Acute Pulmonary Oedema secondary to End-Stage Renal Failure with Underlying Diabetes Mellitus, Hypertension, Cerebrovascular Accidents and Ischemic Heart Disease

66 year old / Malay / female

Known case of Diabetes Mellitus, Hypertension, End Stage Renal Failure, Ischaemic Heart Disease and Cerebrovascular Accident

presented to the hospital due to unresponsiveness at 5am on the 3rd of March- Family member noted that the patient was drowsy:

• Prior to that she had 1episode of seizure
• jerking of both upper and lower limb
• uprolling of eyeballs
• clenching of gum
• drooling of saliva
• this was the first episode and lasted for 1 minute

 She was taken to the Klinik Kesihatan by the ambulance where the patient was still drowsy and restless. She had another episode of fitting at the Klinik Kesihatan but family members were unsure of the medication given.

Past Medical History

She was a previous admission on the December 2013 due to fluid overload secondary to End Stage Renal Failure

•  admitted for 3days
• claimed reduced effort tolerance after last admission

CVA

• in 2002, had left hemiparesis
• in 2005, had right hemiparesis
• Currently, has generalized body weakness and since has reduced effort tolerance.

Chronic Kidney Disease Stage 5

•  Patient had AV fistula done in July 2013 but has yet to go for haemodialysis.
• urea: 16.8
• Creatinine: 568

Diabetes Mellitus
Hypertension
Gouty Arthritis
Ischaemic Heart Disease


At Emergency Department, patient developed nausea and vomiting, shortness of breath and became more tachypneic.

• SpO2 was 88-90%
• lungs had bibasal crepitations
• she was given IV Lasix 40mg stat
• referred to anesthetic team for elective ventilatory support

On Examination
Glasgow Coma Scale: E2 V1 M3 (patient was sedated with IV Midazolam/ Morphine 3ml per hour)

Pupils were 2mm, 2mm; bilaterally reactive
 Blood Pressure: 203/95mmHg

Lung Examination:
reduced air entry bilaterally
bibasal crepitations

Neurological Examination:
Tone: Hypotonia
Reflexes: None were elicited.

Other systemic examination was unremarkable.

Investigations
Full Blood Count

• White Cell Count: 12.9
• Haemoglobin: 9.8
• Platelet: 232

Troponin I: 0.46

 Renal Profile

• urea:24.7mmol/l
• Na: 138 mmol/l
• K: 4.6mmol/l
• Cl: 110mmol/l
• Creatinine: 786mmol/l

Arterial Blood Gas (under High Flow Mask)

• pH: 6.974
• pCO2: 36.4
• pO2: 249.0
• Na: 145.8

Arterial Blood Gas (under Ventilator)

• pH: 7.147
• pCO2: 36.4
• pO2: 249.0
• Na: 145.8

Chest X-Ray
shows evidence of Cardiomegaly with bilateral lower zone haziness.

ECG
T depression seen in leads V1-V6
Sinus tachycardia

Plan of Management

1. Start patient on IV Cefepime 1g BD
2. Strict intake ouput charting
3. To send patient for Haemodialysis if patient has poor urine output and persistent acidosis
4. Repeat Venous Blood Gas
5. Continue Sedation at 2ml/hr

Progress Notes
Day 2(03/03/2014)
Patient still was sedated with no improvement in condition. Blood Pressure was 130/85mmHg. Urine output was 400cc clear urine. Urine sample was sent for urine FEME. Noted that patient was anemic and had a raised white cell count.
Plan of Management:

• Start patient on Inotropes
• Insertion of Ryle's tube for feeding
• IV Lasix 40mg BD
• Start patient on Haematinics
• T. FeSO4 400mg BD
• T. Vit C/T. B complex/ T. Folate

• Refer patient for chest and limb physio
• Regular Suctioning

Day 3 (04/03/2014)
Noted that patient was asystole was at 6.30am. CPR was initiated. Patient was resuscitated after 10minutes. At 7.15am, patient was again noted to be in asystole. CPR was commenced according to protocol. CPR was done for 30minutes. IV Adrenaline 1mg x 6doses were given. Barely palpable pulse was obtained after 30minutes. Cardiac monitor showed extreme bradycardia.
 Patient became asystole again at 8.31am. No pulse were palpable. No spontaneous breathing. Pupils were fixed and dilated (5mm,5mm).
Patient was pronounced dead at 8.31am. Cause of death was identified to be Acute Pulmonary Oedema Secondary to Hypertensive Emergency.