CHEST Guidelines-A-75-Year-Old-Man-With-Supine-Hypotension

A-75-Year-Old-Man-With-Supine-Hypotension_chest

Pdf Summary

This medical case discusses a 75-year-old man with autosomal dominant polycystic kidney disease (ADPKD) who was admitted for abdominal pain due to a choledochal cyst causing biliary dilation. His hospital stay was complicated by pneumonia, encephalopathy, and lower gastrointestinal bleeding (LGIB), eventually leading to supine hypotension during a colonoscopy. The significant drop in blood pressure when placed supine required medical intervention with vasoactive medications and invasive monitoring in the ICU.<br /><br />Upon ICU examination, the patient's blood pressure dropped significantly when placed supine, although it stabilized with IV fluids. Diagnostic evaluations, including laboratory tests and imaging studies like a CT scan and point-of-care ultrasound (POCUS), revealed compression of the inferior vena cava (IVC) by renal cysts. This condition, caused by hypovolemia and exacerbated by anesthesia, resulted in hypotension while supine.<br /><br />The diagnosis was positional IVC compression from polycystic kidneys accompanied by hypovolemia. It highlighted that polycystic kidney patients are at risk of IVC compression, resulting in obstructive shock when lying supine. Treatment involves maneuvers that diminish IVC compression, such as elevating the upper body. Depending on compression severity, treatments may range from conservative management to more invasive procedures like hepatic resection or nephrectomy, though guidelines are lacking, and decisions are made case-by-case.<br /><br />The patient's situation further deteriorated with complications, including sepsis and a new deep vein thrombosis (DVT). Despite treatment and placement of an IVC filter, his condition worsened after discharge, leading to his readmission with sepsis and subsequent death. This case underscores the complexity of managing ADPKD patients prone to IVC compression and related complications.

Keywords

ADPKD

choledochal cyst

biliary dilation

supine hypotension

IVC compression

obstructive shock

hypovolemia

ICU management

deep vein thrombosis

sepsis