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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Fat Embolism | 3A0 Case 3 History
Case 3 History ---- The patient was a 63 year old man who had a positive, screening cardiac stress test that demonstrated significant (>80%) atheromatous coronary artery occlusion. He was admitted for elective coronary artery bypass graft and underwent a four vessel CABG and mitral valve replacement. Abnormality in the function of the replaced value required an immediate second induced cardiac arrest to repair the valve during the same surgery. The following morning, the patient did not tolerate reduction in his epinephrine, responding with decreased Pa02, Sv02, and blood pressure He was also noted to have bilateral perihilar infiltrates thought to be edema. He had a respiratory alkalosis and hypoxemia. His epinephrine was reinstated and he was aggressively diuresed. That evening he was noted to have focal seizures consisting of eye and facial twitching and paralysis of his right leg, right arm, and left hand. At that time a non-contrast enhanced head CT was normal. One day later the patient displayed multiorgan failure, with persistent seizures, increased pressor requirements, and increasing creatinine, decreasing platelets, respiratory alkalosis, a low system vascular resistance with adequate cardiac index, elevated liver function tests, and elevated amylase (3900, normal=45-153). An abdominal CT revealed pancreatic and peripancreatic edema and mild colonic thickening. An exploratory laparotomy was undertaken in order to rule out the possibility of ischemic bowel. The pancreas was noted to be edematous, but the liver, spleen and intestines appeared normal. The next day the patient developed a metabolic acidosis and expired.
