67 year old male presents to the ER with
lethargy exertional dyspnea, fever and hypotension.
reportedly hypoxic. He’s placed on 3L nc. chest film
demonstrated multi focal opacities with superimposed edema. started on abx
and given a 30ml/kg fluid challenge. He is noted to have a creatinine of 6.2
which is new, a potassium of 6.5 and a bicarbonate of 11. First
lactate is 8.1. After EGDT in ED, lactate is 3 and map is 75. he is
admitted to SDU. At 3am rapid
is his called. he is more tachpneic. Placed on bipap empirically by
RT. No fever. He is awake and alert and answers questions but does
appear labored, pausing to speak partial sentences. His stat chest xry looks
more wet but with the same dense multifocal consolidation underneath. You
pull up old records and note his eF last month was 55%. He has no peripheral
edema. HR is about 125 now, MAP 69. Current bipap settings are 18/10 @100%. STAT Abg
7.21/38/51/14 with sat of 86%.
- What is
your plan of care?
Andrew Lee
ReplyDeleteStep one would be to stabilize this patient. With the current bipap settings, worsening acidosis and low oxygen saturation on 100% oxygen this patient would need to be intubated. Hypoxia is most likely driven by the patient’s fluid overload state with the underlying pneumonia. Map is still greater than 65 therefore pressor support is not currently indicated.
Due to the patient’s PaO2/FiO2 being less than 100 this would be severe ARDS with the pneumonia being the likely cause. Patient would need prone positioning and diuresis. If the patient is unable to provide sufficient urinary output due to kidney failure, emergent dialysis would be the next best option. I suspect that the AKI is due to poor perfusion with the patient’s lactic acidosis. Paralysis and prone positioning would be needed in addition to low tidal volumes and an increased respiratory rate on the vent for treatment of the patient’s severe ARDS.
In addition if it had not been done already I would provide measures to lower the patient’s potassium (kayexylate, insulin/d50, continuous albuterol, and calcium gluconate). I would also get an EKG and if the patient had peaked t waves this would also be an indication for dialysis. I would also want repeat labs to see if the patient’s bicarbonate corrected with the improvement of the patient’s lactic acidosis. If not I would also consider a bicarb drip.
https://resident360.nejm.org/pages/home?resource_collection_id=critical-care&subtopic=ards&subgroup=fast-facts-124
This patient appears to have several problems:
ReplyDeleteAcute kidney injury, hyperkalemia likely secondary to acute kidney injury, sepsis secondary to presumed pneumonia, ARDS, hypoxic respiratory failure, metabolic acidosis secondary to lactic acidosis.
It appears the patient is not appropriately responding to BIPAP, so the next step would be mechanical ventilation for ARDS. A PEEP >5 has shown a survival benefit in moderate to severe ARDS. The ARDS-net study demonstrated positive results for ARDS with a low TV (6 ml/kg of ideal body weight) and a max plateau pressure of 30 cm H2O. Prone positioning has also shown reduction in mortality.
Young, Lorna, and Finbar O'Sullivan. "Acute Respiratory Distress Syndrome." Anaesthesia and Intensive Care Medicine, vol. 17, no. 10, 2016, pp. 526-528.
It is unknown whether the patient has EKG changes with the hyperkalemia, but assuming that he does, emergent dialysis would be beneficial to both his hyperkalemia and acute kidney injury. Ultrafiltration would help the volume overload as well. Immediate treatment for his hyperkalemia would be calcium gluconate, insulin & beta blockers. For the pneumonia, broad spectrum empirical antibiotics should be initiated until cultures were available for more targeted therapy.
https://jamanetwork-com.ezproxy.liberty.edu/journals/jama/fullarticle/2673151
The patient has sepsis secondary to pneumonia with ARDS and a possible CHF exacerbation considering the x-ray is starting to look wet. In addition, the patient has AKI. Sepsis requires fluids which the patient received with the 1st 30ml/kg/hr bolus received. Now that the patient is having increased difficulty breathing and is acidotic, he should be intubated because he is still having problems on the bipap. It should also be made sure that the patient received blood cultures x2 and a sputum cultures with a gram stain. Antibiotics should have been broad spectrum to cover gram positive, negative and anaerobes, generally with vancomycin and zosyn. A urine legionella ag and serum strep antigen can also be ordered. Repeat an ABG an hour or 2 after intubation. Due to the history of CHF and the possible fluid overload, a repeat echo can be done, in addition to an EKG. The patient can be diuresed with 20mg of lasix daily to get some fluid off, but not too much due to the AKI. For the hyperkalemia, the patient should be started on kaeyxolate and calcium gluconate to protect his heart. A procalcitonin can be ordered. Repeat a chest xray the next day to see if there is any improvement with the diuresis and the antibiotics. Acute lung injury and ARDS can be a cause of the AKI, even though this generally occurs when ARDS occurs due to the ventillator, it is still likely that the AKI was not only caused by the sepsis component but also due to the lung issue itself.
ReplyDeletehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123396/?report=reader
https://www.renalandurologynews.com/acute-kidney-injury/acute-kidney-injury-linked-to-ards/article/355879/
This patient has acute hypoxic respiratory failure, severe sepsis secondary to likely pneumonia, hyperkalemia, metabolic acidosis, and AKI with unknown baseline creatinine. The patient is still struggling despite BiPap and should be intubated since he has acute onset of PaO2/FiO2 <300,and bilateral patchy infiltrates consistent with pulmonary edema meeting ARDS inclusion criteria. I would also start on Lasix and monitor urine output and consider dialysis if he does not respond. I would continue his antibiotics, and order blood and sputum cultures as well as repeat CXR for his pneumonia. In addition I would treat his hyperkalemia with calcium gluconate and order and EKG as well as a BMP. I would expect his metabolic acidosis to improve with Lasix and would want to monitor follow up ABGs post intubation. I would also like to confirm his baseline creatinine and order and urine sodium and creatinine to calculate a FENa to determine if his AKI is pre renal.
ReplyDeletehttp://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
https://www-uptodate-com.ezproxy.liberty.edu/contents/acute-respiratory-distress-syndrome-clinical-features-diagnosis-and-complications-in-adults?search=ARDS&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
https://www-uptodate-com.ezproxy.liberty.edu/contents/loop-diuretics-maximum-effective-dose-and-major-side-effects?search=lasix%20metabolic%20alkalosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
This 67 year old male has sepsis secondary to multifocal pneumonia with progression to ARDS, acute kidney injury with hyperkalemia, uncompensated metabolic acidosis with unknown gap, and has had has oxygen saturations at 86% despite high BiPAP settings
ReplyDeleteThe patient has ARDS due to PaO2/FiO2 < 300 and bilateral patchy opacities and needs to intubated. The patient needs to have a low tidal volume and PEEP > 5. Two alternative treatments would include Lasix to dry up the lungs and dialysis. Lasix could be used but the creatinine level is 6.5 with unknown baseline indicating acute kidney injury or acute kidney failure. If the patient is anuric, then a diuretic medication would be worthless in this situation. Dialysis is not indicated at this time but could be in the future. Dialysis indications include acidosis below 7.1 that is refractory, hyperkalemia > 6.5 that is refractory to treatment, ingestion of toxins like salicylates, volume overload resistance to diuretics, and uremia. Therefore, mechanical ventilation would be the best option. Regarding hyperkalemia, I would want to get an EKG to check of T wave changes. As I was getting the EKG I would like to get calcium gluconate to stabilize the heart muscle in case we have T wave changes. Longer term management would include, insulin + D50 and beta blockers.
Regarding the patients sepsis, it seems like he was given the appropriate fluids and started on antibiotics. I would get sputum and blood cultures along with strep and legionella urine antigens, and a viral panel.
http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123396/?report=reader
This patient has multiple things going on. His initial diagnosis appears to be sepsis secondary to multifocal pneumonia. He did appear initially fluid overloaded in the received additional fluid with 30 milligrams/kilogram and one can assume was also treated with broad spectrum antibiotics. Additionally patient appears to be in an acidosis due to both renal failure with some uremia, hyperkalemia and lactic acidosis. His hospital course appears to be complicated by worsening pulmonary edema which appears consistent with ARDS. This is especially true given the fact that his recent ejection fraction was noted to be normal and we cannot blame his pulmonary edema on congestive heart failure.
ReplyDeleteAt this point patient has failed conservative therapy with BiPAP. His PaO2 of her FiO2 ratio
Is clearly low given the fact that he is on 100 percent FiO2. At this point patient would be best served by intubation and sedation following the ARDS net protocol. In this case patient should have increased rate on his ventilator in order to create a respiratory alkalosis to compensate for his metabolic acidosis. Further treatment will be required for his hyperkalemia. Initial therapy should be with calcium gluconate to stabilize the cardiac muscle followed by Lasix, insulin and glucose, Kayexalate and nebulizer therapy. Close monitoring of patient's urine output should be followed. If his kidney function, acidosis and lactic acid continued to worsen he may be candidate for emergent dialysis.
ARDSnet protocol