A 69 year-old male with a known history of hypertension, chronic non-oliguric kidney disease, insulin dependent diabetes, and chronic systolic heart failure with an ejection fraction (EF) of 25% secondary to ischemic cardiomyopathy was recovering in the CardioVascular ICU after four vessel coronary artery bypass grafting.
His post-operative course had been complicated by acute respiratory failure, acute on chronic non-oliguric renal failure, delirium and pseudomonas pneumonia. The patient’s oxygenation had been improving on antibiotic therapy with aggressive diuresis and ionotropic support, although his BUN and creatinine remained quite elevated. Family had been reluctant to initiate dialysis given his clinical improvement and ability to make urine with diuretic support. The patient was extubated to high-flow oxygen by nasal cannula after successfully passing a spontaneous breathing trial, although, he had failed extubation one week prior secondary to acute dyspnea and hypoxia.
Two days later, the patient began to have a fever, worsening shortness of breath with increased oxygen requirements, and inability to wean ionotropic and vasopressor support further. Because of concern for septic shock, the patient was given a total of 500ml of crystalloid overnight. Whole blood lactic acid levels returned at 1.6, serum creatinine increased from 5.8 to 6.11, and the patient’s fever and shortness of breath worsened. Repeat cultures were obtained and antibiotic therapy was broadened further while initiating non-invasive positive pressure ventilation for acute respiratory distress.
In the interim, while awaiting laboratory results and chest X-ray imaging, POCUS with a three-point exam (F-TTE, IVC collapsibility, and lung ultrasound) was used for bedside evaluation of the etiology of the patient’s dyspnea. Within minutes, and with the additive information from the combined cardiac, subcostal IVC, and lung ultrasound imaging, the patient was diagnosed with acute on chronic congestive heart failure and flash pulmonary edema as the cause of his respiratory distress and hypoxia.