77 year old man, with myelomonocytic leukemia treated with periodic blood transfusions

1. Fluid Optimization / Overload
- Leukemia
Presentation
77 year old man, with myelomonocytic leukemia treated with
periodic blood transfusions.
Hydroxyurea, COPD, admitted to the ED with diagnosis of
urinary sepsis. (C reactive protein 247.9 mg/L, leukocytes
15.26 10⁹/L, Hb 6,6 g/dl, subsequent detection of urinary
infection from E. Coli), with fever (38.2 C°), hypotension (90/40
mmHg), AF (ventricular rate 108 Bpm), mild renal failure
(creatinine 1.48 mg/dl) and clinical and laboratory signs of
dehydration. Base Excess and serum lactate within the range
of normal, normal StO2 of 80%.
Treatment
Blood transfusion and despite an ultrasound estimation of CVP,
through the measurement of terminal intrahepatic inferior vena
cava, indicative of high venous pressure, the patient was
treated with fluids 4 L of 0.9% NaCl solution and antibiotics.
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2. Fluid Optimization / Overload
- Leukemia
Day 2 Result
BP improved to 100/50 mmHg and creatinine to 1.21 mg/dl, Na
140 mEq/L.
USCOM:
Normal CO (6.4 L/min), SV (66 ml) and SVR at the lower limit
of the normal range (888 ds/cm⁻⁵).
A passive leg raising (PLR) test was negative for fluid
responsiveness.
Ultrasound:
CVP still high (terminal intrahepatic inferior vena cava 2.55 cm
maximum diameter with inspiratory reduction of 20%)
Despite these results the treating physician decided to go
ahead with fluid replacement 3L 0.9% saline solution because
of unsatisfactory BP and diuresis (700 ml the day before but
improving on second day).
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3. Fluid Optimization / Overload
- Leukemia
Result: negative for fluid responsiveness.
Pre Passive Leg Raise Post Passive Leg Raise
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4. Fluid Optimization / Overload
- Leukemia
Day 3 Result
BP improved: 140/70 mmHg, No fever.
Creatinine 1.03 mg/dl, CRP 127 mg/L, leukocytes 6.35 10⁹/L.
USCOM:
CO 4.4 L/min, SV 47 ml, SVR 1609 ds/cm⁻⁵.
An increase in SVR, reduced CO and SV, revealing a latent
cardiac failure, masked in the previous days by the decrease in
SVR due to sepsis.
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5. Fluid Optimization / Overload
- Leukemia
Result:
A reduced CO and SV and an increase in SVR revealing a latent
cardiac failure.
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6. Fluid Optimization / Overload
- Leukemia
Day 3
Treatment:
Despite these readings the treating physician decided to go on
with fluid administration of about 2 L 0.9% saline for two more
days in order to maintain a high diuresis, with further
improvement in renal function (creatinine 0.86 mg/ dl).
Result:
A few days later the patient developed exertional dyspnea,
edema and evidence of bilateral pleural effusions, which
improved quickly with diuretic therapy.
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7. Fluid Optimization / Overload
- Leukemia
Summary:
This clinical case shows how cardiac pre-load measurements
could be misleading.
Initially the patient needed fluids, as correctly indicated by the
global clinical picture, despite ultrasound signs of high CVP.
On the second and third days the USCOM readings told us
clearly that the patient did not need more fluid and he was at
risk of decompensation because of poor cardiac function
revealed after the normalization of SVR.
Conclusion:
Monitoring with USCOM would have prevented excessive fluid
administration and the resultant heart failure if the results were
not ignored.
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