Persistent post-op Persistent post-op hypoxia hypoxia ICU, Pamela Youde Nethersole Eastern Hospital Dr Emily Cheung & Dr Arthur CW Lau 24 Sep 2010 1
Nov 23, 2014
Persistent post-op Persistent post-op hypoxia hypoxia
ICU, Pamela Youde Nethersole Eastern HospitalDr Emily Cheung & Dr Arthur CW Lau
24 Sep 2010
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CaseCaseM/69, ADLIEx smoker, drinkerPMH:
◦eAg negative chronic hep B◦Ulcerative colitis on mesalazine◦HT
Newly diagnosed HCC over right lobe
‘C’ adm for open right hemi-hepatectomy
Uneventful operationIntra-op finding:
◦Large tumor at seg V of liver◦Liver not cirrhotic macroscopically
Post op extubated and transferred to ICU for monitoring◦Post op on 6L O2, gradually tail down
O2 requirement◦On 2L O2 without SOB on discharge ◦Discharge from ICU on D1
Developed abdominal distension with post-op ileus on D3
Increasing O2 requirement and desaturation noted in general ward
Readmitted ICU on D4 Required 12 L O2 on admission to
ICU ABG on O2: unremarkable
CT – lung windowCT – lung window
CXR and CT reviewed◦suggestive of some atelectasis in
dependent part of both lower lobes◦Probably contributed by bowel
distension ◦No evidence of PE or chest infection
Progress◦NIV given for a short period of time,
but not very responsive◦Chest physio with lung expansion by
incentive spirometry started ◦However, still noticed occasional
desaturation
? Causes for persistent hypoxaemia
Detailed history takingComplaints of discomfort on
sitting up while watching TV, feels better if lying down
Symptoms present for 2 yearsP/E:
◦No Stigmata of chronic liver disease◦No clubbing, spider naevi◦No gynecomastia
Patient complaints SOB while sitting up, relieved by lying Platypea
More than three repeated trials of SpO2 measurement on 3L O2 Orthodeoxia◦Lying: SaO2 > 93% ◦Sitting: Desaturated with SaO2 down to
81%, not fully correctable by increasing FiO2
Bedside Echo with contrast by ICU Team ◦ Chamber sizes relatively normal◦ Presence of intrapulmonary shunt, as
indicated by bubbles on left side after 3rd beatDdx:
◦ Intrapulmonary/Intracardiac shunt◦ More likely intrapulmonary shunt because
bubbles did not occur immediately on L side post-bubble contrast injection
Discharged from ICU on D8◦ Reviewed by medical team
ProgressProgressInpatient Echo repeated by Cardiac
team on D14◦mild pul hypertension◦Bubbles contrast was seen in LA and LV
after injection, suggested the presence of right to left shunt
◦no definite intra-cardiac shunt was detected
◦Ddx: intra-cardiac/intrapulmonary AV shuntPatient refused TEE
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Impression of the causes of hypoxemia1. Hepatopulmonary syndrome,
and2. Atelectasis due to bowel
distension
Hepatopulmonary Hepatopulmonary syndromesyndromeCharacterized by a defect in
arterial oxygenation induced by pulmonary vascular dilatation in the setting of liver disease
Trial of ◦Liver disease◦Pulmonary vascular dilatation ◦Defect in oxygenation
Source: Roberto Rodríguez-Roisin, M.D., and Michael J. Krowka, M.DHepatopulmonary Syndrome — A Liver-Induced Lung Vascular Disorder. NEJM, Volume 358:2378-2387 May 29, 2008 Number 22
Clinical featuresClinical features18% asymptomatic
Platypnea :◦ Dyspnea improves when lying flat
Orthodexoia:◦ Hypoxemia worsens upon sitting up
and improves when lying flat◦ pO2 decreased by > 5% or > 0.5 kPa
Opacification of right atrium and right ventricule with microbubbles and delayed opacification of the LA and LV
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PathobiologyPathobiologyGross dilatation of the
pulomonary precapillary and capillary vessels
Absolute increase in no of dilated vessels
Pleural and pulmonary AV communications and portopulomonary venous anastomoses
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Dilated capillaries not uniform blood flow
Venous blood passed rapidly or directly thro intrapulmonaryshunt to pulmonary veins
VQ mismatch
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TreatmentTreatmentNo effective medical therapiesLiver transplantation is the only
successful treatment◦pO2 < 60 mmHg is considered to be
an indication for liver transplantationLong term oxygen therapy
◦For symptomatic patients with severe hypoxaemia
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THE ENDTHE END
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