Case 25: Reversal of Vascular Shock and Lactic Acidosis

This 76 year old female was admitted to the Hospital on the 9th of December, 1993 and discharged on the 17th of December with the following diagnoses:

• Urethral calculus
• Hydronephrosis
• Congestive heart failure
• Septicemia due to E-Coli
• Urinary tract infection
• Septic shock
• Lactic acidosis
• Diabetes mellitus
• Supraventricular tachycardia
• Drug rash.

Her past medical problems had included the diabetes , arterial hypertension, hypercholesterolemia, and the supraventricular tachycardia. The later had taken her to the Emergency Room a few weeks prior to this admission. She also had a history of a small kidney stone. She was admitted through Emergency Room at this time having had sudden severe pain across her mid-abdomen after dinner. She vomited with some relief. The pain moved to her left flank. Hematuria was noted and she was admitted for renal colic.

Laboratory data on admission included a white count of 11,000, hemoglobin 16 gm/dl, sodium 140 mEq/L, blood glucose 214mg/dl, BUN 24 mg/dl, serum creatinine 1.2mg/dl, "trace" for urine protein, "trace" for urine ketones and 2+ bacilluria.

The morning after admission she appeared relatively comfortable and the fever present on admission was not prominent. Her physical examination was not remarkable and Utilization wondered about her need for hospitalization . An abdominal ultrasound examination was scheduled in the afternoon. During the latter examination, she developed shaking chills and had obviously become septic. She was transferred back to her room where blood cultures were obtained and Timentin and gentamicin were started intravenously. In the latter part of the afternoon, her blood pressure became progressively lower and she was transferred to the Intensive Care Unit. There, her urologist determined that the hydronephrosis seen on ultrasound had to be relieved. She was taken to the Operating Room to relieve the obstruction. During the postoperative period, she continued to have a "rocky course"; her high fever abated somewhat with the injection of hydrocortisone but her blood pressure remained low. Because of her hypotension and deteriorating state she was placed on a respirator for maximum support. Extra digitalis was administered in an attempt to slow her heart rate. Her serum lactate level was 7.4 at 11:10PM. Her blood pressure was hard to detect. Intravenous Dopamine was not effective. She was in septic shock.

Her left leg was placed in a Circulator Long-Boot and she was pumped for vascular support through the night. Her blood pressure came up. Her lactate fell to 3.4 at 3:50 AM and to 2.9 at 6:50 AM the following morning. She was more alert and the boot was removed. It was found that her urinary catheter was not functioning and had clotted off. Her urologist replaced the stent in her left ureter and obtained better drainage. The Intensive Care specialist added Dobutamine to her program but her vital signs remained good. She was extubated on the 11th of December. On the 15th of December her urologist placed a left double-pigtail kidney/bladder stent successfully opening her left kidney. The rest of her hospital stay was uneventful.

Comments: The story of this lady is included to illustrate dramatically how the Circulator Boot system may safely support the circulation in very sick patients. It may be applied and removed quickly and non-invasively. It has limitations, of course; it is increasingly less effective at the heart rate increases. The trick in unloading the heart is having an effective boot compression that ends with or just before the next QRS complex. It takes 0.38 to 0.44 seconds to effectively inflate the boot. Sixty seconds divided by 0.38 to 0.42 gives 157 to 143, heart rates in which the entire RR interval would be utilized in inflating the boot leaving no time for deflation. We solve this problem by setting the delay time very low (0-0.12 seconds) and then pumping on every other or every third beat, trying thus to unload every other or every third beat.. In some patients with rapid heart rates these maneuvers work. In patients with rates over 160, we have more difficulty and if boot therapy is desirable pharmacological steps will first have to be taken to slow the rate. Back to this patient... at this moment, the boot appeared to have saved her life. A few years later she came under the care of a cardiologist for angina; an angioplasty was successfully done. Her angina recurred and a second angioplasty was attempted. It succeeded briefly and closed down. A stent was then placed and later perforated the heart. She died after an attempt at corrective heart surgery. She obviously would have done better to have avoided the invasive procedures and tried a course of boot therapy.