A Case of Obstructive Shock and Severe Lactic Acidosis Treated with Mechanical Thrombectomy
Presenter
Jason G Kaplan, MD, McLaren Cardiovascular Institute, Troy, MI
Jason G Kaplan, MD1, Varun Yelamanchili, MD1, Nikhil Gandhi, DO2, Jordan Swisher, DO2 and Jay Mohan, D.O., FSCAI1, (1)McLaren Cardiovascular Institute, Troy, MI, (2)St. John Moross, Detroit, MI
Title
A Case of Obstructive Shock and Severe Lactic Acidosis Treated with Mechanical Thrombectomy Introduction
Obstructive Shock is an acute blockage of blood flow in either the systemic or pulmonary circuit causing the clinical symptoms of shock. The obstructive variant is far less prevalent than other forms of shock accounting for only 0.9% of cases presenting to the emergency department. We present a case of a patient who presented in obstructive shock due to a pulmonary embolism managed with mechanical thrombectomy. Clinical Case
A 63 year old male with no relevant past medical history presented to the emergency department after a syncopal episode at home. Initial vitals revealed a systolic blood pressure in the 70s and an oxygen saturation at 76%. The patient’s blood pressure responded moderately to intravenous fluids to the high 90s and was started on a nonrebreather which improved his oxygen saturation. Initial lactate was found to be 15.1 mmol/L. A CT angiogram of the chest demonstrated a large burden of pulmonary emboli is the main pulmonary arteries bilaterally. The patient was brought emergently to the cath lab for mechanical thrombectomy which was successful in extirpating a large quantity of thrombus from the main pulmonary arteries bilaterally. Hours after the procedure the patient complained of excruciating left lower and suprapubic abdominal pain and bloody stools. A CT abdomen revealed a small infrahepatic hemorrhage and inflammation of the sigmoid and rectum concerning for ischemic colitis which gastroenterology managed with conservative therapy. The patient was discharged on day 5 without any further complications. Discussion
This case exemplifies a great use of an invasive approach in a patient presenting with obstructive shock and severe lactic acidosis. Patients who present with a pulmonary embolism have an overall mortality from 8-11%, however if they are in a shock state that mortality increases dramatically to 40-50%. The literature also demonstrates patients presenting with pulmonary embolism and elevated lactate levels greater than 6 mmol/L hold a greater than 60% mortality. Only after the procedure were the systemic effects of this shock state fully appreciated, causing ischemic bowel which resulted in GI bleeding, as well as an intra-abdominal bleed, also related to ischemic effects on the pancreas. Traditionally, systemic thrombolytics were the mainstay in patients presenting with severe pulmonary emboli, however this case illustrates how systemic thrombolytics can be potentially dangerous in severe cases, as the secondary effects can be exacerbated and how an invasive approach is effective while mitigating the risk of thrombolytics.