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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Fat Embolism | 10A0 Case 10 History
Case 10 History ---- The patient was a 73 year old man with a history of CABG, abdominal aneurysm repair, a fifty pack year smoking history, TURP, and left hip endoprosthesis, who underwent total left hip replacement on June 15 without difficulty. On post-operative day 1, he was found to be dyspneic, lethargic with oxygen saturation of 79% and hypotensive (103/70). He had vomited during the exam but it was unclear whether he had vomited prior to desaturation. He became increasingly diaphoretic with labored respirations. He was subsequently intubated and transferred to the ICU where he remained hypotensive, requiring pressors and Swan-Ganz catheter monitoring. A VQ scan was negative as were lower extremity Doppler ultrasounds, but a repeat Doppler study was positive for a superficial left femoral vein thrombosis for which he was anticoagulated with heparin. Throughout his ICU stay, his ventilatory support required sedation with Diprivan, which was discontinued on 6/20. However he remained unresponsive except for slight reaction to pain and on 6/22, a neurology consultation was called. Examination showed the patient to be comatose, pupils were 1.5 to 2 mm and slightly reactive to light. Extraocular movements and corneal reflexes were intact. There was no spontaneous movement, but there was bilateral extensor posturing in response to noxious stimuli. A head CT on 6/23 showed no abnormalities except a probable small subacute or chronic infarct in the left parasagittal occipital region and the high convexity of the right parietal white matter, periventricular white matter disease and pansinusitis. An EEG showed severe slowing over both hemispheres consistent with severe bi-hemispheric damage but no abnormalities correlated with seizures. The patient remained comatose and after discussion with the family, they decided to withdraw care. The patient expired on June 26th.
