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Abstract

Case Report: A 52 year-old female was transferred to our institution for advanced therapies after failed percutaneous interventions for an acute myocardial infarction. Unknown myocardial viability and social support precluded her from high-risk revascularization and/or ventricular assist device placement. On hospital day 6, she decompensated and required epinephrine, milrinone, and vasopressin. The decision was made to provide comfort measures only. While waiting for family, she developed multi-system organ failure (MSOF). Her fingers were cyanotic. Mottling extended from her hands to her shoulders, and her skin was cold. This distressed her family. Nitroglycerin (NTG), a venodilator, was started at 5mcg/min to decrease peripheral vasoconstriction. Over 2 hours, mottling decreased and hemodynamics were unchanged. NTG was increased to 10mcg/min; mottling and cyanosis resolved and her skin returned to a normal temperature. The remaining family arrived to a patient with a warm, pink appearance; she died without signs of distress hours later. Discussion: Vasopressors are standard therapy of shock but are associated with skin and digital ischemia. While counterintuitive, peripheral venodilators may also have a role in shock. As an adjunct to decrease organ failure, NTG has increased microcirculatory flow in septic shock and been used for dopamine-induced peripheral ischemia. We used this principle of increasing modulating microcirculatory flow with a venodilator in this patient with MSOF and successfully allowed visible increases in skin perfusion. Additionally, mitigating family distress at end-of-life (EOL) reduces the likelihood of affective disorders after patient death in the ICU with a key factor being symptom management. An indicator for quality EOL care includes the family’s comfort that the patient is physically touched by loved ones at EOL. Abating the distorted body image of mottling and alleviating the feeling of cold extremities by restoring microcirculation improved the interaction of this family with the patient at the time of her death. This intervention may provide improved outcomes for her family’s coping in subsequent weeks to months.