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.Spo2 90% on HM  CXR: bilateral effusions  . ST 120.

Past history       Asthma/COAD Ex-smoker >40 yrs Gout CVA Epilepsy Allergy :NKDA     HT IHD cholesterol NIDDM .

Diagnosis   APO due to fluid overload 2o renal impairment ( urea 50. eGFR 33 presumed from ACE-I covelsyl) . creatinine 290.2.

 .  impaired gas exchange  pulmonary blood pressure > 25 mmHg.  failure of the heart to remove fluid from the lung circulation or a direct injury to the lung parenchyma .What¶s APO? fluid accumulation in the lungs.

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classical pattern of CXR in APO .

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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 .

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S3 gallop Appearance: anxious and distressed speech: short phrases Rhythm: prolonged expiratory phase Effort: increased Chest wall status: equal expansion .PATIENT ASSESSMENT         Ankle oedema Moderate respiratory distress Auscultation: Upper airway: clear. L & R scattered wheeze.

R>L basal consolidates  ECG: ST with ectopics  . O2 52.  ABG: PH 7.5  U & E: Na+ 141.  FBE: HB 97.29. PaCO2 51. WBC 17. O2 33.0.03  CXR: cardiomegaly. eGFR33.38.Laborotory Findings VBG: PH 7.1. K+ 5. trop 0.Urea 14. PaCO2 41. Cr 179.

PaCO2 :Gas trapping .

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: Nursing interventions        Observing tongue and sublingual area Assessing chest wall configuration Evaluating respiratory effort Instruct pt in medications. inhalers.

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 Dobutamine IVABs Fragmin Frusemide morphine+midazolam Predinisolone GTN patch        Allopurinol Amlodipine Panadol osteo Methyldopa Glucosamine Pantoprazole Haloperidol .

Dobutamine synthetic catecholamine  Selective effects with minimal receptor effects (HR & PVR)  inotropic force of myocardial contraction  CO  SV  PCWP  .

Dobutamine 250mg/20ml Dose & administration: 2.  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)  .5-15mcg/kg/min.

angina pectoris. headache.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. dyspnea.nausea. palpitations  .

HT. potassium loss  Anti-inflammatory adrenocortical steroid  . sodium and water retention.suppression of inflammation and immune responses  Mineralacorticoid effects. e. e. proteolysis. gluconeogenesis.g.Hydrocortisone Glucocorticoid effects.g. lipolysis.

and anaphylactic reactions (rare). impaired wound healing. pancreatitis. headache CVS:HT. CHF GIT: Peptic ulcer. thin fragile skin Endo: hyperglycaemia. osteoporosis. vertigo. requirements of hypoglycaemics and insulin .Hydrcortisone-adverse effects      CNS: Psychotic derangement. convulsions. ulcerative oesophagitis Musculoskeletal: acute myopathy. abdominal distension. manifestation of diabetes mellitus. salt and water retention and excretion of K+ & Ca2+.

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 ³30´ and ³60´ min sample on each path tube and pathology request .

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: <550.Short Synacthen Test .consistent with adrenal insufficiency .

and depression that in turn. heighten the patient¶s perception of pain Powerlessness: basic functions. to participate in decision making and to control bladder and bowel function Sleep deprivation: sleep fragmentation Grief and loss . anxiety. including the ability to communicate.Feeling safe: Psychosocial Needs of ICU Patients     Interdependence: inadequately managed pain may lead to feelings of powerlessness.to breath on their own.

CXR Renal: Urea 17. TTE improved Resp: SOB High Flow HM. BP is well controlled.3 (14. Crea153(179). restless cooperative CVS: ECG & Echo normal.1). no oedema.Trajectory to date       CNS: drowsy A & O. eGFR 30 Mobility: transfer x 2 assistance Transfer to the ward . AF SR.

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