case study
72 year old male presenting
with SOB, paroxysmal nocturnal dyspnea, orthopnea
Chief Complaint(s)
The patient complained of increasing shortness of breath, paroxysmal
nocturnal dyspnea, orthopnea, and swollen bilateral lower extremities.
History Of Present
Illness
The patient was a 72-year-old male with non-ischemic cardiomyopathy,
functional class III/IV congestive heart failure with an ejection
fraction of 16%.
Past Medical History
His history was notable for renal insufficiency with an admission
creatinine of 1.8 mg/dl, hypertension, bi-ventricular failure, and
resistance to 160mg/day of furosemide.
Physical Examination
Physical exam revealed an apparently older than stated age male
with dyspnea at rest, jugular venous distension supine at 45°,
a distended abdomen and 2+ pre-tibial edema. Heart rate was 61 and
blood pressure was 90/50. Chest PA, Lateral x-rays indicated cardiomegaly,
and mild pulmonary vascular congestion.
He was unable to walk 10 steps before becoming short
of breath and fatigued.
Hospital Course
The patient was admitted directly to the Medical Intensive Care
Unit for veno-venous peripheral ultrafiltration using the System100
(CHF Solutions Inc. Brooklyn Park, MN).
After admission, an IV Therapy trained nurse placed
a 16 ga-35 cm catheter in the basilic vein in the antecubital region.
Systemic heparinization was achieved using a weight-based protocol.
The System100 was primed and therapy commenced. Treatment lasted
8.5 hours and a total of 4.2 liters of fluid were removed.
On day two, he was not dyspneic. His heart rate
and blood pressure were stable. He had no murmur, and pre-tibial
edema was absent. The patient’s electrolytes were within normal
range, creatinine was 1.9 mg/dl and PA and lateral chest x-ray revealed
resolution of pulmonary congestion.
Disposition
The patient was transferred to telemetry in the early afternoon
of day two and was scheduled for a bi-ventricular pacemaker, which
was placed on day three.
Discussion
Fluid volume overload in Class III and IV Heart Failure can
be difficult to treat due to increased resistance to diuretic therapy
secondary to renal insufficiency; necessitating larger doses of
diuretics with less predictable results.
Peripheral ultrafiltration allowed a rapid, predictable,
and safe removal of excess fluid in a patient resistant to diuretics.
Case history courtesy of: Brian Jaski,
M.D.
Medical Director, Advanced Heart Failure and Cardiac Transplant
Program
Sharp Memorial Hospital
San Diego, CA
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