Morning Report

Hypotension and fever in an 18 year female

Mariposa Wolford

ICU nights
18 y/o female with BPs low after nearly 3L NS

Diagnosis of AML, s/p Induction II, CNS negative,

MRD negative Recent course of chemo with Ara C finished on 7/25. Currently neutropenic and has had low plts Had high fevers with her chemo PMHx includes allergic rhinitis and PCOS, on OCPs. Diagnosed with AML

Patient presentation
T 39.9 HR 124 BP 95/31 RR 18 on 0.5LPM O2

with sats 97% Wt 64kg GEN: pt smiling, NAD, alopecia 2/2 chemo, AOx3 HEENT: NCAT, EOMI, PERRL, MMM, no exudates in throat CV: Tachycardic with no m/r/g. Bounding pulses in all 4 extremities. CRT 2s CHEST: CTAB. With mildly increased WOB. No wheezing, no crackles. ABD: S/NT/ND. No HSM.

Over the next few days

Increasing respiratory distress and oxygen need

prompting HFNC after increased NC Trial back on NC resulted in desats to mid 80s CXR showing mild ill defined opacification in lower lungs Patient with diarrhea, continued high fevers into the 40s and increasing fatigue. Mixed venous sats decreasing

Differential diagnosis

Pulmonary hemorrhage Bacterial sepsis Fat embolism syndrome Acute respiratory distress Transfusion associated lung injury (TRALI) Acute eosinophilic pneumonia Acute hypersensitivity pneumonitis Leukemic infiltration Pneumocystic jiroveci pneumonia Bacterial or viral pneumonia Multi organ failure associated with sepsis Respiratory failure Toxic shock syndrome Tumor lysis syndrome

Other info on our pt

Blood culture from 8/2 positive for viridans Strep

On Vancomycin and Ceftazidime, then Cefepime

Mixed venous saturations about 70->59->74->69

Switched to Bipap 12/8, then 14/10 before intubation on

8/6 am since she had coughing spells despite increased Bipap settings
Wt was up from about 64kg to about 68.9 after fluids and

blood pdts. Went on lasix drip, needed bld pts, was febrile/shivering so we paralyzed and sedated her

Course
Had blood from ETT

LS had left lung collapse on 8/8

Bronchoscopy showed excessive secretions Given pulmozyme On VDR ventilator for 3 days, then got

subcutaneous air in limbs Switched back to conventional ventilator Was intubated for 12 total days!

ARDS
Acute resp failure & refractory hypoxemia 2/2

significant lung injury

CXR w bilateral opacities. Lungs are non-compliant

Severity of hypoxemia determines severity of ARDS

using arterial oxygen tension to fraction of inspired oxygen PaO2/FiO2

>200 but < or = to 300, MILD >100 but < or = to 200, MODERATE < or = to 100, SEVERE

ARDS continued
Lung damage increased alveolar-capillary

permeability influx of interstitial & intra-alveolar fluid. Surfactant is diluted and its production decreased Point on pressure-volume PV loop w/ lower inflection point

Pathophysiology of ARDS

ARDS
Histology shows diffuse alveolar damage.
Infection Sepsis Diffuse pulmonary infections* Gastric aspiration* Chemical Injury Heroin or methadone OD Acetylsalicyclic acid Barbituate OD Paraquat Cardiopulmonary Bypass
Hypersensitivity Reactions Organic Solvents Drugs Inhaled Irritants Oxygen toxicity Smoke Irritant gases and chemicals

Physical/Injury Mechanical trauma/ inc head injuries Pulmonary contusions Near-drowning Fractures with fat embolism Burns Ionizing radiation

Hematologic Conditions Multiple transfusions DIC Pancreatitis Uremia

Oxygen delivery: how much oxygen delivered to tissues in a minute

DO2 = CO x CaO2 CaO2 = arterial oxygen content
= amount of O2 bound to Hgb plus amount of O2

dissolved in arterial blood =(Hb x SaO2 x 1.34ml O2/g Hgb) + 0.003ml x PaO2
SaO2 is the arterial oxyhemoglobin concentration

and PaO2 is the arterial oxygen tension.

Outcomes
Mortality for ARDS 26-58% by one estimate. Common causes in Peds: drowning, sepsis & shock Cause of death is usually the underlying cause and

not respiratory failure

Some prognostic factors include:

Younger patients do better Milder cases of ARDS do better Large positive fluid balance do worse Recently transfused pts (pRBCs) did worse

ARDS outcomes long term

Survivors frequently have long term decrease in

exercise tolerance/endurance
80% of pts in one study had reduced diffusing

capacity, regardess of H or LTV trtmt

A better functional outcome at one year correlates

with the absence of steroid treatment, absence of illness acquired during the ICU stay, and rapid resolution of multiple organ failure and lung injury

References
Pediatric ICU Blueprint, Schwartz, MD. 2007.

Pulmonary function and health-related quality of life in survivors of acute

respiratory distress syndrome.Orme J Jr, Romney JS, Hopkins RO, Pope D, Chan KJ, Thomsen G, Crapo RO, Weaver LK. Am J Respir Crit Care Med. 2003;167(5):690.
Robbins Pathologic Basis of Disease, 7th Ed.

UpToDate: Acute respiratory distress syndrome: Clinical features and

diagnosis. Last updated Oct 5, 2012.

UpToDate:Acute respiratory distress syndrome: Prognosis and

outcomes. Last updated July 3, 2012