AC16/8/450/50%
What is your next step in the management of this patient's respiratory failure?
Tuesday, July 31, 2018
68 year old with a history of DM, CHF, ESRD, and asthma was admitted for respiratory failure and hypotension. Her family reported a one to two week history of productive cough, shortness of breath, fever, and dizziness. She was treated with IV antibiotics and required three pressors for septic shock. After 4 days she became afebrile with improvement in her white blood cell count and her vasopressors were weaned off. The patient's CXR and ABG are listed below.
AC16/8/450/50%
What is your next step in the management of this patient's respiratory failure?
AC16/8/450/50%
What is your next step in the management of this patient's respiratory failure?
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Provide supplemental oxygen if patient is hypoxemia (SPO2<90%), continue the patient's antibiotics (as these should have already been deescalated for sensitivities of the likely pneumonia that the patient had). Patient is also likely having an exacerbation of her CHF and can be started on lasix 40mg po daily or either IV lasix 20mg daily since she just finished receiving pressors and IVF due to her septic shock. Patient should also receive dialysis for fluid overload due to her history of ESRD. Repeat CXR and ABG the next morning.
ReplyDeleteResource-UpToDate-Treatment of acute decompensated heart failure: Components of therapy-Wilson S. Colucci, MD
DeleteThe most important step would be to check an ABG to see what adjustments need to be made on the ventilator. If the patient's pO2 is low, I would either increase the FiO2 or the PEEP. The FiO2 would need to be titrated to maintain an SpO2 of 90-94%. The same principal would apply for adjusting the PEEP. The patient is likely fluid overloaded from sepsis fluids. Depending on whether or not the patient makes urine, lasix may be appropriate. If the patient is on dialysis, ultrafiltration would be appropriate as well.
ReplyDelete-Carissa Wilkins
https://res.mdpi.com/def50200686a7b2502bbf05de83b603b11249badfad6e2aa3fa22c99f35969ab259ed21305bff033f76c9c47b26878c4e7a78fcc4a943ff5a18eb420c3c8f6c925767023467e444cf0e18720389d6501544745316a02fbc9a232d87e8606391481a5423b32771a5de310f0e72bbf8cf53408bac08159fa5a0fabbaa0114fc239727845a87a5288?filename=&attachment=1
DeleteAccording to the CXR, this patient has a patent airway and trachea is midline. Ribs and clavicle have no fractures. Heart has clear borders and there is no cardiomegaly. Mediastinum is not widened. Diaphragms cannot be assessed and neither can the costophrenic angles because they aren't visualized. There is no pneumothorax and no consolidations. There is pulmonary congestion throughout both lungs fields.
ReplyDeleteBecause this patient has ESRD, a diuretic would not be a good option to get the fluid out of the patients lungs. Dialysis or ultrafiltration would be the best method of draining the fluid.
I was not able to assess the ABG because I don't see one. I would expect to see a respiratory acidosis due to history of asthma and possible pneumonia. Nevertheless, I would use serial ABG's to manage her ventilator settings in order to address the patient's respiratory failure and wean them off the vent. I would transition the patient's ventilator settings to SIMV to help wean them off the vent.
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ReplyDeleteGiven the patient's PMH of CHF, she is likely fluid overloaded secondary to the IVF that she received for septic shock (which was likely secondary to pneumonia). The CXR shows evidence of pulmonary vascular congestion in both lungs. If the patient is able to produce urine, Lasix may be able to be used; if not, ultrafiltration or dialysis would be appropriate.
ReplyDeleteRegarding the ventilation settings, an ABG should be drawn to adjust the settings appropriately. For example, if the patient's oxygen level is low, the FiO2 or the PEEP could be increased and titrated to maintain the patient's O2 sat. > 92%. The plateau pressure should also be kept < 30 cmH2O. A repeat CXR and ABG should be drawn the next morning.
--Kate Cappetta
This is a patient that was treated with several days of IV fluids for sepsis. Per the surviving sepsis guidelines even patients with CHF and ESRD should at the very least recieve the 30 mg/kg of IVF. In the setting of congestive heart failure and ESRD this is likely contributing to her ongoing hypoxia. The x-ray appears to show bilateral atelectasis and fluid overload. This does not appear to be ARDS like in nature but I would obtain and ABG in order to check PaO2/FIO2 ratio. Patient should receive her maintenance hemodialysis which will hopefully help improve her respiratory state. Diuretics are unlikely to help. The eventual goal would be to wean this patient off the ventilator. Unfortunately the patient continues to require a peep > 5 and FiO2 > 40. Obtain an ABG and adjust settings as tolerated. Perform a daily SBT on this patient for at least 30 minutes but she will likely fail given her ongoing high oxygenation requirements. This may be a good candidate to wean off to BiPAP especially given her history of asthma. (NEJM 360, strategies to reduce the duration of mechanical ventilation)
ReplyDeleteAndrew Lee
ReplyDeleteWith resolution of the patient’s sepsis the next best step would be to wean the patient off of the ventilator. She should have a sedation vacation and a spontaneous breathing trail. The patient’s FiO2 also needs to be weaned down to less than 40 and her PEEP needs to be weaned down to 5. If she passes her SBT (i.e. no tachypnea, decrease in O2 saturation or agitation) then RESBI and NIF can be assessed along with a blood gas to insure that the patient is maintaining their gasses and pH appropriately. If the patient is able to follow commands, cough and manage secretions then the patient may be extubated. If not then the patient would need to maintain ventilation and an attempt would be made the next day.
https://resident360.nejm.org/pages/home?resource_collection_id=critical-care&subtopic=ventilation
This patient presented with septic shock requiring vasopressor support. As the shock has now resolved and the condition requiring mechanical ventilation has improved, we must prepare the patient to be extubated. The patient appears to be fluid overloaded on CXR with pulmonary vascular congestion. As the patient has ESRD, it would be advisable to help improve chances for successful ventilator liberation by ultra filtrating the excess fluid off with hemodialysis. This will help the patient take the deep breaths that help improve successful liberation. Next, we must continue to wean vent settings per ABG. Likely on the day after HD, I would place the patient on a sedation holiday and obtain parameters with spontaneous breathing trial. If the patient has good parameters, then I would extubate. If not, then I would try the patient on SIMV to help decrease dependence on the ventilator with daily SBTs.
ReplyDelete