Page 149 - ACCCN's Critical Care Nursing

126 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Case study, Continued
Initial treatment included: 15L oxygen via non-rebreather system, Day 2
fluid resuscitation of 1.5L with the blood pressure improving to Kevin remained on Pressure control ventilation: FiO 2 0.5–1.0, PEEP
111/42, and broad specrum antibiotics. @ 15, Inspiratory Pressure @ 16 with Nitric Oxide 5–10ppm. Hae-
An urgent portable chest X-ray showed right middle and lower modynamics were supported with noradrenaline, adrenalin and
lobe consolidation and air bronchograms. bicarbonate infusions. Kevin was sedated and administered bron-
chodilators. Antibiotic treatment continued with blood cultures
While there was improvement to SpO 2 readings with the supple- positive for streptococci. Renal function was supported with Hae-
mental oxygen therapy, Kevin’s work of breathing remained high mofiltration. Re-positioning Kevin was limited to small lateral
and following consultation with the intensive care team, arrange- movement because of his continued haemodynamic and respira-
ments were made to transfer Kevin via helicopter to the intensive tory instability. Passive movements of all limbs were instigated
care unit in the city. with physiotherapists assisting with limb and joint movements.
On arrival in ICU Kevin’s problems were severe community acquired pneumonia,
Because of the high suspicion of influenza and the serious respira- shock, acute renal failure and coagulopathy.
tory failure necessitating respiratory support and potential for intu-
bation or bronchoscopy, Kevin was allocated to a single room and Days 3–6
‘contact and droplet’ transmission-based precautions were imple- Volume control ventilation with tidal volumes of 6 mL/L/kg along
mented immediately. with nitric oxide therapy were used to support respiratory func-
tion. PiCCO monitoring was implemented to assist management of
During transport from the country to the ICU, the retrieval team haemodynamic status and continuous veno-venous haemodiafil-
had stabilised Kevin on supplemental oxygen therapy but just tration (CVVHDF) was used for renal support. Strep pyogenes and
prior to arrival in the ICU he was increasingly disorientated and Influenza A H1N1 were confirmed and antibiotic therapy contin-
dyspnoeic and BiPAP therapy was commenced with FiO 2 1.0. The ued. Enteral nutrition was commenced and established over a 4
retrieval team has inserted a central venous catheter and com- day period. A faecal containment device was used to manage
menced a low dose adrenaline infusion to support his blood pres- incontinence and prevent any sacral excoriation.
sure as they did not want to load him with fluids. During transport
Kevin was able to tolerate being semi-recumbent but unable to be Days 7–13
positioned sitting upright while on the barouche due to his large Inotropes were gradually weaned and respiratory function
abdomen causing discomfort to his breathing. improved and nitric oxide ceased. During this time Kevin was
progressively re-positioning more often and with increasing
Kevin was unable to be stabilised on BiPAP and was intubated and lateral turns to aid both his respiratory function and also provide
ventilated using FiO 2 1.0 with PEEP @ 8 on pressure control ventila- pressure relief. Sedation was reduced over this time and ceased
tion (PCV) mode. Tracheal aspirate was obtained and sent for and Kevin was changed to pressure support ventilation (PSV).
microbiological examination including a rapid review for influenza. Kevin responded with his eyes opening to stimuli but he had hypo-
A urinary catheter with temperature monitoring sensor was tonic and areflexic upper and lower limbs. A short-term clonidine
inserted. Kevin was oliguric and his urinary temperature was 39°C. infusion was required for control of a period of severe
Kevin’s haemodynamic instability and de-saturation due to lung hypertension.
compression prevented him from being positioned laterally but
head-of-bed elevation was maintained at greater than 20 degrees. Days 14–20
From initial contact with the local hospital knowledge of Kevin’s Nerve conduction studies confirmed that Kevin had a critical illness
weight had prompted the ICU team to ensure that the bed Kevin polyneuropathy. A progressively increasing respiratory rate and
used had a weight-suitable pressure relief mattress already in decreasing PaO 2 due to low tidal volumes prompted a short return
place. Venous thromboembolism prophylaxis was commenced to pressure-controlled ventilation to re-inflate the lower lobes. A
with a combination of heparin and sequential compression device. tracheostomy was performed to provide long term airway support.
Thigh leggings were chosen along with the sequential compres- Kevin improved again over the next 24 hours and was weaned
sion device in preference to compression stockings because of again to 30% oxygen on pressure support ventilation.
Kevin’s size and potential peripheral oedema.
Days 21–25
After 12 hours following intubation, nitric oxide was added to the Kevin’s limb strength improved with power rated at 4/5 globally.
ventilation system to improve arterial blood gases (ABGs) along Kevin was now able to be supported to sit on the side of the bed
with intermittent muscle relaxants which were also required to twice each day. T-piece oxygenation was now well tolerated during
optimise ventilatory support. Additional attention to Kevin’s eye the day with pressure support ventilation at night. A renal perfu-
care was given with the use of muscle relaxants and the subse- sion scan showed poor perfusion with very delayed function and
quent loss of blink reflex. Hypotension was treated with a further no radioactive excretion. A permacath was inserted to aid with
2 litres of intravenous fluids plus 2 units of red blood cells for a low potential long-term dialysis.
haemoglobin. Antibiotic therapy continued.
Days 26–34
Kevin’s problems included community acquired pneumonia, sepsis Respiratory support was continued with a variation between pres-
and acute renal failure. sure support ventilation and T-piece oxygenation. Intermittent