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A 37-Year-Old Woman With Diabetes Mellitus, Systemic Hypertension, and Chronic Kidney Disease Admitted With Multifocal Pneumonia and EmpyemaMultifocal Pneumonia and Empyema

J. Terrill Huggins, MD; Nithin Karakala, MD; Ruth Campbell, MD; Carlos Kummerfeldt, MD; Jennings Nestor, MD; Nicholas J. Pastis, MD, FCCP; Peter Doelken, MD
Author and Funding Information

From the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (Drs Huggins, Kummerfeldt, Nestor, and Pastis) and the Division of Nephrology (Drs Karakala and Campbell), Medical University of South Carolina, Charleston, SC; and the Division of Pulmonary and Critical Care (Dr Doelken), Albany Medical Center, Albany, NY.

CORRESPONDENCE TO: J. Terrill Huggins, MD, Medical University of South Carolina, Pulmonary, Critical Care, Allergy and Sleep Medicine, 96 Jonthan Lucas St, Charleston, SC; e-mail: hugginjt@musc.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):e41-e46. doi:10.1378/chest.13-2711
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Extract

A 37-year-old woman with a medical history of type 1 diabetes mellitus, systemic hypertension, and chronic kidney disease due to glomerulosclerosis was admitted with multifocal pneumonia and empyema. She underwent a small-bore tube thoracostomy placement and rapidly developed respiratory failure and shock. She was intubated and started on norepinephrine. Table 1 is a summary of the daily urine output (UOP), fluid balance per day, and corresponding serum creatinine level during the initial ICU stay. Mechanical ventilator settings were as follow: pressure-regulated volume control; tidal volume, 450 mL; respiratory rate, 20 breaths/min; positive end-expiratory pressure (PEEP), 8 cm H2O; and Fio2, 50%. Urinary sediment was positive with granular casts. The calculated plateau pressure (PP) was 32 cm H2O. On day 4, consultation requested a point-of-care echocardiography (POCE) to be performed. Video 1A shows the subcostal longitudinal view of the inferior vena cava (IVC), and Figure 1 shows the corresponding M mode of the IVC. Figure 2 shows an apical 5C view of the pulse-wave Doppler of the left ventricular (LV) outflow tract (LVOT) and Video 1B, an apical 4C view. Video 1C shows the lung ultrasound (abnormal lung finding seen diffusely). Pulse-wave Doppler of the mitral inflow showed an impaired relaxation pattern with E to A wave reversal. Calculated E/e′ was < 8 (not shown).

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Figures

Tables

Video 1A

Subxiphoid Long-axis IVC

Running Time: 0:02

Video 1B

Apical 4-C view ACP

Running Time: 0:06

Video 1C

Lung Utraound with Diffuse B-line Pattern

Running Time: 0:06

Discussion Video

Discussion Video

Video 2

Apical 4-C resolution of ACP

Running Time: 0:06

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