A 72-year-old man was admitted to the intensive care unit with hypotension, fever, and presumed sepsis. He had been in reasonably good health until one week prior to admission, when he noted decreased appetite and continuous hiccoughs. On the morning of admission his wife found him incoherent.
Past medical history was significant for hypertension, treated with a diuretic, and a distant history of head and neck cancer treated with radiation therapy.
On admission to the ICU, the patient’s blood pressure was 70 by Doppler measurement, pulse 115/min, and temperature 38.4°C rectally. Examination of the chest showed normal heart sounds and bilateral râles and rhonchi. The abdomen was diffusely rigid with marked right upper quadrant tenderness. Chest x-ray revealed a small right pleural effusion. Arterial blood gases on a 50% Ventimask showed pH 7.23, PCO2 45, PO2 65, O2 saturation 47%. SMA-6 results were significant only for a serum bicarbonate level of 11.3 mEq/L. A scintigraphic scan with paraisopro-pylacetanilido-iminodiacetic acid (PIPIDA) failed to visualize the gallbladder after 4 hours.
The trachea was intubated and respiration was supported mechanically at an initial FiO2 of 1.0. While preparations were being made to place arterial and pulmonary artery catheters, 500 ml of 5% albumin was infused over 15 minutes and was repeated once. After the fluid challenge, the blood pressure was 70/40 mmHg. A right heart catheterization was performed with the following results: right atrial pressure 0 mmHg, right ventricular pressure 24/2 mmHg, pulmonary artery pressure 26/14 mmHg, pulmonary artery wedge 14 mmHg. Cardiac output was 6.59L/min. Systemic vascular resistance was calculated as 607 dyne: sec: cm.
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