Patient presentation:
T.T., a 53 year old male, presented to the ER after several days of fever,
cough, sore throat, runny nose, body aches, headache, chills, fatigue,
shortness of breath, and progressive difficulty breathing. His PMH
included: hypertension, GERD, chronic back pain, hyponatremia, bilateral
inguinal hernia, vasectomy, lumbar disc surgery, and genital herpes. Upon
examination T.T’s had labored breathing with accessory muscles, crackled
lung sounds, and vital signs were: HR: 104, BP: 78/48, SaO2: 80% on 100%
non-rebreather, temp: 37.9°C. As he progressively became more lethargic,
produced incomprehensible words, and went into an unresponsive state, he
was intubated and transferred to the MICU.
Differential list:
Flu, ARDS
Diagnosis:
The symptoms and the results of the tests were consistent with ARDS
secondary to H1N1 flu.
Treatment:
The patient was placed on the ventilator, had a femoral arterial line
inserted, and a subclavian triple lumen catheter placed. T.T. was started
on Levophed®, which was titrated according to the hospital protocol to
treat hypotension for a target MAP of 60. In addition, the patient was
placed on the ARDS protocol. According to the protocol, the ventilator’s
FiO2 and PEEP were adjusted according to the patient’s oxygenation status.
As the PaO2 and SaO2 decreases, oxygenation is supported by raising the
FiO2 and PEEP in the vent settings. The increased FiO2 provides more
oxygen to treat the hypoxia while the PEEP helps to recruit the alveoli.
Despite attempts to maintain the patient’s PaO2 and SaO2 above 88%, the
patient minimally responded to the vent setting adjustments. The patient
was sedated on a continuous infusion of fentanyl and Versed® for a RASS
(Richmond Agitation-Sedation Scale) goal of -4. This allows the ventilator
to do the work and while preventing the patient from bucking,
overbreathing, and fighting the vent. Despite all efforts, the patient
continued to decompensate to the point that the patient’s vent settings
had an FIO2 100% and PEEP: 18. The physicians decided to add nitric oxide
to the vent, which causes pulmonary vasodilation and bronchodilation. By
this point, the patient continued to be hypoxemic, hypotensive, and ABG
showed that he was in respiratory acidosis (pH: 7.17, PaCO2: 65, PaO2: 65,
HCO3: 22). At this point, he continued to deteriorate, was septic, and had
multisystem failure (renal, GI, pulmonary, cardiac, etc.).
Outcome:
After 3weeks of attempting to treat the underlying problem of H1N1 flu and
ARDS, the patient continued to be hypotensive (despite being on multiple
vasopressors) and hypoxemic. Due to the patient’s poor prognosis of having
multiple organ failure, H1N1, and ARDS, the physician decided to consult
the family about his condition, patient’s wishes, and code status. As a
result, the family understood what was going on, decided to not escalate
care, and made him a DNR. Two days after the family’s decision, the
patient passed away.
Case created by Tina Thieu, 2011.