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SB: 40 Year Old Female in Respiratory Failure
Published July 16, 2001

William French and Christopher Joyce
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm

Contents (click to jump directly to that section, or scroll down to read the case)


INTRODUCTION

SB, a 40-year-old female, was admitted to the intensive care unit for shortness of breath, respiratory failure, and sepsis. Past medical history medical history was significant only for a splenectomy experienced in 1974 following a MVA. Recent history included cold and flu-like symptoms for the past five days. Upon admission, she had inspiratory crackles in the mid- and lower-lung fields, dry, non-productive cough, and a temperature of 38.5 C.


CASE PRESENTATION

Examination revealed a female who is alert and oriented, but extremely short of breath, with accessory muscle use. SpO2 on a nasal cannula at 4 Lpm was 95%. Arterial blood gases taken an hour after admission were as follows:

pH 7.31 PaO2 98
PaCO2 24 SaO2 97%
HCO3 12 base excess -15

 

The oxygen was increased to 6 Lpm, and the patient was monitored over the next ninety minutes with no improvement in shortness of breath. A second set of ABGs was obtained:

pH 7.26 PaO2 119
PaCO2 18 SaO2 98%
HCO3 9 base excess -15

On the basis of the blood gas results and the patient's clinical appearance, it was decided to intubate her and place her mechanical ventilation via a Puritan-Bennett 7200 ventilator. The settings were:

Mode CMV Rate 30
Tidal Volume 450 mL Flow 100 Lpm
FiO2 50% PEEP +5 cmH2O

The patient was assisting the ventilator at 38 breaths per minute. Approximately one hour later, another arterial blood gas sample was obtained:

pH 7.26 PaO2 153
PaCO2 21 SaO2 97%
HCO3 9 base excess -15

In response to these data, the FiO2 was decreased to 35% and the patient was started on sodium bicarbonate via IV.

Physical examination revealed coarse crackles throughout both lung fields and sinus tachycardia. Chest radiograph showed atelectasis of the left lower lobe with mild edema. Analysis of ventilator pressures indicated an increased airway resistance. Subsequent laboratory data revealed extreme leukocytosis (WBC count 44,900), mild anemia (Hgb 9.8), renal failure, and an increased anion gap. SB was started on four different antibiotics, Lasix, and moderate sedation.

She was maintained on ventilatory support for nine days until renal and liver function improved, sedation was decreased, and she successfully weaned. ABGs taken post-extubation were:

pH 7.44 PaO2 87
PaCO2 34 SaO2 98%
HCO3 23 base excess -2
FIO2 via NC 2 Lpm    

 


DISCUSSION:

Do you think the staff recognized and managed the case appropriately? Post your thoughts or ask other questions related to this case.

 


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