Abstract: FR-PO649
Airway Compromise and Failed Extubation Due to Central Venous Stenosis in a Hemodialysis Patient
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 704 Dialysis: Vascular Access
Author
- Kovvuru, Karthik, University of Mississippi Medical Center, Jackson, Mississippi, United States
Introduction
Central Venous Stenosis (CVS) in hemodialysis (HD) patients is common and is not always easy to manage. We encountered a patient who presented with a unique complication of central venous stenosis.
Case Description
57 Yr old Female pt with HIV and ESRD on HD for more than eight years via left AV fistula presented to the hospital for large bloody bowel movement and hypotension (80/50). She was given a liter of fluid and three units of red blood cells with improvement of blood pressure to (110/70). She was admitted to floor and started on maintenance IV fluids at 75cc/hr. Dialysis was held for two days due to stable labs, clinical euvolemia and borderline blood pressures. Pt developed shortness of breath, difficulty breathing and got intubated. During intubation it was noted that pts airway was swollen, angioedema was clinically diagnosed and started on Rx. Chest x ray did not show any fluid in the lungs and she continued to remain clinically euvolemic other than swollen face and left arm. No precipitant for angioedema could be found and the swelling did not resolve with medical treatment. CT scan of the chest was performed which showed subcutaneous edema throughout the neck bilaterally (left greater than right), subcutaneous edema of upper chest wall, mucosal edema of base of tongue and supraglottic larynx, Extensive collateral venous vessels in left anterior upper chest with narrowing of brachiocephalic vein. Angiogram showed occlusion at the level of left brachiocephalic vein which was difficult to open. Left arm AV fistula doppler showed wide patency with flow of 2.4 Liter per min. Pt was trached and weaned off ventilator after aggressive removal of volume with help of midodrine and cold dialysate. However she could not be decannulated due to persistence of edema from CVS. After 8 months of hospital stay she was sent to hospice care.
Discussion
Our patient developed upper airway edema secondary to CVS and high flow AV fistula on the same side. The volume resuscitation she received for GI bleed resulted in worsening airway edema leading to intubation. Once intubated the positive pressure in the chest cavity will decrease venous return worsening the airway edema leading to failed extubation. CVS should be considered as potential cause of airway edema and failing extubation in hemodialysis patients.