• Case Study 2
Hypotensive Patient in ICU Following Cocaine Overdose
Background: A 32 year-old male patient is admitted to a combined medical/surgical ICU following a crack cocaine overdose complicated by rhabdomyolysis, acute renal failure, and presumed sepsis. The patient was supported with mechanical ventilation and dialysis. Two liters of intravenous fluid were empirically administered, and Levophed was initiated to support the patient’s systemic blood pressure. The patient was persistently hypotensive (systemic BP 79/56 mmHg) despite increasing doses of Levophed.
Method: The attending ICU physician ordered a bedside transesophageal echo (TEE) exam using the ClariTEE™ probe (ImaCor, Inc, Uniondale, NY). The patient was significantly hypotensive, and the procedure was performed without sedation.
Results: The miniaturized TEE probe was placed without difficulty, and a transgastric short-axis view (TGSAV) of the left ventricle (LV) was rapidly obtained.
Qualitative and quantitative assessment of left ventricular size and function indicated that the patient was hypovolemic. Additionally, the interventricular septum was observed to be hypokinetic. Given the young age, lack of cardiac history, and known recent Cocaine usage, the wall motion abnormality was presumed to represent previously unrecognized ischemia.
More aggressive volume resuscitation with intravenous fluids was instituted and the Levophed was titrated. Intravenous nitroglycerin was initiated to support vital organ perfusion. The ClariTEE™ probe was left indwelling overnight. Using TEE monitoring as a guide to fluid administration, Levophed was subsequently discontinued completely.
Upon re-examination on rounds the next morning, the patient’s blood pressure was normal (145/70 mm Hg), intravascular volume status was normalized (as evidenced by normal LV size) and left and right ventricular pumping function had improved.
Conclusion: Hemodynamic instability is a common complication in ICU patients with multisystem organ dysfunction. Intensivists need to rapidly correct underlying fluid imbalance and/or cardiac dysfunction. Rapid and accurate assessment and monitoring of the etiology of hemodynamic deterioration is often inadequate utilizing conventional monitoring methods. The ClariTEE™ probe is a unique and effective tool for assessing and monitoring hemodynamically unstable patients over a prolonged period of time in the intensive care environment.
