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VentWorld
Case Studies
Published August 9, 2001
William French and Sandra Robinson
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm
Contents (click to jump directly to that
section, or scroll down to read the case)
INTRODUCTION
JJ was a 49-year-old male admitted to the
emergency department with a decrease in alertness and speech
for the past three days. In addition, he had a decreased urinary
output and no bowel movement over that period. Initial examination
revealed that he was difficult to arouse, did not verbalize,
but had spontaneous eye movement. He also had coffee ground
emesis and was had a fresh bleed from his nose. Vital signs
were: heart rate 68, blood pressure 128/80, respiratory rate
20, temperature 38.9 C, and SpO2 99% on room air. Breath sounds
revealed bilateral expiratory rhonchi. His abdomen was distended
and tender. Pedal edema was present. Chest radiograph showed
bilateral infiltrates.
The patient had a prior history of cirrhosis
of the liver, ETOH abuse, esophageal and gastric varices,
portal gastropathy, and Hepatitis C and B. He had been on
the waiting list for a liver transplant, but was recently
removed from the list and referred to counseling for continuing
alcohol use. Admitting diagnosis was cirrhosis due to ETOH
abuse, GI bleed, hepatic encephalopathy, and probably renal
failure.
CASE PRESENTATION
Initial treatment consisted of packing the nose. He was
also intubated with a #8 ET tube for airway protection since
he had no gag reflex. Subsequently he was transferred to
the intensive care unit and placed on mechanical ventilation
via a P-B 7200 ventilator. Ventilator settings were:
| Mode |
CMV |
Rate |
12 |
| Tidal Volume |
600 mL |
Flow |
60 Lpm |
| FiO2 |
100% |
PEEP |
+5 cmH2O |
Secretions removed from the airway were both bloody and
yellowish. Blood and urine cultures were obtained, and a
lumbar puncture and CT scan were performed to rule out meningitis.
The patient was started on Folic acid, Thiamine, and Pepcid.
In addition, he was given Ativan for sedation, Fentanyl
and Levo-Dromoran for analgesia, and low dose Dopamine for
renal insufficiency. First day lab results were:
| serum bilirubin |
7.1 mg/dL |
BUN |
39 mg/dL |
| glucose |
146 mg/dL |
creatinine |
1.9 mg/dL |
| albumin |
1.8 g/dL |
ammonia |
219 µg/dL |
| Hgb |
9.2 g/dL |
Hct |
26.2% |
Over the next two days, the patient was treated
for liver and kidney malfunction. In addition, he was given
four units of packed red blood cells, six units of platlets,
and two units of plasma. Efforts were made to stop the nasal
and GI bleeding. Blood cultures revealed E coli and the patient
was started on appropriate antibiotic therapy.
The patient's condition continued to deteriorate.
A follow up chest radiograph showed an increase in bilateral
infiltrates. Peak inspiratory pressures on the ventilator
reached levels of 55 - 60 cmH2O. An arterial blood gas sample
drawn at this time showed:
| pH |
7.25 |
PaO2 |
70 |
| PaCO2 |
42 |
SaO2 |
91% |
| HCO3 |
18 |
base excess |
-9 |
| FiO2 |
45% |
PEEP |
+5 cmH2O |
The patient was changed from volume control
to pressure control with the following settings:
| Mode |
CMV |
Rate |
18 |
| PEEP |
+5 cmH2O |
PIP |
38 cmH2O |
| FiO2 |
45% |
i-time |
0.94 sec |
Follow up arterial blood gas results on the
above settings were:
| pH |
7.29 |
PaO2 |
78 |
| PaCO2 |
32 |
SaO2 |
94% |
| HCO3 |
15 |
base excess |
-12 |
In response to the above data, the respiratory
rate was increased to 20. This caused the pH to increase to
7.39 and the PaCO2 to decrease to 28. However, there was also
an increase in auto-PEEP levels.
Twelve hours later, the patient's pH dropped
to 7.23 and the PaCO2 increased to 44. The respiratory rate
was increased to 24, which corrected the acidosis and relative
hypercapnia but resulted in a further increase in auto-PEEP.
In addition, it was observed that the delivered tidal volumes
were steadily decreasing as the patient's ARDS continued to
progress. At the same time, the patient's renal failure worsened,
as indicated by a significant difference between fluid input
and urinary output. There was also an increase in dependent
edema. Jet ventilation was considered. However, due to the
patient's chronic liver problems and his apparent end-stage
organ failure, and the fact that he did not respond to therapy,
after consultation with the family, the decision was made
to withdraw life support.
DISCUSSION:
Do you think the staff recognized and managed
the case appropriately? Post your thoughts or ask other questions
related to this case.
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