AB216. SOH21AS036. An unexpected cause of acute decompensation in an elderly inpatient

Abstract: We present the case of a 76-year-old patient initially admitted with epistaxis on a background of oral anticoagulation for atrial fibrillation and a hiatus hernia. On the second day of admission the patient became acutely dyspnoeic, hypoxic, hypotensive and tachycardic. Metabolic acidosis was present on blood gas analysis. Vasopressor support was commenced and the patient was intubated and sedated. Initial stabilisation allowed an urgent CT scan to be performed which diagnosed a left diaphragmatic hernia with the stomach, descending colon, distal transverse colon and obstructed proximal jejunum located within the left hemithorax. Complete atelectasis of the left lung and volume loss in the right hemithorax with mediastinal shift to the right were present. The patient was ventilated on pressure control ventilation. Initially, inspiratory pressures of 40 cmH₂O were required to achieve tidal volumes of approximately 310–330 mL. Following orogastric tube insertion and gastric decompression, tidal volumes increased to approximately 420–440 mL and required inspiratory pressure decreased. Electrolyte replacement and vitamin K were administered to optimise the patient for surgery. The patient was transferred to a specialised surgical centre for emergency surgical intervention. This case highlights diaphragmatic hernia to be considered as a cause of life-threatening rapid decompensation in a patient with a history of a hiatus hernia and the ventilatory value of gastric decompression when the stomach lies in the thorax.

Keywords: Acutely decompensated diaphragmatic hernia; diaphragmatic hernia gastric decompression; hiatus hernia; mechanical ventilation