VentWorld Case Studies

JJ: 49 YO End Stage Organ Failure
Published August 9, 2001

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

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INTRODUCTION

JJ was a 49-year-old male admitted to the emergency department with a decrease in alertness and speech for the past three days. In addition, he had a decreased urinary output and no bowel movement over that period. Initial examination revealed that he was difficult to arouse, did not verbalize, but had spontaneous eye movement. He also had coffee ground emesis and was had a fresh bleed from his nose. Vital signs were: heart rate 68, blood pressure 128/80, respiratory rate 20, temperature 38.9 C, and SpO2 99% on room air. Breath sounds revealed bilateral expiratory rhonchi. His abdomen was distended and tender. Pedal edema was present. Chest radiograph showed bilateral infiltrates.

The patient had a prior history of cirrhosis of the liver, ETOH abuse, esophageal and gastric varices, portal gastropathy, and Hepatitis C and B. He had been on the waiting list for a liver transplant, but was recently removed from the list and referred to counseling for continuing alcohol use. Admitting diagnosis was cirrhosis due to ETOH abuse, GI bleed, hepatic encephalopathy, and probably renal failure.


CASE PRESENTATION

Initial treatment consisted of packing the nose. He was also intubated with a #8 ET tube for airway protection since he had no gag reflex. Subsequently he was transferred to the intensive care unit and placed on mechanical ventilation via a P-B 7200 ventilator. Ventilator settings were:

Mode CMV Rate 12
Tidal Volume 600 mL Flow 60 Lpm
FiO2 100% PEEP +5 cmH2O

Secretions removed from the airway were both bloody and yellowish. Blood and urine cultures were obtained, and a lumbar puncture and CT scan were performed to rule out meningitis.

The patient was started on Folic acid, Thiamine, and Pepcid. In addition, he was given Ativan for sedation, Fentanyl and Levo-Dromoran for analgesia, and low dose Dopamine for renal insufficiency. First day lab results were:

serum bilirubin 7.1 mg/dL BUN 39 mg/dL
glucose 146 mg/dL creatinine 1.9 mg/dL
albumin 1.8 g/dL ammonia 219 µg/dL
Hgb 9.2 g/dL Hct 26.2%

Over the next two days, the patient was treated for liver and kidney malfunction. In addition, he was given four units of packed red blood cells, six units of platlets, and two units of plasma. Efforts were made to stop the nasal and GI bleeding. Blood cultures revealed E coli and the patient was started on appropriate antibiotic therapy.

The patient’s condition continued to deteriorate. A follow up chest radiograph showed an increase in bilateral infiltrates. Peak inspiratory pressures on the ventilator reached levels of 55 – 60 cmH2O. An arterial blood gas sample drawn at this time showed:

pH 7.25 PaO2 70
PaCO2 42 SaO2 91%
HCO3 18 base excess -9
FiO2 45% PEEP +5 cmH2O

The patient was changed from volume control to pressure control with the following settings:

Mode CMV Rate 18
PEEP +5 cmH2O PIP 38 cmH2O
FiO2 45% i-time 0.94 sec

Follow up arterial blood gas results on the above settings were:

pH 7.29 PaO2 78
PaCO2 32 SaO2 94%
HCO3 15 base excess -12

In response to the above data, the respiratory rate was increased to 20. This caused the pH to increase to 7.39 and the PaCO2 to decrease to 28. However, there was also an increase in auto-PEEP levels.

Twelve hours later, the patient’s pH dropped to 7.23 and the PaCO2 increased to 44. The respiratory rate was increased to 24, which corrected the acidosis and relative hypercapnia but resulted in a further increase in auto-PEEP. In addition, it was observed that the delivered tidal volumes were steadily decreasing as the patient’s ARDS continued to progress. At the same time, the patient’s renal failure worsened, as indicated by a significant difference between fluid input and urinary output. There was also an increase in dependent edema. Jet ventilation was considered. However, due to the patient’s chronic liver problems and his apparent end-stage organ failure, and the fact that he did not respond to therapy, after consultation with the family, the decision was made to withdraw life support.


DISCUSSION:

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