AKI Consult: 👵 ➡️ ED with severe DKA. CT Abdomen and Chest to look for infectious trigger: negative. Tx with IV insulin and balanced crystalloid + 6 L with obvious improvement. Cr was 2.7
Remained oliguric, now in sudden shock with increasing NE dose (0.5 ucg/kg/min) 🚨 1/12
#POCUS Very hyper-dynamic🫀 with increased contractility and no RV dysfunction.
🔎 Look carefully at color of flow exiting the LV:
Aliasing (green color): This means ultrasound system is trying to image an event that is occurring faster than the sample rate
This means flow is fast. But how fast? Choose the CW doppler setting and find out!
In this case acceleration was almost 6 m/s!
Flow acceleration occurs in the setting of obstruction (similar to putting your finger on the hose exit)
So what is causing the obstruction? 3/12
Aortic stenosis is one possibility, if you look at #POCUS 👆 aortic valve looks normal.
In the setting of a hyper-dynamic LV, Dynamic Obstruction of the Left Ventricular Outflow Tract (DOLVOT) should be the first thing that comes to mind!
DOLVOT can occur suddenly whenever there is
🚨Decreased LV filling volume🚨
Asymmetric septal hypertrophy
Motion wall abnormalities (including 🐙)
Systolic anterior motion of the mitral valve (SAM)
Decreased LV filling is always secondary to any of this three variables:
⬇️ Preload: Hypovolemia, Obstruction (RV failure w interdependence)
⬆️ Contractility and Heart Rate: Beta agonist, Norepinephrine
⬇️ Afterload: Sepsis
As such, treatment should focus on:
⬆️ Preload: Fluids.
*sometimes this is enough if the cause is hypovolemia (attached case)
⬆️ Afterload: Alfa agonists with no inotropism
⬇️ Contractility and heart rate: Beta Blockers
In this case, even though cause was not clear, I started fluid bolus and stopped NE.
Then...the patient had abundant GI bleeding 🩸🩸🩸
We aggressively resuscitated with fluid and blood products. Patient improved immediately 8/12
However, one hour later we were back at square one:
Patient was in shock again!
Did patient need more fluid? I performed #LUS: Clear B-lines. Even thought patient is still fluid responsive. She is no longer fluid tolerant!!!
I was not keen on continuing fluids... 9/12
I ordered AngioCT to rule out active recurrent bleeding.
However diverticulitis with abscess formation was diagnosed!!
Not previously seen because of lack of IV contrast 🤦♂️
We started antibiotics and vasopressin (⬆️ afterload with no inotropism). *IV beta-blocker was not available at the moment (public hospital shortage).
Fortunately, vasopressin did the trick and patient improved and oliguria resolved! Repeat #POCUS showed DLVOTO resolution 11/12
💎DLVOTO is easy to diagnose (CW Doppler)
💎Norepinephrine should be avoided at all costs
💎Although these patients improve rapidly with fluid,
THIS IS NOT A PERMANENT SOLUTION
💎Treat with Phenylephrine + IV BB
Bonus: Always use IV contrast even in AKI! @PulmCrit
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