Abstract Intro Hypotension is a well-known complication in patients with cirrhosis, often stemming from an interplay of portal hypertension, autonomic dysfunction, ascites, and hyperdynamic circulation, and other factors. We present a patient that was normotensive by blood pressure (BP) cuff but arterial line revealing severe hypotension, raising potential debate on necessity of invasive BP monitoring, especially in cirrhotic patients with tenuous hemodynamic stability and where worsening hypotension may be sign of pending decline. Case An 80 year-old female with a history of hepatocellular carcinoma, cirrhosis secondary to MASH (with ascites, esophageal varices), systemic hypertension, and diabetes mellitus, presented from home for hematemesis. She had 3 EGD’s within the past 4 months, found to have esophageal varices each instance, treated with banding. She was started on IV protonix and octreotide drip with BP noted as 116/57 mmHg. She later had an RRT evaluation on floors for BP of 90/40 mmHg prompting transfer to ICU. She underwent EGD which revealed 3 cords of Grade III esophageal varices, features of prior variceal ligation, portal hypertensive gastropathy, and gastritis. She had esophageal banding but despite this, later had worsening mentation throughout the day, culminating in obtundation, agonal breathing, with arterial line revealing BP of 62/23 mmHg. She was started on vasopressor support but continued to worsen with family opting for comfort care. Discussion Patients with cirrhosis are known to have both cardiac and circulatory compromise, and the pathophysiology of hypotension is complex including portal hypertension-related systemic and splanchnic vasodilation (leading to a decreased effective arterial blood volume), portosystemic shunting and hyperdynamic state. A lower mean arterial pressure (MAP) of 60-65 mmHg is often tolerated in these patients; although any degree of insult to the system can result in significant hypotension and decompensation. This system is fragile to circulatory homeostasis and cirrhotic cardiomyopathy makes this more complex. New-onset of hypotension in patients with cirrhosis may signal the presence of insult that has capacity to cause multiorgan involvement and liver failure. Our patient might have warranted earlier invasive BP monitoring even with MAP 65 mmHg on non-invasive BP measurement considering her history of systemic hypertension, and given the significant risks of managing cirrhotic patients with unstable circulatory hemodynamics. With this information, the patient may have been started on vasopressor support sooner, and may not have had as rapid of a decline. This abstract is funded by: None
Tao et al. (Fri,) studied this question.