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Washington University Experience | VASCULAR | Infarct, watershed | 11A0 Case 11 History
Case 11 History ---- The decedent was a 71-year-old man with past medical history significant for peripheral artery disease s/p right iliac artery stent, COPD, hypertension, and diabetes mellitus type II. He started to experience shortness of breath, dyspnea on exertion, and chest pain and presented at an outside hospital where an echocardiogram showed moderate ventricular hypertrophy, moderate left ventricle dysfunction, LVEF: 45-50%, and mild diastolic dysfunction. A stress test showed a large severe inferior wall infarct with no evidence of stress induced ischemia. A left heart catheterization was then performed and showed significant three vessel disease and the decedent was transferred to BJH for further cardiac intervention. On 8/10 he underwent a three vessel CABG and once sedation was weaned, he was noted to not follow commands on the right side as well as automatisms. A head CT showed multiple evolving regions of hypoattenuation in the bilateral frontal, left parietal, and bilateral occipital lobes likely consistent with evolving infarcts. On 8/15 he suffered a cardiac arrest secondary to ventricular tachycardia and required approximately 13 minutes of CPR. Acute and Critical Care Surgery was called for worsening abdominal distention concerning for abdominal compartment syndrome. An exploratory laparotomy was performed and reveled tension pneumoperitoneum; the abdominal cavity was left open with a vac pack. Bilateral chest tubes were in place. Thoracic surgery evaluated for the source of the air leak via multiple bronchoscopies and EGD, but found no source of the subcutaneous emphysema. The patient was too unstable at this point to be taken for a CT of his abdomen/pelvis. His hospital course was further complicated by persistent acidosis (combined, multifactorial metabolic and respiratory acidosis), hypotension, oliguria likely secondary to acute tubular necrosis and cardiogenic shock, hypoglycemia, hyperkalemia, hypernatremia, and gram-negative pneumonia. Continuous venovenous hemodiafiltration (CVVHD) was started as well as hydrocortisone for refractory hypotension. Despite these measures, he remained acidotic with metabolic derangements. On 8/15 after a family meeting, a decision was made to place the decedent on comfort care and he passed away on 8/16.
