Clinical Case Presentation
CHANGJUAN LI
CDP-CCU
15/12/2009
Basic information
Mr. Bennett, 72 years
Italian speaking man, Lives alone
Independent with ALDS
No religious belief
Weight 80kg, height 180cm BMI 24.7
on admission
BIBA, unwell for 1/52 with ↑SOB, HT &
worsening asthma
O/E: alert, lethargy but comfortable
Obs: afebrile, HR 100, BP 160/70, sats 98%
on 2 L/min O2
JVP 3cm
Talking in words ins/exp wheeze
Transfer to ICU
Increasing SOB & WOB
Tachypoenic >40 bpm, ST 120,Spo2 90% on
HM
CXR: bilateral effusions
Past history
Asthma/COAD HT
Ex-smoker >40 yrs IHD
Gout ↑cholesterol
CVA NIDDM
Epilepsy
Allergy :NKDA
Diagnosis
APO due to fluid
overload
2o renal impairment
(↑urea 50.2, creatinine
290, ↓ eGFR 33
presumed from ACE-I
covelsyl)
What’s APO?
fluid accumulation in the lungs.
failure of the heart to remove fluid from the
lung circulation or a direct injury to the lung
parenchyma .
impaired gas exchange
pulmonary blood pressure ↑> 25 mmHg.
classical pattern of CXR in APO
PATHOPHYSIOLOGY of APO
↓ LV contractility → LV dilates & HR ↑
↑preload or ↓LV compliance → ↑LV diastolic pressure
↑ LA & PVP →Pulmonary congestion & oedema
PCOP > 30mmHg, fluid leak →pulmonary interstitial
space→oedema
↓O2 → O2 exchange
R) heart pressure ↑→ R) heart failure
PATIENT ASSESSMENT
Ankle oedema
Moderate respiratory distress
Auscultation: Upper airway: clear; L & R scattered
wheeze; S3 gallop
Appearance: anxious and distressed
speech: short phrases
Rhythm: prolonged expiratory phase
Effort: increased
Chest wall status: equal expansion
Laborotory Findings
VBG: PH 7.38, PaCO2 41, O2 33;
ABG: PH 7.29, PaCO2 51, O2 52;
FBE: HB 97, WBC 17.5
U & E: Na+ 141, K+ 5.0,Urea 14.1, Cr 179,
eGFR33, trop 0.03
CXR: cardiomegaly, R>L basal consolidates
ECG: ST↓ with ectopics
PaCO2↑:Gas trapping
Dyspnoea: Nursing interventions
Observing tongue and sublingual area
Assessing chest wall configuration
Evaluating respiratory effort
Instruct pt in medications, inhalers, spirometry
Turn pt frequently to moblize secretions
Place the patient in a comfortable position that
maximizes air exchange
O2 therapy monitor Spo2,ABG if necessary
Dyspnoea: medical interventions
Auscultation: bronchial BS over areas of
consolidation
Treat the cause
Medications: diuretics & morphine (↓preload)
CXR
ABG analysis
Intubation & mechanical ventilation
Medication
Amiodarone Allopurinol
Dobutamine Amlodipine
IVABs Panadol osteo
Fragmin Methyldopa
Frusemide Glucosamine
morphine+midazolam Pantoprazole
Predinisolone Haloperidol
GTN patch
Dobutamine
synthetic catecholamine
Selective β effects with minimal αreceptor
effects (HR & PVR)
↑inotropic force of myocardial contraction
↑CO
↑SV
↓PCWP
Dobutamine 250mg/20ml
Dose & administration: 2.5-15mcg/kg/min.
Titrate to effect (maximum dose 40
mcg/kg/min)
IV infusion: 250 mg in 100ml N/Saline or
D5W (1ml/hr=2500mcg/hr=41.6mcg/min)
Dobutamine-Adverse effects
Tachycardia, HT & VE’s -effects are dose
related
Hypotension has occasionally been noted
Reduction in serum K+ concentrations
Phlebitis at site of infusion
Occasionally- nausea, headache,angina
pectoris, dyspnea, palpitations
Hydrocortisone
Glucocorticoid effects, e.g.
gluconeogenesis, proteolysis,
lipolysis,suppression of inflammation and
immune responses
Mineralacorticoid effects, e.g. HT, sodium
and water retention, potassium loss
Anti-inflammatory adrenocortical steroid
Hydrcortisone-adverse effects
CNS: Psychotic derangement, convulsions, vertigo,
headache
CVS:HT, salt and water retention and ↑excretion of K+ &
Ca2+, and anaphylactic reactions (rare), CHF
GIT: Peptic ulcer, pancreatitis, abdominal distension,
ulcerative oesophagitis
Musculoskeletal: acute myopathy, osteoporosis, impaired
wound healing, thin fragile skin
Endo: hyperglycaemia, manifestation of diabetes mellitus,
↑requirements of hypoglycaemics and insulin
Short Synacthen Test
Principles: serum cortisol in measured
before and after adrenal stimulation with
synacthen
Short Synacthen Test - procedure
Collect baseline blood sample for cortisol (white
tube) and blood sample for ACTH (purple tube)
Give 250mcg of synacthen IV (or IM)
Take further blood samples for cortisol (white
tubes) at 30 min and 60 min intervals
Clearly mark “30” and “60” min sample on each
path tube and pathology request
Short Synacthen Test - interpritation
Normal- 30 or 60 min sample : > 550 and 200
above baseline level
Borderline – 30 or 60 min sample: >550 and not
200 above baseline level (consider exogenous
steroids)
Abnormal – 30 or 60 min sample:
<[Link] with adrenal insufficiency
Feeling safe: Psychosocial Needs of ICU Patients
Interdependence: inadequately managed pain
may lead to feelings of powerlessness, anxiety,
and depression that in turn, heighten the patient’s
perception of pain
Powerlessness: basic functions, including the
ability to communicate,to breath on their own, to
participate in decision making and to control
bladder and bowel function
Sleep deprivation: sleep fragmentation
Grief and loss
Trajectory to date
CNS: drowsy →A & O, restless→ cooperative
CVS: ECG & Echo normal, AF → SR, no oedema,
BP is well controlled, TTE improved
Resp: ↑SOB → High Flow → HM; CXR
Renal: Urea 17.3 (14.1), Crea153(179), eGFR 30
Mobility: transfer x 2 assistance
Transfer to the ward