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Tricuspid Regurgitation: Interference with Resuscitation in Critical Care Units?
Description
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A3523 - Tricuspid Regurgitation: Interference with Resuscitation in Critical Care Units?
Author Block: J. Virk1, K. Yashi1, A. Shawkat2; 1Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, United States, 2Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, NY, United States.
Introduction
It is important to achieve arterial/venous access during cardiac arrest and the confirmation of this access is usually sought with a pressure waveform. Through this patient we want to highlight tricuspid regurgitation (TR) as an interfering cause in these efforts.
Case description
69-year-old female presents with generalized fatigue and her vital signs show blood pressure (BP) was 76/65 mm Hg, pulse is 120 beats/minute, and is saturating 100 % on room air. Her labs revealed potassium of 7.2 m mol/L, creatinine of 4.3 mg/dL. Initial management with intravenous fluid resuscitation and correction of acute hyperkalemia was performed and her potassium decreased to 4.9 m mol/L in a day. Her BP improved to 120/60 mm Hg and her symptoms improved. The following day she had nonspecific complaints of impending doom and was then found to be pulseless. Resuscitation was initiated and return of spontaneous circulation was obtained with 2 rounds of CPR. An urgent femoral arterial line was placed under ultrasound guidance. The line had an arterial tracing, but the systolic BP readings were in the range of 30-40 mm Hg. She was on 4 vasopressors, but her BP did not improve beyond 40 mm Hg. An urgent ECHO was performed which showed an ejection fraction of 35% and severe tricuspid regurgitation (TR). An arterial blood gas (ABG) from the line was performed which showed an oxygen saturation of 25% when her pulse oximetry was 100%. Another femoral artery access was obtained and was confirmed with a blood gas analysis showing oxygen saturation of 100%. The BP reading from this line was 160-180 mm Hg and vasopressor support was decreased. However, she developed cardiac arrest and family did not want resuscitation to be continued and she passed away soon.
Discussion
This case highlights that TR can significantly interfere with emergent arterial line insertion and false BP readings can lead to excessive vasopressor exposure. This can lead to worsening cardiac ischemic and poor outcome as our patient had ST elevations in EKG. We recommend that TR should be kept in mind when an arterial waveform has a persistently low reading. Confirmation with a simultaneous ABG from another site should be used to differentiate a true arterial line from a venous line with arterial waveform.
Author Block: J. Virk1, K. Yashi1, A. Shawkat2; 1Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, United States, 2Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, NY, United States.
Introduction
It is important to achieve arterial/venous access during cardiac arrest and the confirmation of this access is usually sought with a pressure waveform. Through this patient we want to highlight tricuspid regurgitation (TR) as an interfering cause in these efforts.
Case description
69-year-old female presents with generalized fatigue and her vital signs show blood pressure (BP) was 76/65 mm Hg, pulse is 120 beats/minute, and is saturating 100 % on room air. Her labs revealed potassium of 7.2 m mol/L, creatinine of 4.3 mg/dL. Initial management with intravenous fluid resuscitation and correction of acute hyperkalemia was performed and her potassium decreased to 4.9 m mol/L in a day. Her BP improved to 120/60 mm Hg and her symptoms improved. The following day she had nonspecific complaints of impending doom and was then found to be pulseless. Resuscitation was initiated and return of spontaneous circulation was obtained with 2 rounds of CPR. An urgent femoral arterial line was placed under ultrasound guidance. The line had an arterial tracing, but the systolic BP readings were in the range of 30-40 mm Hg. She was on 4 vasopressors, but her BP did not improve beyond 40 mm Hg. An urgent ECHO was performed which showed an ejection fraction of 35% and severe tricuspid regurgitation (TR). An arterial blood gas (ABG) from the line was performed which showed an oxygen saturation of 25% when her pulse oximetry was 100%. Another femoral artery access was obtained and was confirmed with a blood gas analysis showing oxygen saturation of 100%. The BP reading from this line was 160-180 mm Hg and vasopressor support was decreased. However, she developed cardiac arrest and family did not want resuscitation to be continued and she passed away soon.
Discussion
This case highlights that TR can significantly interfere with emergent arterial line insertion and false BP readings can lead to excessive vasopressor exposure. This can lead to worsening cardiac ischemic and poor outcome as our patient had ST elevations in EKG. We recommend that TR should be kept in mind when an arterial waveform has a persistently low reading. Confirmation with a simultaneous ABG from another site should be used to differentiate a true arterial line from a venous line with arterial waveform.
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