COPPER REPLETION RESOLVES VENTILATOR DEPENDENCE IN A GASTRIC BYPASS PATIENT: A CASE LINKING MICRONUTRIENT DEFICIENCY TO CRITICAL CARE OUTCOMES

ABDELRAHMAN Shehata; KEVIN Meek; MILAN Regmi; PAARMIT Chhabra

doi:10.1016/j.chest.2025.07.1399

INTRODUCTION: Copper is crucial for normal function of different oxidative enzyme, which is primary bonded with ceruloplasmin in extracellular fluid, is necessary for normal function of all living cells in human body, significant portion of patient in ICU are found to have trace elemental deficiency despite being on appropriate nutritional support. Critical illness neuropathy leading to muscle weakness and poor inspiratory capacity can lead to delayed weaning causing prolonged days on mechanical ventilation, it has been proposed that trace element like copper, zinc and chromium may be the reasons for severe neuromuscular weakness as the cause. Copper deficiency in critically ill patient was found to be associated with significant number of ICU patient and replacement was associated with decreased mortality CASE PRESENTATION: A 49-year-old male with a history of Roux-en-Y gastric bypass (20 years prior), copper deficiency, coronary artery disease, systemic lupus erythematosus (SLE), and recurrent dysphagia presented to the emergency department with altered mental status and acute hypoxemic respiratory failure. Initial evaluation revealed septic shock secondary to suspected aspiration pneumonia, prompting immediate intubation and vasopressor support. Blood cultures identified MRSA bacteremia, and a respiratory pathogen panel confirmed concurrent MRSA and Klebsiella pneumoniae pneumonia. Transthoracic echocardiography ruled out endocarditis.The patient required prolonged mechanical ventilation despite resolution of septic shock (vasopressors discontinued by hospital day 5) and antibiotic escalation to vancomycin and ceftriaxone. By hospital day 10, repeat blood cultures were sterile, and chest imaging showed improving infiltrates. However, daily spontaneous breathing trials (SBTs) failed due to inadequate respiratory effort and persistent hypercapnia.On hospital day 12, micronutrient workup revealed severe copper deficiency (serum copper: 0.4 mcg/mL [normal: 0.8–1.6 mcg/mL]), likely secondary to long-standing malabsorption from gastric bypass. Oral and intravenous copper supplementation was initiated (elemental copper: 4 mg daily). Within 72 hours of repletion, the patient demonstrated marked improvement in respiratory drive and neuromuscular coordination. A spontaneous breathing trial on hospital day 15 was successful, and he was extubated without complication. Post-extubating, he maintained adequate oxygenation and ventilation, with normalized copper levels (1.2 mcg/mL) confirmed prior to discharge. DISCUSSION: This case highlights copper deficiency as a reversible cause of refractory ventilator dependence. Copper is essential for mitochondrial cytochrome C oxidase activity, and its deficiency impairs cellular energy production, particularly in highly metabolic tissues like skeletal muscle. The patient's chronic malabsorption from gastric bypass, compounded by critical illness, likely exacerbated neuromuscular weakness, delaying weaning.Notably, ventilator liberation occurred only after copper normalization, despite earlier resolution of infection and hemodynamic stability. This temporal relationship underscores the role of copper in respiratory muscle function and the importance of micronutrient screening in post-bariatric surgery patients with unexplained critical care challenges. CONCLUSIONS: Copper deficiency should be considered in patients with prolonged ventilator dependence, particularly those with malabsorptive histories. Rapid correction can lead to dramatic clinical improvement, reducing ICU stays and morbidity. This case reinforces the need for heightened suspicion of micronutrient deficiencies in post-bariatric surgery populations, even decades after the procedure.

COPPER REPLETION RESOLVES VENTILATOR DEPENDENCE IN A GASTRIC BYPASS PATIENT: A CASE LINKING MICRONUTRIENT DEFICIENCY TO CRITICAL CARE OUTCOMES

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