Abstract | November 18, 2023
Atypical Treatment of Patient with Erythrocytosis on Mechanical Ventilation Secondary to CAP vs COPDe
Learning Objectives
- Understanding the association between secondary polycythemia and respiratory failure: This case report highlights the development of secondary polycythemia in a patient with pulmonary hypertension who presented with acute hypoxic and hypercapnic respiratory failure. Learners can explore the underlying mechanisms and the impact of erythrocytosis on oxygen-carrying capacity in respiratory pathologies.
- Recognizing the importance of comprehensive interdisciplinary case evaluation: Despite initial appropriate management, this case emphasizes the significance of a comprehensive evaluation that considers nuanced details from the patient's medical history. Learners can understand the value of interdisciplinary collaboration, incorporating insights from different specialties to ensure a thorough assessment and identification of potential contributing factors.
- Considering unconventional interventions for complex medical conditions: This case report highlights the successful implementation of therapeutic phlebotomy and anticoagulation in the management of secondary polycythemia associated with impaired blood flow and hypoxemia. Learners can explore the rationale behind these interventions and consider their potential efficacy in select patient populations with similar presentations, encouraging a broader approach to treatment options.
This case report describes a unique instance of secondary polycythemia in a patient with a history of pulmonary hypertension requiring mechanical ventilation. A 43-year-old female with a past medical history of substance abuse, anxiety, and depression presented with dyspnea. The initial diagnosis was severe sepsis secondary to community-acquired pneumonia, resulting in acute hypoxic and hypercapnic respiratory failure. Initial laboratory results revealed erythrocytosis with a hemoglobin level of 18.8, compared to her baseline of approximately 16.
Despite the administration of broad-spectrum antibiotics (vancomycin, meropenem, and antifungals), routine breathing treatments, SoluMedrol, and diuretic therapy (lasix) due to congestive heart failure and edema, the patient’s respiratory status continued to deteriorate. Chest X-ray and laboratory findings,
including complete blood count and comprehensive metabolic panel, remained within normal limits or stable.
Despite these interventions, the patient’s ventilator settings progressively increased, necessitating a FiO2 of 100% and positive end-expiratory pressure (PEEP) of 18. Notably, the patient’s CBC showed worsening erythrocytosis. In light of this observation, we postulated that although the patient appeared edematous, she might be hemoconcentrated, leading to impaired blood flow due to sludging and resulting hypoxemia. Consequently, we discontinued lasix, initiated full-dose anticoagulation, and augmented hydration with free water with tube feeding. Additionally, therapeutic phlebotomy was performed, removing 500mL of blood.
Remarkably, the patient demonstrated improvement the following day. Furthermore, sildenafil was introduced as a treatment for pulmonary hypertension. Gradually, the patient’s ventilator requirements diminished, ultimately resulting in successful extubation. This case presentation underscores the significance of collaborative teamwork and thinking outside the box. Although the initial management was appropriate, certain nuanced details from the patient’s medical history were overlooked. Therefore, comprehensive interdisciplinary case evaluation is imperative. While therapeutic phlebotomy and anticoagulation for secondary polycythemia are atypical interventions, they proved efficacious in this particular scenario and should be considered for select patient populations.
References and Resources
- Dunlap, B., & Weyer, G. (2016, September 15). Pulmonary hypertension: Diagnosis and treatment.
American Family Physician. https://www.aafp.org/pubs/afp/issues/2016/0915/p463.html
