Major Case Study

Melissa Perry April 23, 2014

Patient Overview

S.M. is a 51 year old female 56 (1.676m) and weighs 267 lbs (121 kg) Admitted to the MICU on Monday, Jan. 27, 2014 Study began Wednesday, Jan. 29, 2014 and ended a week later on Wednesday, Feb. 5, 2014. Admitting diagnosis: Acute Respiratory Failure secondary to drug intoxication

Social History

S.M. was sedated and intubated since admission, which prevented interviews She was home alone at the time of her accident Based on S.M.s last admission notes in the hospital from June 2013, she lived with her husband in a house with a ramped entrance
- S.M. had a left BKA in Nov. 2012 -Mobilized in a wheelchair or walker -Unemployed and received disability benefits -Recovering alcoholic; quit 2 years ago -current smoker; 20 year history -History of marijuana and cocaine use

Past Medical History

Anxiety, depression, borderline personality disorder Alcohol dependence Noncompliance with medication regimens Hepatitis B, Hepatitis C MRSA (methicillin resistant Staphylococcus aureus) Neuropathy, cellulitis Hypertension COPD, acute respiratory failure Debridement on left ankle Left BKA (below the knee amputation)

Past Admissions

June 2013: slip and hit her head while trying to use her walker -Sepsis and Leukocytosis May 2013: dyspnea, pneumonia, and COPD exacerbation January 2013: fall with dizziness and lightheadedness -likely related to EtOH abuse and BKA

November 2012: progressive pain and swelling in left ankle -S.M. underwent surgery for her left BKA due to osteomyelitis in her left ankle

Acute Respiratory Failure secondary to drug intoxication

Excessive amounts of certain drugs can leave the kidneys unable to properly filter fluids from the body -Common side effect: pulmonary edema - the build up of fluid in the lungs and it can severely hinder the bodys respiratory system and can lead to respiratory failure -Kidneys filter waste materials out of the bloodstream, so when toxic substances reach dangerous levels, the kidneys fail to function

When the kidneys are not filtering enough acid out of the system, the high levels of acid interfere with the body's vital systems leads to metabolic acidosis -may cause cardiac and neurological complications

Acute Respiratory Failure

Ineffective

gas exchange by the respiratory system across the lungs Involves sudden absence of respirations, with unresponsiveness or confusion and a failed mechanism of pulmonary gas exchange
-Pulmonary system: lungs and muscles that aid in breathing to pump air in and out of lungs -Causes: chronic bronchitis, asthma, emphysema, stroke, chest wound, obesity, and in S.M.s situation, drug intoxication.

Acute Respiratory Failure

ARF is a common complication of drug abuse -Drugs may precipitate respiratory failure by either causing pulmonary pathology or by compromising respiratory pump function Excessive amounts of Seroquel have also been found to have several effects on the body, including tachycardia, somnolence, and hyperglycemia Respiratory center is located at the base of the brain -This regulates breathing and determines how often and how deeply we breathe -When pulmonary system is unable to perform its functions respiratory failure occurs

Acute Respiratory Failure

In ARF, the patient requires oxygen provided through a nasal cannula or mechanical ventilation

Oxygen levels must be normalized as soon as possible Ventilatory support is essential especially for patients with high CO2 levels Ventilators provide pressure gas that increases when triggered by the patients inspiratory effort

Treatment of Acute Respiratory Failure

Depends on the underlying cause and includes improving the individuals ventilation and increasing their oxygen Antibiotics, bronchodilators, corticosteroids, oxygen therapy, mechanical ventilation, and nutrition therapy -Enteral feedings started within 3 days of the onset of ARF may improve critically ill patients outcome or reduce length of time on a ventilator -Major interventions: relieve breathlessness, decrease CO2 production, and elevate pts head in order to prevent aspiration S.M. was placed on EN the day after she was admitted to the hospital, sedated, and intubated with mechanical ventilator support

S.M.s Symptoms

S.M. was at home when she started experiencing shortness of breath, which was found to be caused by an overdose of an antipsychotic drug Complained of chest discomfort and emesis, which led to aspiration pneumonia Blood pressure was noted to be 200/100s She presented to the hospital with respiratory distress and altered level of consciousness -led to intubation and sedation

Laboratory Findings
Lab Values upon admission: 1/27/14 Result
Sodium Potassium Chloride CO2 Glucose BUN Creatinine Calcium eGFR African American WBC RBC HGB HCT MCV Ammonia Lactic Acid ALT

Value
137 4.1 104 24 134 (*) 9 0.97 8.4 (*) >60 8.1 3.75 (*) 11.3 (*) 33.8 (*) 90.0 41 (*) 3.5 (*) 109 (*)

Normal Range
136-145 mmol/L 3.5-5.1 mmol/L 98-107 mmol/L 21-32 mmol/L 74-106 mg/dL 7-18 mg/dL 0.60-1.30 mg/dL 8.5-10.1 mg/dL >60 ml/min/1.73m2 4-10.5 10*3/uL 3.86-5.17 10*6/uL 12.1-15.8 g/dL 35.8-46.5 % 85-99 fl 11-32 umoL/L 0.4-2.0 mmol/L 12-78 U/L

AST

371 (*)

15-37 U/L

1/27
Result
Sodium Potassium Chloride CO2 Glucose

2/4
Value
137 4.1 97 (*) 32 115 (*)

Value
137 4.1 104 24 134 (*)

Normal Range
136-145 mmol/L 3.5-5.1 mmol/L 98-107 mmol/L 21-32 mmol/L 74-106 mg/dL

BUN
Creatinine Calcium eGFR African American WBC RBC HGB HCT MCV Ammonia Lactic Acid ALT AST

9
0.97 8.4 (*) >60 8.1 3.75 (*) 11.3 (*) 33.8 (*) 90.0 41 (*) 3.5 (*) 109 (*) 371 (*)

25 (*)
0.76 8.3 (*) >60 13.8 (*) 3.09 (*) 9.1 (*) 27.3 (*) 88.5 -9 (*) 66 104 (*)

7-18 mg/dL
0.60-1.30 mg/dL 8.5-10.1 mg/dL >60 ml/min/1.73m2 4-10.5 10*3/uL 3.86-5.17 10*6/uL 12.1-15.8 g/dL 35.8-46.5 % 85-99 fl 11-32 umoL/L 0.4-2.0 mmol/L 12-78 U/L 15-37 U/L

Medications Upon Admission 1/27

nalOXone 0.4 mg Etomidate 20 mg Rocuronium 100 mg Activated charcoal-sorbitol 50 g Propofol 20 mg Piperacillin-tazobactam in NS 4.5 g Ciprofloxacin in D5W 400 mg Vancomycin in dextrose 1000 mg Propofol 14.136 mcg/kg/min ONCE ONCE ONCE ONCE ONCE ONCE ONCE ONCE Infusion

Medications Upon Admission to the Intensive Care Unit

Potassium Chloride 20 mEq Pantoprazole 40 mg Chlorhexidine 15 mL Insulin lispro 2-10 units Vancomycin 1000 mg ClonazePAM 1 mg Piperacillin-tazobactam 3.375 g Levofloxacin 750 mg Two times daily Daily at 0600 Two times daily Every 4 hours Every 12 hours Two times daily Every 8 hours Every 24 hours

Thiamine (B-1) 100 mg

Heparin (Porcine) 5000 units Albuterol 2.5 mg

Daily
Every 8 hours Nebulization: every 6 hours

Ipratropium 0.5 mg
Propofol between 14.136 to 40 mcg/kg/min

Nebulization: every 6 hours

Infusion

Observable Physical and Psychological Changes

Due to S.M. being intubated and sedated the entire time she was hospitalized, she could only be observed since she was inappropriate to be interviewed Unable to ask family members/friends about S.M.s history and present situation

1/29: S.M. became agitated and frequently attempted to pull at

her Endotracheal tube (oxygen therapy) -Bilateral soft wrist restraints and increased Propofol rate

1/30: Tachypneic (rapid breathing) and tachycardic (increased

heart rate)

2/2: Stage 2 coccyx pressure ulcer

Diagnostic Tests

CVS (Cardiovascular) Examination -Examination of the heart, but it also includes examination of other parts of the body, such as neck, face, and hands -Purpose: cardiovascular pathology that could be causing the patients symptoms that include chest pain and breathlessness Chest X-Ray revealed abilateral basilar opacities suggestive of atelectasis (collapse of part or all of the lung) versus infiltrate (anything found in the lung) per radiology -Revealed a concern for aspiration pneumonitis secondary to emesis with intubation

Diagnostic Tests

Echocardiogram -contrast injection of Definity was performed to improve assessment of LV (left ventricle) function -LV systolic function and wall motion was normal -sinus tachycardia rhythm (elevated heart rhythm) Conclusion: S.M. did in fact accidentally overdose on Seroquel, which led to her acute respiratory failure -Acute respiratory failure, along with all of S.M.s other past medical history problems, ultimately led to her bodys failure to properly function

Urea Nitrogen Urine Test

Determines nitrogen lost in the urine by a 24 hour urinary urea nitrogen test -measures a persons protein balance and the amount of food protein that is needed -if the nitrogen balance is negative, protein intake needs to be increased S.M.s 24 hour UUN test from 2/3-2/4 revealed -4.4 N-balance 4.4 x 6.25 = 27.5 additional grams protein needed daily

As of 2/4, S.M. was only receiving 65 grams protein from Nutren Pulmonary at 40 mL/hr 65 gms + 27.5 gms = 92.5 gms protein needed daily

Medical Nutrition Therapy

Since S.M. remained intubated and sedated and there were no family members present to interview, information about her nutrition history came from past admissions to the hospital.

Past admissions reveal S.M. to be on a Regular diet -Heart Healthy diet during last admission (June 2013) -During this admission, an RD was consulted because she had a Stage 2 pressure ulcer and needed to have her calorie and protein needs evaluated -S.M. requested a diet change from Heart Healthy to Regular -S.M. consumed 75-100% of all meals

Medical Nutrition Therapy: 1/29

S.M. was placed on tube feeding by her Physicians orders January 28, 2014 (the day after she was admitted to the hospital) -inappropriate for oral feedings placed on enteral nutrition support NutriHep @ 30 mL per hour = 1080 calories, 29 grams protein, & 547 cc free H2O -NutriHep: enteral nutrition formula used for hepatic patients; rich in branchedchain amino acids, calorically dense, and provides a high calorie-to-nitrogen ratio -likely chosen due to S.M.s drug intoxicated liver and elevated AST and ALT lab values -Excessive amounts of Seroquel can damage liver cells and cause the injured cells to leak higher than normal amounts of these liver enzymes
Lab ALT AST 1/27 109* 371* 1/28 99* 273* 1/29 83* Normal range 12-78 U/L

170* 15-37 U/L

Enteral Nutrition Support

1/29: S.M.s Physician canceled NutriHep and ordered

Fibersource HN to run at 40 mL per hour = 1152 calories, 52 grams protein, and 778 cc free water

Fibersource HN: high protein, fiber containing tube feeding formula -Overall reason why S.M.s Physician changed the EN to Fibersource HN is unclear, but it is possibly because her ALT and AST lab values were slowly improving and Fibersource HN is higher in protein, which is important for the healing process

Medical Nutrition Therapy

1/30: S.M.s tube feed was advanced to Fibersource HN at 50 mL per hour = 1449 calories, 65 grams protein, and 972 cc water 2/2: Physician changed TF formula to Nutren Pulmonary at 40 mL per hour =1440 calories, 65 grams protein, and 749 cc free water -Nutren Pulmonary: enteral nutrition formula for patients with respiratory issues -modified carbohydrate and balanced fat profile for better tolerance -designed with a carbohydrate level to help reduce production of CO2 and respiratory quotient
Lab CO2 (Normal range 21-32 mmol/L) 1/27/14 21 1/30/14 31 2/2/14 34*

Medical Nutrition Therapy

On February 1, 2014, it was discovered that S.M. had a Stage 2 coccyx pressure ulcer -When S.M. was reassessed on February 3, 2014, her protein and calorie needs increased
The Urea Nitrogen Urine test was also taken into account, revealing an increase in protein needs

S.M.s tube feeding of Nutren Pulmonary remained at 40 mL per hour until February 4, 2014 = 1440 calories, 65 grams protein, and 749 cc free water UUN test revealed low protein in S.M.s urine and stage 2 coccyx pressure ulcer increased her protein and energy needs Afternoon of 2/4, Physician advanced S.M.s tube feed of Nutren Pulmonary to 65 mL per hour = 2340 calories, 106 grams protein, and 1217 cc free water daily The tube feed of Nutren Pulmonary ran at 65 mL per hour until the last day of the study, February 5, 2014. Overall, S.M. tolerated the tube feedings with minimal residuals noted.

Prognosis

S.M. had a long list of problems in her past medical history, including hypertension, COPD, sepsis, alcohol and substance abuse, Hepatitis C, Hepatitis B, as well as her most recent admittance to the hospital for acute respiratory failure and drug overdose. S.M. remained sedated, intubated, and received her nutrition through tube feeding the entire time she was hospitalized. Inappropriate to be interviewed, which prevented any nutrition education.

On February 1, 2014, S.M. had some episodes of what was described as vtach -Ventricular tachycardia (vtach) is a rapid heart beat that originates in one of the lower chambers (ventricles) of the heart -Ventricular tachycardia is usually caused by other heart problems, such as high blood pressure or coronary artery disease -It can also develop in people who do not have heart disease, and it may be caused by certain medications, excessive alcohol consumption, or drug abuse

Per Physicians note 2/5, it was suspected S.M. had a loss of consciousness secondary to her overdose, which resulted in a largevolume aspiration.
As of February 5, 2014, S.M.s left lung infiltrate had worsened and her white blood cell count continued to increase -About one hour after the Physician had visited with S.M., her oxygen saturation dropped to 85 and she was put on 100% oxygen support with PEEP of 14 -She was also ordered a bariatric bed so she could be pronated -S.M. developed progressive hypoxemia (low oxygen in the blood) and did not respond well to ambu-bag ventilation. -This was followed by bradycardiac (slow heartbeat), where she responded to epinephrine for a brief moment, and then went into PEA (Pulse-less electrical activity) arrest -Resuscitation with good-quality chest compression was given for about 5 minutes without a return of spontaneous circulation -The nurse tried to reach her family but was unsuccessful as all numbers were disconnected -The resuscitation attempt was then stopped

Conclusion

S.M. had a long list of past medical problems that ultimately led to her healths decline in the end. At age 51, her body could no longer properly function due to all of the stress and harm it had been put through over the years. I have learned a lot through doing this extensive research case study. -Familiar with acute respiratory failure secondary to drug intoxication, the key risk factors, common medications used for people with pulmonary infections and heart-related medical problems, and proper nutrition prescriptions for people trying to recover from respiratory failure or a similar health issue. This has given me the opportunity to practice extensive documentation in the medical records. This case study has justified the importance of taking preventative measures in order to have a healthy lifestyle.

Bibliography
1. 2. 3. 4. 5.

6.

7.
8. 9. 10. 11. 12.

13.

14.

Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th Ed. Philadelphia: Wolters Kluwer; 2011. Megarbane B, Chevillard L. The large spectrum of pulmonary complications following drug use: features and mechanisms. Science Direct Journals. 2013; 206:444-451. Nava S, Hill N. Non-invasive ventilation for acute respiratory failure. Lancet 2009; 374:250 259. Mahan LK, Escott-Stump S. Krauses Food and Nutrition Therapy. 13th Ed. St. Louis: Saunders Elsevier; 2011. LiveStrong Foundation. Acute Renal Failure Symptoms from Overdose. Available at http://www.livestrong.com/article/238654-acute-renal-failure-symptoms-from-overdose/. Accessed March 20, 2014. Drugs.com. Drugs A to Z. Available at http://www.drugs.com/drug_information. html. Accessed March 24, 2014. WebMD. Digestive Disorders. Available at http://www.webmd.com/digestive-disorders/ammoniatest. Accessed March 24, 2014. WebMD. Lactic Acid Blood Test. Available at http://www.webmd.com/a-to-z-guides/lactic-acidblood-test. Accessed March 24, 2014. WebMD. Liver Function Test. Available at http://www.webmd.com/a-to-z-guides/liver-functiontest-lft. Accessed March 28, 2014. OSCE Skills. Cardiovascular Examination. Available at http://www.osceskills.com/elearning/subjects/cardiovascular-examination/. Accessed March 28, 2014. PHC. Nestle NutriHep Nutrition. Availableat http://www.phconline.com/Nestles_NutriHep_p/nutrihep.htm. Accessed March 29, 2014. PHC. Nestle Nutren Pulmonary Nutrition. Available at http://www.nestlehealthscience.us/products/Pages/NUTREN%C2%AE- PULMONARY.aspx. Accessed March 29, 2014. Cleveland Clinic. Ventricular Tachycardia. Available at http://my.clevelandclinic.org/heart/disorders/electric/ventricular-tachycardia.aspx. Accessed April 2, 2014. Muller C, Reuter H, Dohmen C. Intoxication after extreme oral overdose of Quetiapine to attempt suicide: pharmacological concerns of side effects. Case Reports in Medicine. 2009; 210: 1-12.