Respiratory Failure
Patient Presentation:
M.M., a 44 year old female presented to the emergency department with complaints of abdominal pain, nausea, vomiting, weakness and lethargy times 4 days. Pt was found to be lethargic, but oriented, somewhat anxious/restless and hypoxic with O2 sats of 85% on room air. O2 via 100% non-rebreather mask was started. O2 sats came up to 89-91%. Pt had labored breathing and lung sounds with bibasilar rales. Vitals: BP 88/42, HR 120 - sinus tachycardia with no ectopy, RR 24 and shallow, oral temp 99.2. Labs: CBC normal, Chem panel normal except BUN and creatinine mildly elevated at 25 and 1.1 respectively, ABGs: ph 7.39, PaCO2 44, PaO2 60. Blood, urine and sputum cultures were drawn. Cortisol level 15. Amylase was normal, liver panel was normal. CXR showed bibasilar infiltrates
Differential Diagnosis:
Gastroenteritis, Respiratory failure secondary to ARDS, Aspiration pneumonia, Sepsis
Diagnosis:
Based on the presentation and lab results, M.M. was diagnosed with ARDS and septic shock.
Treatment:
M.M. was intubated in the ER and transferred to the ICU. She was placed on mechanical ventilation in assist control mode with 100% FIO2, tidal volume 400ml (6ml/Kg), respiratory rate 16, 8 cm PEEP. Broad spectrum antibiotics were started empirically for aspiration pneumonia as patient had been vomiting at home prior to admission. Levophed® (norepinephrine) was started as an IV drip and titrated for goal MAP of 65. IV steroids were started for adrenal insufficiency as cortisol level was not elevated as would be expected in this setting. Unable to perform CT scan of chest as patient could not tolerate lying flat – patient desaturated to low 80s with attempts to lay flat. Patient’s course was tenuous, difficulty improving PaO2. PEEP was increase to 12 cm and FIO2 maintained at 100% which brought PaO2 to 65mmHg. Nitric oxide was started for pulmonary vasodilation to improve oxygenation. Nutrition via tube feedings was started along with sequential stockings for deep vein thrombosis prophylaxis and IV Protonix® for GI prophylaxis. Frequent ABGs and vent changes were performed to monitor and improve oxygenation.
Outcome:
5 days after admission to ICU, Levophed was weaned to off. Nitric oxide was started on day 2 and discontinued on day 6, PaO2 was consistently in the 65-68 mmHg and 100% FIO2 was able to be weaned. On day 14 ventilator weaning protocol was started. Pt was extubated on day 17 and transferred to the medical floor on day 19.
Case created by Michelle Michaels, 2010.