Background: We are presenting the case of a patient with multiple co-morbidities including systemic lupus erythematosus with pulmonary and cardiac disease with severe pulmonary hypertension and right heart failure from massive right heart dilatation presenting with acute abdominal hemorrhage resulting in abdominal compartment syndrome.
Case Description: 40 year old female ASA 5E in the medical ICU was emergently taken to the operating room for an exploratory laparotomy to control bleeding and relieve abdominal compartment syndrome (bladder pressure of 20). She has a history of systemic lupus erythematosus with pulmonary disease and pulmonary hypertension, pericardial effusion secondary to her SLE, and anti-phospholipid antibody syndrome on enoxaparin. She in atrial fibrillation and atrial flutter, on an amiodarone drip. Prior to being taken to the operating room, her pulmonary artery pressures of 90-100/30-40 and central venous pressures 19-29, system blood pressure was 100-110/60-70 on inotropic support such as dobutamine and vasopressin. Transthoracic echocardiography was significant for moderate-sized pericardial effusion, dilated inferior vena cava, severely elevated right atrial pressure, and "massively" and "severely" enlarged right atrium and ventricle, respectively. Her starting hemoglobin was 6.2 and she was saturating 85-90% on 100% oxygen with baseline brain-ox level of 20. In order to treat the severe pulmonary hypertension, inhalational nitric oxide was started 40 ppm without any improvement in pulmonary artery pressures. In the operating room, the patient was induced with small doses of ketamine 10 mg at a time (total dose 50 mg), sevoflurane 1.5%, and morphine was titrated to respiratory rate. Rapid sequence induction with cricoid pressure was performed with succinylcholine 100mg for muscle relaxation. Patient was gradually resuscitated with 6 units of blood, 4 units of fresh frozen plasma and 10 units of platelets. Acidosis was treated with bicarbonate. Epinephrine was increased and a low dose of nitroglycerin drip was started simultaneously with blood transfusions. Blood pressure improved to 120-125/70-75, heart rate was 110, pulmonary artery pressures improved to 75-80, brain-ox increased to 40, and peak inspiratory pressures improved from 40 to 36. Surgical exploration yielded a 4L hematoma in the rectus sheath that was evacuated. Patient’s hemodynamic parameters remained stable at the end of surgery and on transfer back to the Medical ICU. In the post-operative period in the ICU, nitric oxide and nitroglycerin were continued with dobutamine and epinephrine. She was extubated the next day in stable condition, alert and oriented following commands, moving all extremities, and had decreasing inotropic requirements.
Discussion: Severe pulmonary hypertension often results in right heart failure, tricuspid regurgitation, and increasing renal pressures which result in renal failure. Transfusion of blood products may exacerbate pulmonary hypertension and heart failure through circulatory overload. The combination of nitroglycerin and nitric oxide with epinephrine and dobutamine are beneficial in minimizing pulmonary hypertension, improving right heart failure and transfusion related problems.
