D-Sign Seen on Point-of-Care Ultrasound (POCUS) from Volume Overload and Used to Avoid CT Pulmonary Embolism (CT-PE) in Severe Contrast Allergy Patient
- Hemodialysis: Case Reports, Series, QI Projects
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 801 Dialysis: Hemodialysis and Frequent Dialysis
- Barnes IV, Sylvester, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States
A 50y M w/ PMHx of osteosarcoma c/b chemotherapy induced cardiomyopathy now s/p OHT (11/10/17), severe iodine contrast allergy resulting in previous anaphylaxis, ESRD on HD (TTS) with last dialysis one day prior to admission, and RCC with metastases was brought to the ED for low O2 levels at home of 78%. Significant medications include fentanyl patch 25mcg every 72hours, oxycodone 5mg q8 prn, gabapentin 300mg TIW on MWF, tacrolimus, and prednisone. Obtained vitals are BP of 164/82, HR 81, RR 18, 87%O2 sat improved to 96% on 2L NC. The patient is drowsy on exam, lungs clear to auscultation, HR is RRR with no JVD noted, no cyanosis in nail beds or lips. Labs are significant for a negative troponin I, negative viral respiratory panel, BNP 2813pg/nl increased from 1620pg/ml three months prior, and D-Dimer 2655 ng/ml. CXR showed mild interstitial pulmonary edema and a small right pleural effusion. The patient’s pain medication was held but there was a concern for possible PE secondary to his underlying malignancy and decreased O2 levels.
Bedside POCUS showed cardiac flatting of the interventricular septum with an eccentricity index > 1 ; “D” sign indicating right heart strain. This patient’s D sign pattern was observed only in diastole which is more indicative of fluid overload then PE. CT PE protocol was planned for the following day with starting of prophylaxis planned to start the following day as well. The pt underwent HD with removal of 2L of fluid. The next day repeat POCUS was performed showing resolution of the “D” sign along with oxygenation improvement.
The patient was discharged the next day without a PE CT scan, EDW adjustment for his dialysis and lower pain medication. The use of POCUS helped to identity a right heart strain pattern with an eccentricity index >1 in diastole only. The POCUS findings before and after HD negated the need for additional studies which in this patient carried significant risk secondary to his severe contrast allergy.