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A Man in His 60s With Cirrhosis, Encephalopathy, and ShockA Man in His 60s With Cirrhosis and Shock

Ariel L. Shiloh, MD; Muhammad Adrish, MD
Author and Funding Information

From The Jay B. Langner Critical Care Service, Montefiore Medical Center, Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.

CORRESPONDENCE TO: Ariel L. Shiloh, MD, Montefiore Medical Center, Division of Critical Care Medicine, Critical Care Administration, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467; e-mail: arielshiloh@gmail.com


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


Chest. 2015;148(1):e5-e7. doi:10.1378/chest.14-2201
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Extract

A 62-year-old man with a past medical history of hepatitis C, liver cirrhosis, end-stage renal disease, and cerebrovascular accident was admitted to the medical wards with hepatic encephalopathy. Therapy with lactulose was initiated and resulted in resolution of the encephalopathy. On hospital day 3, the patient again became encephalopathic, less responsive, and developed hypotension. The primary team bolused the patient with 250 mL of 5% albumin, and a critical care medicine consultation was requested. At the time of evaluation the patient was awake but not following commands. Vital signs were BP of 75/45 mm Hg, pulse rate of 84/min, respiratory rate of 22/min, and temperature of 37.1°C. His finger stick was 180 mg/dL, and oxygen saturation was 99% on room air. Lungs were clear to auscultation bilaterally, and cardiac examination was unremarkable. The abdomen was distended and resonant, and there was no evidence of pedal edema. There were no overt signs of GI bleeding (hematemesis or melena). A sepsis workup sent on admission (blood cultures and urinalysis) was negative. Chest radiography was grossly clear (Fig 1). Laboratory specimens drawn 5 h prior to the evaluation were significant for a drop in hematocrit level from 37.2% to 28.6%. Arterial blood gas results at the time of evaluation showed the following values: pH 7.45; Pco2, 32 mm Hg; Po2, 101 mm Hg; potassium, 6.8 mEq/L; hematocrit, 26.3%; and lactic acid, 14 mM. The intensivist team prepared for intubation to protect the airway in the setting of worsening mental status and shock. Per report, the patient had not eaten since the prior day.

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Figures

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Video 1

Cardiac views demonstrating normal left and right ventricular function; no pericardial effusion is present.

Video 2

Pleural views showing sliding lung with A-line pattern bilaterally.

Video 3

Abdominal views. FAST exam demonstrating no evident free fluid. Left upper quadrant/stomach is fluid filled.

Video 4

Discussion.

Running Time: 4:41

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