Initial Assessment
What caused the shaking chills?
- chills indicate increased temp (due to increased muscle activity)
- chills are due to her body's response to an infection
What caused the hypotension?
bacterial toxins cause:
- decreased cardiac contractility
- blood vessel dilation
Interpret the chest X-ray.
(refer to handout)
- dense opacification of right lung
- patchy opacification in left lung
- consistent with pneumonia filling the entire right lung and mildly affecting the left lung
Is Ms. T in respiratory failure and would it be appropriate to intubate and provide mechanical ventilation?
- patient is in respiratory failure
- no indicators demanding immediate intubation and mechanical ventilation
- however, confusion, decreased mental activity, poor cough, poor clearance of sputum, extensive right pulmonary opacification on CXR suggests that intubation and MV may be needed
What is the significance of elevated WBC count and bands?
- elevated WBC suggests infection
What is the significane of the confusion?
- common in people with infections
- evidence of inadequate cerebral perfusion, hypoxemia, and toxins produced by bacteria (infection)
What is causing the tachycardia?
- neuromuscular response to low blood pressure
- due to decreased contractility, the heart can only increase cardiac output by increasing HR
Interpret ABG.
(refer to handout)
- acute and chronic hypoventilation
- elevated HCO3 suggests the PaCO2 is chronically elevated
- pH is just below normal (suggest the PaCO2 isn't normally this high)
- O2 level is normal range, but not for someone on 100% oxygen!!
- therefore, relative hypoxemia caused by physiological shunting of blood through alveolar capillaries that do not have air because of the pus in airways
Should Ms. T be intubated and placed on life support or should "palliative care" be provided? How would you decide?
- depends on patient wishes or (if the patient is unable to understand circumstances and make an informed decision) a person designated by power of attorney for health care (DPAHC) or next of kin
- consider the pre-existing severity of illness
- life expectancy prior to acute illness
- proportionality of pain and stress caused by the life support vs. potential for recovery, and quality and quantity expected in postrecovery life
The Hgb A1C was normal, suggesting that the patient did not have diabetes. Is it important to vigorously control blood sugar in this patient?
- patients in septic shock survive more often with careful control of blood sugar in the hospital even though they may not have been diabetic prior to hospitalization
What is the significance of the rusty red right lung secretions and yellow left lung secretions?
- pneumonias can cause rusty red secretions.
- cystic fibrosis patients have copious thick yellow or green sputum
Why is the urine output low?
- kidneys filtrate fluid out of the blood
- filtration requires pressure gradient across blood vessel wall; low filtration occurs when the mean arterial pressure <60mmHg
- low BP
- bacterial toxins decrease kidney effectiveness and functions of all organs in the body
Why would a CT scan be done in addition to the chest a-ray that was already done?
- CT scans differentiate pleural fluid from consolidated lung tissue and demonstrate the severity of lung destruction
- Volume-limited ventilation is safer due to amount of airway secretions
- target SaO2 would be 90%
- target pH would be 7.35-7.40
- target peak airway pressure would be less than 40cmH20
- target Pplat would be less than 30cmH2O
- right lung has lots of consolidation, therefore Vt will likely be small. If patient can't be adequately ventilated with fast RR and acceptable pressures, then hypercapnia may be permitted to a pH of approx. 7.20
What is the significance of the high-normal lactic acid level?
- shock means the tissues are "starved" for blood
- tissues will use an aerobic pathway to generate energy
- end product of aerobic pathway is lactic acid
- high-normal value suggests that lactic acid level had been elevated and that volume replacement restored tissue perfusion and that the lactic acid is being cleared
Is she in shock? If so, is it cariogenic, hypovolemic, or septic shock?
- hypotension and confusion suggests she is in shock
- preexisting condition of cystic fibrosis makes infection likely
- onset of shaking chills also suggests infection
- based off history, this strongly suggests septic shock
What is the significance of fine crackles vs. course crackles?
Course crackles:
- excess secretions retained in the larger airways
- louder, lower in pitch
- last longer
Fine crackles:
- high pitched, soft and brief
- excess fluid in small bronchi causes them to stick shut on exhalation
- surface forces of the fluid hold the airways shut until the lungs stretch enough to overcome these surface forces and pop airways open
Interpret CT scan
(refer to handout)
- dense consolidation of the right lung
- air bronchograms
- severe bronchiectasis with destruction of much of the lung
Should PEEP be used, and if so how much?
- PEEP may be needed, but must be conscious of the severe consolidation of right lung because it may cause hyper expansion of left lung (barotrauma) and poor ventilation-perfusion matching
- PEEP levels should be used that are more appropriate for the more compliant left lung. Could start with a PEEP of 5cmH2O
What are the first priorities for treatment?
- ABC
- supplemental oxygen required
- fluid therapy (correct hypotension - vassopressors?)
- broad spectrum antibotics
What is the significance of the course crackles in a patient who denies cough and sputum?
- suggests the patient cannot generate a strong enough cough to expel retained secretions
- doesn't require immediate intubation and mechanical ventilation, but raises concern that they might eventually need to be intubated
Should a pulmonary artery catheter be placed at this time?
Measurements important for management of this patient include:
- CVP -> indicates adequate volume replacement when CVP is 4-12cmH2O
- ScvO2 -> indicates adequate tissue oxygenation when it is 70% or more
- Urine output -> indicates organ function
Therefore, cardiac output, cardiac index and systemic vascular resistance are not needed at this time.
What are the chances for this patient's survival?
- Diffuse intravascular clotting can destroy organ tissue, with kidneys and lungs being most susceptible to injury
- patient appears to have life-threatening infection but responded well to initial therapy with improved BP, urine output, and lactic acid clearance.
- patients with septic shock have a mortality rate of 40%-50%
- Ms. T has cystic fibrosis and pneumonia. Therefore, could cause respiratory failure and increased risk of mortality