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

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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Published online

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.

Figure Jump LinkFigure 1 –  Chest radiography at the time of consultation.Grahic Jump Location

The intensivist team performed a goal-directed ultrasonography examination to determine the cause of the acute drop in hematocrit and shock state. Additionally, the left upper quadrant was evaluated to determine the need for gastric decompression prior to intubation (Video 1, Video 2, Video 3).

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.

Question: Based on the interpretation of Videos 1-3 and the patient’s clinical presentation, what is the most likely diagnosis?
Answer: Hemorrhagic shock from acute GI bleeding

Video 4

Discussion.

Running Time: 4:41

An Extended Focused Assessment with Sonography for Trauma (e-FAST) examination was performed to evaluate the sudden drop in hematocrit and shock state (Video 4). Cardiac views revealed a hyperdynamic state, evidenced by tachycardia and left ventricular end-systolic effacement. Right ventricular function was normal, and there was no pericardial effusion. Sliding lung with an A-line pattern was present bilaterally, and no pleural effusions were present. There was no anechoic free fluid identified in the perihepatic and perisplenic recesses, paracolic gutters, or retrovesicular space. The evaluation of the left upper quadrant visualized the stomach medial to the spleen. The stomach was distended by echogenic fluid dotted with mobile, punctate echoes that were agitated with respiratory motion. Intraperitoneal blood loss was unlikely, but in the setting of acute blood loss and shock, the intensivist team suspected the stomach contents to be representative of an upper GI bleed. A nasogastric tube was placed to decompress the stomach prior to intubation, with the return of approximately 1 L of coffee-ground colored contents. The patient was intubated, proton pump inhibitor and octreotide infusions initiated, and packed red cells transfused. After resuscitation, esophagogastroduodenoscopy identified severe, grade D, erosive esophagitis as the etiology of GI bleeding. Ultimately, the patient’s encephalopathy improved, the bleeding resolved, and liberation from mechanical ventilation was successful.

The traditional FAST examination was initially developed for the evaluation of free fluid (bleeding) in trauma patients and ultimately replaced the diagnostic peritoneal lavage in the 1980s. The foundation of the FAST consists of the four-view examination of the perihepatic, perisplenic, retrovesicular, and paracolic spaces: the areas where free fluid commonly collects. As the use of point-of-care ultrasound for assessing and treating critically ill patients has increased, the e-FAST, which includes the assessment of the lung and pleura bilaterally and the subcostal cardiac view has developed.1 Ultrasonography is > 95% sensitive and specific for the presence of hemoperitoneum when at least 250 mL of intraperitoneal fluid is present. Furthermore, in addition to diagnosing pneumothorax, thoracic ultrasonography is able to detect as little as 20 mL of pleural fluid.1-3 Subcostal cardiac evaluation quickly determines cardiac function and determines the presence of pericardial fluid. Ideally, in shock states, multiple cardiac views provide the most accurate evaluation of cardiac function and pericardial effusion. Abnormal findings on e-FAST, such as pneumothorax, pleural fluid, pericardial effusion, and intraperitoneal fluid should prompt further investigation and intervention; this includes additional focused imaging (CT scanning), diagnostic and therapeutic ultrasound-guided aspiration, or both.

In our case, despite a large drop in hematocrit, there was no obvious free intraperitoneal or intrathoracic fluid visualized; but ultrasonography of the left upper quadrant diagnosed the presence of a large amount of gastric contents, presumed to be blood. Gastric decompression led to the retrieval of large amount of coffee-ground stomach contents and likely prevented massive aspiration peri-intubation. Patients requiring emergent intubation are most often not fasting. Additionally, in critically ill patients, gastric emptying is often altered, with approximately 60% of patients experiencing delayed gastric emptying. These patients are at high risk of aspiration and subsequent comorbidity during urgent and emergent intubations, making airway management extremely challenging.4,5 In an observational study of urgent endotracheal intubation, Koenig et al6 performed left upper quadrant ultrasonography to assess the presence of gastric fluid contents. Sixteen percent of the cohort had sufficient gastric fluid contents to prompt gastric tube insertion and evacuation of gastric contents preceding endotracheal intubation. The type of gastric contents can be classified based on their echogenic appearances. Gastric secretions and clear liquids appear anechoic or hypoechoic. Thicker fluids and solids have a more echogenic appearance. As with our case, mobile, echogenic air and gas bubbles within the liquid give a “starry night” appearance.5,7

Bedside ultrasonography is a versatile and invaluable tool when assessing critically ill patients. In addition to providing useful hemodynamic information, focused ultrasonography assists in the management of acute blood loss and can potentially prevent aspiration during emergent intubations. Adapted for use in both medical and surgical emergencies, the e-FAST is a rapid screen for detection of cardiac, intrathoracic, and intraabdominal pathology. The addition of preintubation ultrasonography of the left upper quadrant is warranted even in patients that have been nil per os.

  • 1. Further investigation or intervention should be triggered by abnormal findings on e-FAST. This includes additional focused imaging, ultrasound-guided aspiration, or both.

  • 2. Peri-intubation aspiration and subsequent complications in critically ill patients can be reduced by ultrasonographic visualization and decompression of the stomach.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Grewal Y, Shiloh AL, Eisen LA. The extended FAST protocol.. In:Lumb P, Karakitsos D., eds. Critical Care Ultrasound. Philadelphia, PA: Elsevier Sanders; 2014:238-240.
 
Röthlin MA, Näf R, Amgwerd M, Candinas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma. 1993;34(4):488-495. [CrossRef] [PubMed]
 
Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476-478. [CrossRef] [PubMed]
 
Nguyen NQ, Ng MP, Chapman M, Fraser RJ, Holloway RH. The impact of admission diagnosis on gastric emptying in critically ill patients. Crit Care. 2007;11(1):R16. [CrossRef] [PubMed]
 
Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12-22. [CrossRef] [PubMed]
 
Koenig SJ, Lakticova V, Mayo PH. Utility of ultrasonography for detection of gastric fluid during urgent endotracheal intubation. Intensive Care Med. 2011;37(4):627-631. [CrossRef] [PubMed]
 
Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound assessment of gastric content and volume. Anesthesiology. 2009;111(1):82-89. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Chest radiography at the time of consultation.Grahic Jump Location

Tables

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

References

Grewal Y, Shiloh AL, Eisen LA. The extended FAST protocol.. In:Lumb P, Karakitsos D., eds. Critical Care Ultrasound. Philadelphia, PA: Elsevier Sanders; 2014:238-240.
 
Röthlin MA, Näf R, Amgwerd M, Candinas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma. 1993;34(4):488-495. [CrossRef] [PubMed]
 
Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476-478. [CrossRef] [PubMed]
 
Nguyen NQ, Ng MP, Chapman M, Fraser RJ, Holloway RH. The impact of admission diagnosis on gastric emptying in critically ill patients. Crit Care. 2007;11(1):R16. [CrossRef] [PubMed]
 
Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12-22. [CrossRef] [PubMed]
 
Koenig SJ, Lakticova V, Mayo PH. Utility of ultrasonography for detection of gastric fluid during urgent endotracheal intubation. Intensive Care Med. 2011;37(4):627-631. [CrossRef] [PubMed]
 
Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound assessment of gastric content and volume. Anesthesiology. 2009;111(1):82-89. [CrossRef] [PubMed]
 
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