Download - Hypotension and Respiratory Distress
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Mariposa Wolford
Morning ReportHypotension and fever in an 18 year female
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ICU nights
18 y/o female with BPs low after nearly 3L NS
Diagnosis of AML, s/p Induction II, CNS negative,
MRD negative
Recent course of chemo with Ara C finished on7/25. Currently neutropenic and has had low plts
Had high fevers with her chemo
PMHx includes allergic rhinitis and PCOS, on
OCPs. Diagnosed with AML
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Patient presentation T 39.9 HR 124 BP 95/31 RR 18 on 0.5LPM O2
with sats 97%
Wt 64kg
GEN: pt smiling, NAD, alopecia 2/2 chemo, AOx3
HEENT: NCAT, EOMI, PERRL, MMM, noexudates in throat
CV: Tachycardic with no m/r/g. Bounding pulsesin all 4 extremities. CRT 2s
CHEST: CTAB. With mildly increased WOB. Nowheezing, no crackles.
ABD: S/NT/ND. No HSM.
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Over the next few days
Increasing respiratory distress and oxygen needprompting HFNC after increased NC
Trial back on NC resulted in desats to mid 80s
CXR showing mild ill defined opacification inlower lungs
Patient with diarrhea, continued high fevers into
the 40s and increasing fatigue.
Mixed venous sats decreasing
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Differential diagnosis Pulmonary hemorrhage Bacterial sepsis
Fat embolism syndrome
Acute respiratory distress
Transfusion associated lung injury (TRALI)
Acute eosinophilic pneumonia Acute hypersensitivity pneumonitis
Leukemic infiltration
Pneumocystic jiroveci pneumonia
Bacterial or viral pneumonia
Multi organ failure associated with sepsis Respiratory failure
Toxic shock syndrome
Tumor lysis syndrome
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Other info on our pt Blood culture from 8/2 positive for viridans Strep
On Vancomycin and Ceftazidime, then Cefepime
Mixed venous saturations about 70->59->74->69
Switched to Bipap 12/8, then 14/10 before intubation on8/6 am since she had coughing spells despite increasedBipap settings
Wt was up from about 64kg to about 68.9 after fluids andblood pdts. Went on lasix drip, needed bld pts, wasfebrile/shivering so we paralyzed and sedated her
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Course
Had blood from ETT
LS had left lung collapse on 8/8
Bronchoscopy showed excessive secretions
Given pulmozyme On VDR ventilator for 3 days, then got
subcutaneous air in limbs
Switched back to conventional ventilator
Was intubated for 12 total days!
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ARDS Acute resp failure & refractory hypoxemia 2/2
significant lung injury
CXR w bilateral opacities. Lungs are non-compliant
Severity of hypoxemia determines severity of ARDS
using arterial oxygen tension to fraction of inspired
oxygen PaO2/FiO2
>200 but < or = to 300, MILD
>100 but < or = to 200, MODERATE
< or = to 100, SEVERE
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ARDS continued
Lung damage increased alveolar-capillarypermeability influx of interstitial & intra-alveolar
fluid.
Surfactant is diluted and its production decreased
Point on pressure-volume PV loop w/ lower
inflection point
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Pathophysiology of ARDS
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ARDS Histology shows diffuse alveolar damage.
InfectionSepsis
Diffuse pulmonary
infections*
Gastric aspiration*
Chemical InjuryHeroin or methadone OD
Acetylsalicyclic acid
Barbituate OD
Paraquat
CardiopulmonaryBypass
Hypersensitivity
ReactionsOrganic SolventsDrugs
Physical/InjuryMechanical trauma/ inc
head injuries
Pulmonary contusions
Near-drowning
Fractures with fat
embolism
Burns
Ionizing radiation
Hematologic ConditionsMultiple transfusions
DIC
Pancreatitis
Uremia
Inhaled IrritantsOxygen toxicity
Smoke
Irritant gases and
chemicals
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Oxygen delivery: how much oxygen
delivered to tissues in a minute
DO2 = CO x CaO2
CaO2 = arterial oxygen content
= amount of O2 bound to Hgb plus amount of O2dissolved in arterial blood
=(Hb x SaO2 x 1.34ml O2/g Hgb) + 0.003ml x PaO2
SaO2 is the arterial oxyhemoglobin concentrationand PaO2 is the arterial oxygen tension.
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Outcomes Mortality for ARDS 26-58% by one estimate.
Common causes in Peds: drowning, sepsis & shock
Cause of death is usually the underlying cause andnot respiratory failure
Some prognostic factors include: Younger patients do better
Milder cases of ARDS do better Large positive fluid balance do worse Recently transfused pts (pRBCs) did worse
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ARDS outcomes long term
Survivors frequently have long term decrease inexercise tolerance/endurance
80% of pts in one study had reduced diffusing
capacity, regardess of H or LTV trtmt
A better functional outcome at one year correlates
with the absence of steroid treatment, absence of
illness acquired during the ICU stay, and rapid
resolution of multiple organ failure and lung injury
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References Pediatric ICU Blueprint, Schwartz, MD. 2007.
Pulmonary function and health-related quality of life in survivors of acute
respiratory distress syndrome.Orme J Jr, Romney JS, Hopkins RO,
Pope D, Chan KJ, Thomsen G, Crapo RO, Weaver LK. Am J Respir Crit
Care Med. 2003;167(5):690.
Robbins Pathologic Basis of Disease, 7th Ed.
UpToDate: Acute respiratory distress syndrome: Clinical features and
diagnosis. Last updated Oct 5, 2012.
UpToDate:Acute respiratory distress syndrome: Prognosis and
outcomes. Last updated July 3, 2012