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Washington University Experience | VASCULAR | Infarct - Air Embolism | 1A0 Case 1 History
Case 1 History ---- The decedent was a 59-year-old man with a history of HAART-Rx HIV, osteoporosis and benign prostatic hyperplasia. He presented to BJH following a fall. He returned after developing shortness of breath and increasing chest pain and was found to have six broken ribs, a left pleural effusion and a cervical spine fracture. He developed an empyema and hemothorax, which was treated with surgery for evacuation of hemothorax, decortication, pleurectomy, and mechanical pleurodesis with resection of lung/peel. He experienced nausea and vomiting with persistent intermittent fevers. Abdominal x-ray examination showed a pneumoperitoneum, and CT scan showed perforated duodenal ulcer prompting an exploratory laparotomy. Surgery demonstrated free bile in the peritoneum and hemoperitoneum and he was treated with pancreatic debridement, primary repair of duodenal perforation and retrograde jejunostomy and was then transferred to the SICU and put on non-rebreather mask. Two days later he developed acute kidney injury and acidosis. On 2/23 he became increasingly tachypneic, tachycardic, acidotic and decompensated. He was intubated and started hemodialysis (CVVHD). The patient was extubated on 3/1 and on 3/19 he experienced declining of the mental status upon moving from chair to bed, he become more lethargic and the CVVHD machine indicated air in the line. The patient became unresponsive. Echocardiogram showed air throughout all chambers of the heart. Subsequently he was placed in left lateral decubitus position and continued NRB and was returned to the SICU. Brain MRI showed diffuse cortical FLAIR changes consistent with cerebral edema secondary to air embolism and infarction. One day later he had increased difficulty of breathing and was paralyzed and intubated. On 3/25 he was placed on pressure support ventilation for 2 hours and extubated to nasal cannula. On 2/4 he was noted to be tachypneic, desaturating to low 90s with increased O2 requirements. He then failed multiple extubation trials and continued to have respiratory failure and bilateral cortical infarcts. His family asked for comfort care and patient made DNR/DNI, was extubated and died ten days after his 3/19 decompensation. ---- Autopsy findings demonstrated the weight of the unfixed brain was 1300g.
