Patrick Laird, DNP(C), MSN, RN, ACNP-BC, CCRN;Susan D. Ruppert, PhD, RN, ANP-BC, NP-C, FCCM, FAANP,

2011. Published on Wolters Kluwer Health

Case Study

Pathophysiology of the disease

ECMO Summary

First patient encounter Day 2-4

V/S P/E Lab result CXR Plan

Outline:

55 y/o male recently diagnosed with influenza A. Presented to the emergency department (ED)

accompanied by his wife with worsening shortness of breath, fever, productive cough ( green ) sputum,

and new onset altered mental status.

Primary assessment revealed oxygen saturation of 61% on room air. Respirations were labored with abdominal accessory muscle use.

BIPAP was used but his respiratory status continued to deteriorate ------- ( intubation ) .

Difficult intubation.

After intubation the patient became hypotensive. A Levophed drip was initiated.

Once hemodynamically stable the patient was admitted to the intensive care unit (ICU) for continued management.

Continue

CHIEF COMPLAINT :“Shortness of breath and confusion” PAST MEDICAL AND SURGICAL HISTORY :

• Hypertension — Diagnosed in 2009.• Hyperlipidemia — Diagnosed in 2009.• No history of surgical procedures.• Denied any history of smoking and drinks approximately 2 alcoholic beverages per week.

SOCIAL AND FAMILY HISTORY :Married for 28 years , Employed with Anadarko

petroleum division. His parents both diagnosed with hypertension treated with medication.

CURRENT HOSPITAL MEDICATIONS : Levophed infusion at 0.4 μg/kg/min

intravenous (IV). Propofol infusion at 55 μg/kg/min IV. Protonix 40 mg IV daily. Lovenox 40 mg subcutaneous daily. Azithromycin 500 mg IV daily.

REVIEW OF SYSTEMS :Patient orally intubated at the time of interview and

examination. Chest :Complains of increased dyspnea and cough with

increased green sputum production 2 days prior to admission.

Heart: Complains of weakness for 10 days prior to

arrival. Urinary system:decrease in normal urinary output because of

decreased oral intake.

Neurological :His wife reports change in his mental status over last 2 days. States patient is “not making any sense and is saying inappropriate things.

Day 2

Vt: 700mL = 8mL/Kg PEEP 10 cm H2ORR 18 bpm

FiO2 100%

Vent management:IBW = 90 Kg

A/C VCTube size 8 Fr, at point of 22 near lip line.

VS:

Temp.: 37.2oC. HR: 93b/min. RR: 16 b/min. BP: 89\50 mmHg. O2 Sat.: 86%

Day 2

Overall status: General: well nourished. Skin: No skin rashes/lesions

observed. HEENT. Chest: Symmetrical expansion. Heart: (S1, S2) are noted. Regular

rhythm. No murmurs, gallops, or rubs are appreciated.

Abdomen: Soft, nontender and nondistended.

Day 2

Cont. Extremities: Warm. No edema, clubbing, or

cyanosis was appreciated. Capillary refill: +2 seconds. Nail beds are

pale. Neurological: Sedated on mechanical

ventilation.

Spontaneous movement of all 4 extremities is noted. Does not follow verbal commands.

Day 2

CXR:

Endotracheal tube tip located 2 cm above the carina.

Interval worsening perihilar air space opacity suggestive of worsening pulmonary edema or ARDS.

No pneumothorax or pleural effusion.

Day 2

ABG:

parameters ValuespH: 7.42

PCO2: 41 mmHg.PO2: 34 mmHg.

HCO3: 26 mmol/L

Normal acid base balance with sever hypoxemia.

Day 2

CBC

WBC 10.2 kg/mm3 4.0-10 kg/mm3Hb 15.1 gm/dL 13.0-16.8 gm/dL

Platelets

325 kg/mm3 150-430 kg/mm3

Na 143 mEq/L 135-148 mEq/LK 3.9 mEq/L 3.5-5.5 mEq/LCl 97 mEq/L 98-106 mEq/L

BUN 42 mg/dL 10-26 mg/dLCret. 2.2Mg/dL 0.5-1.2 mg/dLBNP 18 0-100 pg/mL

Day 2

DIAGNOSTIC IMPRESSIONS

Differential Diagnoses:ALI, ARDS,

pneumonia, cardiogenic

pulmonary edema, PE.

Working diagnosis Acute

respiratory distress syndrome (ARDS).

Additional Diagnoses: CAP,

severe sepsis, recent influenza A (H1N1), and acute

renal failure.

Day 2

ARDS

Berlin definition:ARDS is an acute, diffuse, inflammatory lung injury , defined by:

Severity is defined by degree of oxygenation impairment.

RISK FACTORS: Direct “pulmonary etiologies” Indirect “extrapulmonary etiologies”?

Pneumonia. Aspiration. Inhalational injury. Pulmonary contusion. Fat emboli.

Sepsis. massive blood transfusion. Burns. Acute pancreatitis. Severe trauma.

Pneumonia35%

Sever Sepsis26%

Aspiration15%

Trauma11%

Other13%

Causes of ARDS

June 20, 2012,

Pathophysiology:

↓ surfactant

Accumulation of fluid

Atelectasis

Pulmonary edema

❶

❷

Pathophysiology Consequences of lung injury include:

Impaired gas exchange V/Q mismatch Increased dead space

Decreased compliance

PLAN The main goal is to optimize oxygenation and prevent

further inflammation that may lead to multi-organ failure and that may done by :

Low tidal volume Low PEEP/high Fio2

Initial ventilator settingsmade by ED physician were not compliantwith current therapy recommendations.

Ventilator settings were adjusted in the ICU immediately following initial evaluation.

Day 2

Ventilator management

A/C VC IBW = 90 KgVT= 8mL/Kg = 700mL PEEP= 10 cm H2ORR = 18 bpmFio2 = 100%

VT= 6mL/kg = 540mLPEEP= 14 cm H2O

Day 2

Community Acquired Pneumonia ..

For the treatment of CAP for patients in the ICU include a B-lactam, and either azithromycin or a respiratory fluroquinolone.

Patients with a penicillin allergy should receive a respiratory fluroquinolone and aztreonam.

Neuromuscular blocking agents

(NMBA) Are used : In the ICU to facilitate and optimize mechanical ventilation. To improve chest wall compliance, eliminate dysynchrony, and reduce

peak airway pressures. Muscle paralysis used :

In decreasing the work of breathing and respiratory muscle blood flow thereby reducing oxygen consumption

Cont.

The patient displayed mild ventilator dysynchrony and refractory hypoxemia.

Paralytics were initiated to gain full control of ventilation and eliminate ventilator asynchrony.

Once paralytics were initiated, the patient’s ventilator asynchrony resolved.

Day 4

Subjective data ..

• Remains critically ill.• Orally intubated on mechanical ventilation.• Oxygen saturations remain less than 86%.

Day 4

Objective data ..oVital Signs:• T = 38.4 C• Pulse = 102 B/min• RR = 20 B/min• BP = 101/52• O2 sat =84 %

Day 4

Physical examination .. No murmurs, gallops, or rubs. CV

Bilateral breath sounds with course crackles; diminished in bilateral bases; no wheezes noted. RESP

Warm, 2+ pitting edema to bilateral lower extremities, no cyanosis or clubbing noted.

EXT

Paralyzed on Nimbex drip at 3 μg/kg/min , Sedated onpropofol infusion at 50 μg/kg/min. NEURO

Day 4

• Norepinephrine at 0.5 μg/kg/min IV• Nimbex at 3 μg/kg/min IV• Propofol at 50 μg/kg/min IV• Clindamycin 600 mg IV every 8 hours• Rocephin 2 grams IV every 24 hours• Albuterol/Atrovent unit dose nebulized every 4 hours .

Day 4

Current medications ..

Chest X-ray films ..• Bilateral infiltrates and pulmonary edema • Endotracheal tube in adequate position above the

carina.

Day 4

LABORATORY DATA ..Day

4

ASSESSMENT ..• ARDS• Metabolic acidosis• Septic shock• Community acquired pneumonia• Acute renal failure• Recent influenza A (H1N1)

Day 4

PLAN ..

Despite optimal medical therapy, the patient failed conventional

treatment, and without further intervention death was eminent.

Day 4

Controversial ( adults ) Common indications for use of ECMO in adults include

postcardiotomy, postcardiac transplant, severe refractory heart failure, ARDS, pneumonia, trauma, or primary graft failure following lung transplant.

Consult cardiovascular surgeon forplacement of extracorporeal membraneoxygenation (ECMO):

Use of ECMO results in 1 extra survivor for every 6 patient treated .

A total of 201 adult patients received mechanical ventilation for confirmed or suspected influenza. 68 of these patients received ECMO and the remaining 133 received conventional mechanical ventilation.

48 patients (71%) that received ECMO survived to ICU discharge and 32 patients survived to hospital discharge. Overall mortality of the ECMO group was 21%. The researchers contributed the lower mortality to the age of the study participants and the cause of ARDS (H1N1).

Use of ECMO has a multitude of potential complications including life-threatening bleeding, coagulopathy, air embolism, thromboembolism, intracerebral hemorrhage (in neonates), and limb ischemia.

risks must carefully be weighed against benefit prior to initiation

Despite optimal medical therapy, the patient failed conventional treatment, and with- out further intervention death was eminent. After consulting cardiovascular surgery, available therapy options were discussed with the patient’s spouse and the decision was made to place the patient on ECMO as salvage therapy.

In this scenario

Continuity Of Care

VT = 4-6 ml/kg RR= 5-10 bpm PEEP= 12-15 cm H2O Inspiratory time longer FiO2= 0.21

Recommended Ventilator Settings

day 4 : taken to OR , ECMO wasinitiated.

ECMO for 6 days

day 10 ,returned to the OR for removal ofECMO and insertion of a percutaneous tracheostomy , and percutaneous endoscopic gastrostomy (PEG) tube placement

continued to make marked improvements following removal of ECMO .Day 18 :was weaned from the

ventilator. Physical therapy, occupational therapy, and speech therapy were consulted. Day 21, the patient was discharged from the ICU.

day 25 transferred to a long-term acute care (LTAC) facility for continued physical and occupational therapy

On day 25 transferred to a long-term acute care facility for continued physical and occupational therapy( 2 weeks ).

The patient was discharged to his home with no physical or cognitive deficits noted.

Since his discharge from LTAC, the patient has returned to work and has no limitations .

Summary

55 y/o male recently diagnosed with influenza A. Presented to the emergency department (ED)

accompanied by his wife with worsening shortness of breath, fever, productive cough

( green ) sputum, and new onset altered mental status.

This case study explores the management of an unusually complicated case of (ARDS) extending

over 52 days of hospitalization. Despite the utilization of conventional medical treatments

and optimum respiratory support modalities, the patient’s condition worsened and death was

imminent without salvage therapy. After cardiovascular surgery consultation, (ECMO) therapy was initiated for 6 days. The patient recovered and was able to return to regular

employment.

Conclusion Acute respiratory distress syndrome (ARDS) is a life-

threatening medical condition where the lungs can't provide enough oxygen for the rest of the body.

ARDS can affect people of any age and usually develops as a complication of a serious existing health condition.

(ARDS) has a mortality rate of 34% to 58% .