Case Study-Note 1

A Complex ICU Patient Case

1. One-Liner

Mr. James A., a 68-year-old male, hospital day 12, admitted with septic shock secondary to aspiration pneumonia, complicated by ARDS, AKI requiring CRRT, atrial fibrillation with RVR, and delirium.

2. Overnight Events

• Became hypotensive at 3 AM requiring norepinephrine titration from 8 → 15 mcg/min.

• Febrile spike to 39.1°C, acetaminophen administered.

• Brief desaturation episode with O₂ sat 84% on current vent settings → RT increased FiO₂ from 50% → 60%.

• Foley output dropped to 5–10 mL/hr despite 500 mL LR bolus.

• Family updated, code status re-affirmed as full code.

Rationale: Overnight events highlight instability (septic shock, worsening renal perfusion, infection, oxygenation issues). Nurse and RT input essential here.

3. Vital Signs

• Temp: 39.1°C (febrile, likely ongoing infection vs line sepsis).

• BP: 92/56 mmHg, MAP ~62 on norepinephrine 15 mcg/min.

• HR: 126 bpm, irregularly irregular (A-fib with RVR).

• SpO₂: 92% on volume control ventilation, FiO₂ 60%, PEEP 10.

• RR: Set 20, patient breathing 28 (overbreathing).

Interpretation:

• Septic shock with vasoplegia requiring escalating vasopressors.

• Uncontrolled A-fib likely exacerbating hemodynamics.

• Hypoxemia despite moderate PEEP/FiO₂ → ARDS physiology.

4. Intake & Output (past 24h)

• Intake: 2.5 L IV fluids (including antibiotics and sedation), TF 1.2 L.

• Output: 300 mL urine (oliguric), 200 mL chest tube drainage (serosanguinous), 100 mL from JP abdominal drain.

• Net balance: +3.1 L.

Rationale: Positive fluid balance in septic patient → worsens ARDS; oliguric → AKI/renal failure; chest tube output needs trending (risk for bleeding, infection).

5. Ventilator

• Mode: Volume Control.

• FiO₂: 60%.

• PEEP: 10.

• Tidal volume: 6 mL/kg IBW (lung protective).

• Set RR: 20, patient RR: 28.

• Plateau pressure: 32 → concerning for stiff lungs (ARDS).

Interpretation & Intervention:

• Lung-protective ventilation ongoing.

• Over-breathing → evaluate sedation/analgesia.

• Consider paralysis if refractory hypoxemia persists.

6. Lab Data & Cultures

• CBC: WBC 22K (up from 17K), Hb 8.1 (down from 9.3), Plt 68K (falling).

• BMP: Na 148, K 3.2, Cl 115, CO₂ 18, BUN 78, Cr 3.9 (baseline 1.0).

• LFTs: Mild cholestasis, Tbili 2.0, AlkPhos 210.

• ABG: pH 7.29 / PaCO₂ 48 / PaO₂ 62 / HCO₃ 20.

• Cultures: Blood culture from 3 days ago growing Klebsiella pneumoniae (ESBL); line culture pending.

Rationale:

• Leukocytosis + fever → ongoing infection.

• Hb trending down → possible dilution vs slow bleed (monitor drains).

• Worsening AKI → CRRT indicated.

• Electrolytes (low K, high Na) → replacement, careful fluid strategy.

• Metabolic acidosis + hypoxemia → ARDS + renal failure contributions.

7. Imaging

• CXR: Bilateral diffuse infiltrates consistent with ARDS; worsening from yesterday. ETT and lines in appropriate position.

• CT Abdomen (2 days ago): Post-op ileus with JP drain near anastomosis, no new abscess.

• Echo: LVEF 55%, moderately dilated RV, mild tricuspid regurg, RVSP elevated → possible cor pulmonale from ARDS.

Rationale:

• Radiology confirms ARDS progression.

• Echo rules out LV dysfunction but highlights right-sided strain → PEEP management must be cautious.

8. Lines, Tubes, Drains

• Right IJ central line (day 10) → infection risk, consider replacement.

• Arterial line (day 8).

• Foley catheter (day 12).

• Chest tube (day 3, post-thoracentesis for empyema).

• JP drain (day 5, post-bowel resection).

• Endotracheal tube (day 10).

Rationale:

• Multiple devices = multiple infection risks.

• Central line >7 days → strong candidate for exchange.

• Foley 12 days → likely source for urosepsis; consider removing when stable.

9. Medications

• Antibiotics: Meropenem day 3 (for ESBL Klebsiella), plan 10–14 days pending sensitivities.

• Pressors: Norepinephrine 15 mcg/min; vasopressin added at 0.03 units/min.

• Sedation/analgesia: Propofol infusion + fentanyl drip.

• Other: Protonix for stress ulcer prophylaxis, heparin gtt held due to thrombocytopenia, insulin sliding scale (range 180–240).

Rationale:

• On broad-spectrum abx → appropriate for resistant Klebsiella.

• Dual pressors → refractory septic shock.

• Heparin held due to low Plts → risk for HIT vs sepsis-induced thrombocytopenia.

• Glycemic control needed → may escalate to basal insulin.

10. Physical Exam

• Neuro: Sedated, not following commands. Pupils reactive. Moves minimally to pain.

• CV: Tachy, irregularly irregular. Peripheral pulses weak, extremities cool.

• Resp: Diffuse crackles bilaterally. Decreased breath sounds at bases.

• Abdomen: Distended, hypoactive bowel sounds, JP drain in place.

• GU: Foley with minimal concentrated urine.

• Skin: Sacral erythema developing, mottling on lower extremities.

11. Assessment & Plan

Problems & Interventions

1. Septic shock due to ESBL Klebsiella pneumoniae

   • Continue meropenem, monitor cultures.

   • Source control: evaluate central line (possible removal/replacement).

   • Escalating pressors → consider hydrocortisone stress dosing.

2. Acute Hypoxemic Respiratory Failure (ARDS)

   • Continue lung-protective ventilation (low TV, high PEEP strategy).

   • FiO₂/PEEP ladder adjustment per ARDSnet protocol.

   • Consider proning and paralysis if PaO₂/FiO₂ < 100 persists.

3. Acute Kidney Injury, oliguric, worsening

   • CRRT initiation.

   • Avoid nephrotoxins, adjust antibiotic dosing.

   • Monitor electrolytes and acid-base.

4. Atrial fibrillation with RVR

   • Optimize sedation/analgesia.

   • IV amiodarone loading, rate control as tolerated by BP.

   • Anticoagulation deferred due to thrombocytopenia and bleeding risk.

5. Anemia & Thrombocytopenia

   • Trend CBC q12h.

   • Transfuse if Hb <7.

   • Evaluate for HIT (check 4T score, PF4 assay).

6. Nutrition

   • Continue tube feeds at goal rate.

   • Reassess caloric/protein needs daily.

7. Delirium / Sedation management

   • Sedation vacations daily when feasible.

   • Consider dexmedetomidine if agitation persists when off propofol.

8. Lines/Tubes

   • Replace central line.

   • Reassess Foley necessity daily.

   • Monitor chest/JP drain output for infection/bleeding.

9. Family & Goals of Care

   • Continue daily family updates.

   • Discuss prognosis given multiorgan failure.

Summary: This patient integrates every concept from the script:

• Overnight instability → informs interventions.

• Vitals & pressors → hemodynamic interpretation.

• I/O + AKI → fluid and renal decisions.

• Vent settings → ARDS management.

• Labs & cultures → infection, sepsis, hematology, renal context.

• Imaging → ARDS and RV strain.

• Lines/tubes → infection prevention.

• Meds → antibiotics, sedation, pressors.

• Exam → ties it all together.

• Plan → system-based, actionable, with rationale.