CME INDIA Presentation by Dr. Anand Malani and Team Critical Care UAIMS (Ushahkal Abhinav Institute of Medical Sciences) Hospital, Sangli, Maharashtra.
A story of Dead vs Alive, Perseverance and Patience.
“You cannot swim for new horizons until you have courage to lose sight of the shore.” – William Faulkner.
That Sunday Night
- A 46-year-old female with past history of pulmonary embolism almost 10 years ago, with negative thrombophilia workup then, on clopidogrel and statins, without any other medical comorbidities was shifted from other tertiary care hospital with CT and Cath lab facilities in a very critical stage on multiple life supports on a Sunday night.
- She was apparently alright the same morning when she had an episode of syncope after returning from washroom and later had chest discomfort with breathlessness and rapid loss of consciousness. She was immediately taken to above hospital for further management where she arrested on admission and was revived with CPR and was put on ventilator and vasopressors.
- She remained in same state for over 12 hours requiring very high dose of pressors and deeply comatose WITH FIXED AND DILATED PUPILS. Relatives were apparently counselled to consider taking her home as she was considered BRAIN DEAD.
- Thereafter on request of relatives she was shifted to UAIMS.
She was deeply comatose with fixed and dilated pupils
- On arrival she was deeply comatose with fixed and dilated pupils, on mechanical ventilation and very high doses of dual vasopressors through central line.
- HR 130/m. BP 110/70, RR 30/m, Spo2 99% on Fio2 100%.
- On arrival a clinical diagnosis of Massive Pulmonary Embolism and Cardiac Arrest with Return of Circulation after CPR and Hypoxic Ischemic Encephalopathy with Acute Kidney Injury was made.
- Was decided to go ahead with CT brain and CT pulmonary angiogram despite oliguria (Choice between LIFE or KIDNEYS was quite easy). Her creatinine had increased from 0.9 to 1.3 mg% in a day and was expected to rise.
- CT brain showed no any bleed.
- CT PULM ANGIO showed Massive Pulmonary Thromboembolism with Saddle Thrombus in RT Pulmonaty Artery.
- Echo screening showed dilated RA and RV.
Presently CPR is a relative contraindication to thrombolysis and not absolute
- We decided to thrombolyse with ALTEPLASE as a lifesaving and first measure as per guidelines after discussion with relatives. Presently CPR is a relative contraindication to thrombolysis and not absolute as it used to be earlier.
- She was lysed with above. Started to bleed from endotracheal tube massively after about 60 mg of Alteplase was infused. Alteplase was stopped immediately and 4 units of FFP ordered. She bleed for about 300 ml through ETT and aspirated large amount of blood as well. And continued to remain in a critical stage with fixed dilated pupils.
- Bleeding stopped after 2 hours. Remained to be on high dose dual vasopressors.
- Her level of consciousness showed slight improvement next morning but continued to remain on pressors and ventilator. Hence was decided to go for catheter guided pulmonary intervention and preparations were hurried. Was decided to start her with LMWH after a bleeding free span and institute RRT- Haemodialysis for renal failure.
- Was taken for Catheter Pulmonary Angiography and Penumbra Aspiration with patient on ventilator and pressors. PULM ANGIOGRAM showed no evidence of saddle thrombus. PTFE guidewire crossed both RPA and LPA easily. Penumbra aspiration was not needed. This meant that THROMBOLYSIS was successful in its purpose.
- She gradually improved over next day with level of consciousness improving and needing reduced doses of vasopressors. Vasopressors were weaned off over next 48 hours.
- She was put on full doses of LMWH – Dalteparin 5000 units s/c bid, and RRT- Haemodialysis.
- She was weaned off mechanical ventilation over next 3 days and was extubated. She continued to have haemoptysis of altered blood over next few days. CT revealed pulmonary haemorrhages- mostly aspirated blood.
- She continued to remain anuric for almost 10-12 days and needed RRT on regular basis.
- Her kidneys started opening up and creatinine started dropping down in third week. RRT was stopped thereafter.
- Dalteparin was continued for 10 days then crossover to ACITROM was done and INR maintained around 2.5 to 3.0.
- Intercurrent LRTI and UTI were treated as per cultures.
- Homocysteine was bit high and was treated.
- ANA and Antiphospholipid antibodies were negative.
At Discharge [25th Day]
- Totally asymptomatic and completely independent and ambulatory
- Vitals normal. Output around 2 litres a day.
- No PULM HTN or CHF.
- Off RRT
- RFTs improving.
- INR 2.5
- No any fever/ infection.
Plan
- LIFE LONG ANTICOAGULATION.
- Switchover to NOACS after complete recovery from renal failure.
- NGS clinical EXOME SEQUENCING for further evaluation of thrombophilia and other undiagnosed genetic conditions.
Diagnosis
- Massive pulmonary thromboembolism [underlying thrombophilia] with cardiac arrest revival.
- Hypoxic ischemic encephalopathy.
- Acute tubular necrosis – AKI- [post cardiac arrest and prolonged hypotension.]
- Massive haemoptysis [endotracheal tube bleed] and aspiration -post thrombolytic therapy.
15 days post discharge
- Leading a normal life.
- Creatinine normalised.
- Switched on to Rivaroxaban. The only other medicine she is taking is for hyperhomocysteinemia.
Key turning and Learning points
- Brain death is a specific diagnosis done upon meeting laid down criteria and not a ‘EMPIRIC’ diagnosis. And a BRAIN DEATH COMMITTEE needs to certify brain death. FIXED AND DILATED PUPILS IS NOT SYNONYMOUS WITH BRAIN DEATH. We ignored fixed dilated pupils and treated her!
- RETURN OF SUSTAINED CIRCULATION POST CPR IS PRECIOUS and needs HIGHEST CARE. Many a times such cases fall in ‘Given UP’ category. ‘NEVER GIVE UP’.
- Choose LIFE over ORGANS. Organ failure can be managed. Not doing a CT Pulmonary Angio because she was anuric/azotemic would have been the end for all.
- BLEEDING due to thrombolytics can be LIFE THREATENING and is to be feared but IS MANAGEABLE many a times. Risk Vs Benefit analysis on case-to-case basis and merits is extremely important while considering THROMBOLYSIS.
- TEAM WORK MADE IT ALL POSSIBLE. TEAMS PERFORM MUCH BETTER THAN INDIVIDUALS.
Thanks, And Credits To
- The Team and Hospital Doing Cpr and Reviving Her.
- Dr. Omkar, Dr. Nikhil, Dr. Swapnil, Dr. Praveen, Dr. Pawan, Dr. Santosh, Dr. Ganesh- Team ICU.
- Dr. Bharat Mudalgi, Dr. Bipin Munjappa, Dr. Rohit Shriwastav, Dr. Sandeep Nemani.
- All Resident Doctors and Nurses-ICU-Uaims.
Pondering…
“I believe that imagination is stronger than knowledge. That myth is more potent than history. That dreams are more powerful than facts. That hope always triumphs over experience. That laughter is the only cure for grief. And I believe that love is stronger than death.” – Robert Fulghum, All I Really Need to Know I Learned in Kindergarten.
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