide appropriate treatment, avoiding further deterioration.

Keywords

pancreatic cancer

hepatic vein thrombosis

pulmonary embolism

shock

hypoxemia

colitis

aspiration

DLVOTO

ultrasound

metoprolol