CHEST Guidelines-A-70-Year-Old-Develops-Refractory-Hypotension-in-t

A-70-Year-Old-Develops-Refractory-Hypotension-in-t

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A 70-year-old woman in the ICU developed refractory hypotension while being treated for status epilepticus with mechanical ventilation. With a medical history including a previous ischemic stroke and recent breast cancer treatment, her condition worsened on day 13 with fever, low blood pressure, hyperlactatemia, and impaired gas exchanges. Suspecting septic shock, broad-spectrum antibiotics and fluid resuscitation were administered, but the patient's condition showed only transient improvement, leading to the use of norepinephrine.<br /><br />Despite aggressive fluid resuscitation and medication adjustments, the patient remained hypotensive with increasing hyperlactatemia and no urine output. An ultrasound examination was undertaken, revealing a pericardial effusion causing cardiac tamponade—compressing the right heart structures and impeding diastolic filling, indicative of an obstructive shock mechanism.<br /><br />The echocardiographic signs associated with tamponade included a small, hyperkinetic right ventricle with diastolic collapse, a fixed, distended inferior vena cava, and a small left ventricle, indicating reduced preload. Given these ultrasound findings, urgent percutaneous pericardiocentesis was performed, removing 500 mL of blood from the effusion. Consequently, the patient's hemodynamic status improved significantly, allowing for the cessation of norepinephrine and recovery of urinary output.<br /><br />This case highlights the critical value of focused cardiac ultrasound in diagnosing the underlying cause of shock in critical patients. It underscores the need for ultrasound expertise in the ICU setting to distinguish between differential diagnoses of hypotension and guide effective treatment strategies. It also emphasizes the importance of recognizing the specific echocardiographic features of tamponade, distinguishing it from other conditions with pericardial effusion.

Keywords

ICU

refractory hypotension

status epilepticus

septic shock

cardiac tamponade

pericardial effusion

focused cardiac ultrasound

percutaneous pericardiocentesis

echocardiographic signs

fluid resuscitation