Respiratory Failure
Patient Presentation:
B.K., a 61 year old male was admitted to the hospital for a right BKA with no complications during the surgery. On day 2 post-op he had complaints of chest tightness, shortness of breath, and a constant non-productive cough. Pt was awake, alert and oriented but has increased anxiety and restlessness with O2 sats ranging from 85-88% on a 100% NRB. Vitals: BP 158/96, HR 118, RR 28 and oral temp 37.8°C. The pt’s lung sounds had bilateral expiratory wheezing. The right BKA sutures are clean, dry and intact with no active signs of bleeding, redness or swelling at the site.
Labs/Tests:
Hgb 12, Hct 36, WBC 14, Chem panel WNL, Coags WNL, LFT’s WNL
ABG: pH 7.30, PaCO2 30, PaO2 51, HCO3- 25
Sputum, Urine and Blood cultures were sent
EKG showing sinus tachycardia with no ectopy
CXR shows bilateral infiltrates
Differential Diagnosis:
Pneumonia, pulmonary embolism, respiratory failure, sepsis
Diagnosis:
After assessing the lab values, ABG and CXR, B.K. was diagnosed with respiratory failure secondary to pneumonia.
Treatment:
B.K. was transferred to the ICU, intubated and placed on mechanical ventilation due to his increased work of breathing and decreasing oxygenation status on 100% NRB. He was placed on assist control mode (AC) mechanical ventilation with 100% FiO2, RR 16, Tidal Volume (TV) 350, and PEEP 5. Two new peripheral IV’s were started to allow medication administration intravenously. B.K. was placed on broad-spectrum IV antibiotics while the cultures were pending growth. The patient was placed on an IV fentanyl drip at 75mcg/hour for pain and sedation. The ventilator settings were adjusted according to the patient’s oxygenation status (SaO2) and ABG’s. B.K. was taken down for a CT scan of the chest to further evaluate lung fields and severity of pneumonia.
Outcome:
After 24 hours in the ICU the pt’s ABGs were: pH 7.38, PaCO2 34, PaO2 143, HCO3- 26 on ventilator support AC, FiO2 60%, RR 16 (breathing 3-4 breaths over the set rate), TV 350, and PEEP 5. No growth reported after 24 hours from any cultures sent to the lab. The chest CT clarified the diagnosis of pneumonia with no further issues. The pt was placed on a ventilator weaning protocol and the IV fentanyl drip was slowly titrated down to allow B.K. to become more alert and awake. Day 3 in the ICU B.K. was extubated and placed on 4L NC. He was transferred to a medical/surgical floor on day 4 and discharged to home shortly after.