Eye See You..

Clinical case study By David Quintero

Patient data
Initials: M.Q. Age: 66 weight: 117kg or 258lbs Race: Hispanic Height: 64 Admitted: 5/08/2012 Was Married with children-is now widower Chief Complaint: Found unresponsive Social history: Patient is a nonsmoker, drinks a beer infrequently. He is retired.

Past Medical History

hypertension, has had previous admission at a hospital for MRSA septicemia, meningitis, septic shock, recent onset seizures, type II diabetes, osteoarthritis Past Surgical History: Benign prostatic hyperplasia (increase in the size of the prostate) Home meds: back in 2010 he had been taking metformin and glyburide for diabetes, and flomax to treat symptoms of BPH.

Physician notes at admittance

Patient was found unresponsive at home by his son. Patient said he had complained about back pain. Blood glucose was high. He had evidence of seizure and was only moving his left side. He was brought into ER where he was intubated for airway protection. He developed some hypotension and received 4 liters of normal saline in the ER. Additionally, he received 10 units of regular insulin and has been started on propofol for status epilepticus.

Physical Exam

Vital signs: blood pressure 166/88, HR 85, O2 Sat 98, RR 8 General: he is awake lethargic oriented x2. His hypophonic (soft speech from lack of coordination). Neurological: cranial nerves 2-12 are intact. Motor, the pt has generalized weakness in all extremities. Sensation is intact to light touch. Cardiovascular: S1 and S2, regular. Hr 87, blood pressure 166/88, respiratory rate 11, oxygen saturation 100, decreased air entry at both bases. Abdomen: soft, nontender with good bowel sounds. Skin: pink, he has a few bruises and peripheral edema. Cardiovascular: regular rhythm, mild tachycardia. No murmurs, clicks or rubs. Pulmonary: no crackles, or wheezes appreciated. There are bilateral breath sounds. Chest excursion was inadequate

Cont
Genitourinary: Foley catheter is in place. Musculoskeletal: no gross bony deformities Right 1st toenail ecchymotic- pertaining to a discolored area on the skin or membrane caused by blood seeping into the tissue as a result of a contusion Mild thoracic on upper back abscess, Right lateral footulcer by visual exam Breath Sounds: Diminished w/ rhonchi Capillary refill: wnl Jvd: wnl Eyes: pearl Allergies: no known drug allergies

Admitting Diagnosis
1 status epilepticus 2 diabetic ketoacidosis with coma 3 hypotension 4 acute renal failure 5 elevated CK and CK-MB most likely secondary to hypotension (Creatnine Kinase and Creatnine Kinase in the Cardiac Muscle indicating damage to heart ex. MI)

Admittance Plan
Admit to neuro ICU, He is laying in bed, frequent neuro checks, intubated, sedated ID consult, GI with propofol. prophylaxis. IV fluids, Currently there are no pain control, continue convulsions antibiotics, EEG, MRI of The endotracheal spine, drainage of tube is in place. OG upper back abcess tube is in place with Aspiration pneumoniasome dark bilious coffee ground in fluid in the collection. Nasogastric tube

Initial Labs low/high

WBC thous/ mcl 19.4 BUN mg/dl 37 Alb g/dl 3.2 Hb g/dl 14.2 Cr mg/dl 2.4 Ast uKa/L 42 Plt thous/ mcl 130400 Na+ mEql/L 133 Mg mg/dl 3.3 Neutro Bands phils 61% ClmEq/L 93 Ck U/L 355 29% HCO3 mEq/L 12 Ck-Mb 14.6 INR

1.3 Phosph orus 7.8 mg/dL Anion gap 28

EKG

Sinus rhythm pr. 14, qrs .10, qt .36

CHECK THAT VENT!

5/8/12 2020 Esprit ventilator: pt intubated 8.0 cass tube. AC 16, 650 ml, pt total RR 25 total VE 12.6 L, FIO2 100, peep +5, sens 2.0 , peak flow 60 LPM PIP 19 cmH2O MAP 10 cmH2O PLAT 18cmH2O HR 111 POX 97% B/P 81/42

8.0 CASS Tube

Continuous aspiration of subglottic secretions (CASS) has been shown to reduce the incidence of ventilator-associated pneumonia in these patients. This is accomplished using an ET tube that incorporates a suction lumen above the cuff, with a separate evacuation line and connecting port. Subglottic suction is provided using a standard wall suction unit set to apply continuous low suction not exceeding 20 mm Hg. For safety, The suctioning port should be clearly marked so it is not confused with the cuff pilot balloon. Standard setting is 40 mmHg

We can tell nothing without ABG!

5/08/2012 2106 temp 98.8F pH 7.139 PCO2 37.4 PO2 224 mmHg HCO3 12.7 mmol/L -16 BE Acute metabolic Acidosis

5/09/12
1125 sputum sample obtained, + MRSA, S. Aureus. ETT @ 27 at lip 1420 to CT no problems encountered 5/10/12 0750 Vent check: AC 26, 600, pt RR 27 pt Vt exhaled 596 total VE 16.1, FIO2 40, peep +5, sens 2.0, peak flow 100, pip 29, map 13, plat 21, stat 37, HR 94, pox 97, bp 116/67, 24cm @ lip cuff 26 cmH2o Alarms: High Rate 40, high pressure 60, low pressure 10, low peep 2, low Vt minute 200, High VE 25, low VE 6.0, apnea 20 101.1F pH 7.349 PCo2 34.7 HCO3 18.8 mmol/L BE -6 PO2 89 mmHg My interpretation and research: Compensated Respiratory Acidosis Kirstens interpretation: Normal w/ a acid HCO-3 Harrys interpretation:

Chuck Norris of Respiratory Therapy: Harry McAlpine says..

HCO3/H2CO3 RATIO The ratio of bicarbonate to carbonic acid determines the pH of the blood. Normal ratio is about 20:1 bicarbonate to carbonic acid. Ratio range is 18.5-21.5/1 with acid<18.5 and alkalotic>21.5. pH of 7.35 = 18.5 ratio and pH of 7.45 = 21.5 ratio PaCO2 x 0.03 = H2CO3 34.7 x 0.03 = 1.041 HCO3/H2CO3 18.8/1.041 = 18.06 The base excess is also defined as the amount of acid (in mEq/liter) that would have to be added to the patients blood to bring it to normal pH of 7.4 BE2 normal BE +3 and above = Metabolic Alkalosis BE -3 and below = Metabolic Acidosis Anion Gap: Na- (Cl + HCO3) 133 (93 + 12) = 133 105 = 28 Normal 7-16 mEq/L Hi=Metabolic Acidosis Low=Metabolic Alkalosis Harry says: Partially compensating Metabolic Acidosis

5/10/12 cont
1120 readvanced ETT 24-27 large leak present ETT 1330- 1600 MRI transport 5/11/12 0930 changed Hollister. No sores noticed on mouth. ETT was found at 25 cm, low cuff pressure. Tube is now 27 cm @ lip where it was previously since intubation, cuff pressure is now 26 cmH2o

5/12/2012

0845 Vent check: AC 22, 600, pt 27, pt exhaled Vt 593 total ve 15.3, fio2 30, peep +5, sens 2.0, peak flow 80, pip 23, map 6.5, plat 22, HR 83, pox 97, bp 156/79, 27cm @ lip 1100 Lumbar puncture was done, CSF was tan, possible previous tap. 1230 Nurse calls RT dept 5/13/12 0730 Vent Check: CPAP, pt rr 11, spont Vt 981, total ve 12.5, fio2 30, peep +5, pressure support 15, HR 78, pox 97, bp 130/84 0747 Temp 100.6F ABG pH 7.433 PCO2 36.3 mmHg PO2 78 mmHg HCO3 24 BE 0 1110 Pt placed on AC for TEE moderate sedation, will return to CPAP once more alert

5/13/12
1230 RT called to bedside by RN to extubate PT, upon arrival to ICU pt noted to have RR 30-35 Spo2 85% with paradoxical breathing noted, DR. B. notified orders, received to place pt on previous CPAP settings, Spo2 noted to remain 85-90% Fio2 60% pt also bag sxn, lavaged with RN assistance for moderate amounts of thin, tan secretions. Spo2 94% or 60% Fio2. Dr B. @ bedside, orders received to maintain current settings & titrate Fio2 1740 Dc Hollister, ET tube 27 @ lip

5/14/2012
0745 CPAP pt RR 10, Spont Vt 1020, total VE 12.3, FIO2 40, peep +5, pressure support 15, HR 86, POX 95, B/P 170/81 ETT @ 25 28 cm @ lip Tube found at cm marking 25, advanced to 28 cm at lip per x-ray & Dr. B. 0800 I & D of infected sebaceus cyst of upper back done @ bedside w/ local anisthetic-pt tolerated well

5/15/2012
0845 vent Check: CPAP pt RR 8, spont Vt 1162, total ve 9.3, peep +5, pressure support 10, sens. 2.0, HR 81, pox 98, bp 119/55, tube @ 26cm at lip 0920 called to bedside because of low Vt alarm RN, stated that dr.b advanced ETT, and added air to cuff-26 cmh2o, tube at 20 lip 1010 ABG temp 100.7F pH 7.466 PCO2 40.2 PO2 77 mmHg HCO3 28.7 mmol/L BE 5 mmol/L 1040 extubated to 3L NC, RR 16, HR 102, no distress observed

Rayos-Equis aka X-ray

Tube placement-5/09/12-view AP supine portable view. ETT is 4-5 cm above the carina and nasogastric tube is in the stomach. Lung expansion has worsened. Vent-5/14/12-AP partially upright portable view. Lungs are still poorly expanded. Stable hypoventilated chest. MRI-Spine Lumb/Thoracic-5/10/12-Multilevel thoracic disc degeneration-nonspecific edema in posterior paraspinal musculature and subcutaneous fat over the lumbar spine.

WHAT DOES IT MEAN?!

PIP Plat EX cmH cmH VT 2O 2O ml Peep Stat Dyn Peak Raw flow cmH LPM 2O/l /sec 60 1 100 80 4.8 0.75

5/8

19

18
21 22

504
596 593

5
5 5

38
37 33

36
24 32

5/10 29 5/12 23

What does it mean? Part deux

5/10/2012 .40(694-47)-(34.7 x 1.25)=PAO2 215.42mmHg (A-a)O2= 215.42- 89= 126.42 mmHg PaO2/FIO2= 89/.40= 222.5 below normal a/A is 89/215.42 =0.413 v/q mismatch

Drugs.our friend

Magnesium replacement protocol Flush heparin lock Potassium replacement Chlorhexidine for oral care-all icu Ocular lubricant for eye dryness Polyvinyl alcohol for dry eyes Flush sodium chloride-flush purple power picc pre and post use and every 12 hrs rocephin 2g iv Q 12 treat bacteria Ampicillin 1 g iv Q8 treat bacteria Vancomycin 1g iv q12 treat bacterial inflammation of the intestine Pepcid 20mg iv q 12 treat ulcers Albuterol 2.5mg=3ml q12

Depakon 500 mg iv q 12 for epileptic seizures Kcl 20 meq per ogt x2 q2 Acetaminophen rectal suppository Midazolam for anxiety or agitation Morphine for pain Ondansetron prevent naseau and vomiting Alteplase (cathflo) treat MI Bisacodyl rectal suppository for constipation Dextrose for dka order Sodium chloride (insulin) Acyclovir decrease pain and heal sores Famotidine treat ulcers Metoprolol for high B/P Fentanyl for pain Pantoprazole iv treat GERD

DKA: Dont Kick AirI mean Diabetic Ketoacidosis

Occurs with people with diabetes when the body cant use glucose (sugar) as a fuel because there is none or not enough insulin and instead fat is used. Symptoms include deep rapid breathing, nausea and vomiting, fatigue, muscle stiffness, dry skin and mouth, and sob. The disease may also affect results of electrolytes such as Mg, Ph, Na, CSF, and urine pH Goal is to correct the high glucose level with insulin and replace fluids lost through urination and vomiting. Systems affected can be confusion, cerebral edema, heart attack, death to bowel tissue due to low b/p, renal failure and coma. Other signs can be acute pancreatitis, appendicitis, and gastrointestinal perforation. Coffee ground vomiting can occur which originates from erosion of the esophagus. The physical exam could include decreased skin turgor, tachycardia, and increased RR. Although bicarb was decreased the administration of bicarb could actually worsen acidity inside the bodys cells and increase the risk of certain complications so it is discouraged. Treatment then is fluid replacement, plenty of insulin, electrolyte replacement, proper nutrition, treat nausea, kidneys, hypotension, and epileptic seizures relating to DKA

plan

will need surgical debridement given CSF findings and still septicemic Unable to place ogt or ngt transferring to another facility today Esophagogastroduodenoscopy-procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum. His antibiotics have been optimized and he is now on daptomycin. He remains on Depakote for partial seizures. His respiratory status since arrival to the neuro ICU, has been acceptable. He was however found to have a mass in his L4-S2 region on MRI and has been transferred to another facility for further evaluation and management of the mass.