Pulmonary “Steal” Syndrome

I wanted to share this fascinating and incredibly educational case – one where I learned an enormous amount about critical care medicine, pulmonary physiology, and ventilator management.

24 y.o. previously healthy female transferred from an OSH with ARDS.  She developed nausea and vomiting three days after sinus surgery with subsequent shortness of breath.  At presentation, had RLL infiltrate which progressed to diffuse bilateral infiltrates with some cavitary lesions, worse on the right.  Sputum culture grew MRSA – she is on vancomycin.  She also has developed a pneumothorax on the right and has a chest tube in place, although it was clamped during her medical flight to our hospital and she has developed lots of subcutaneous emphysema.  The sq emphysema slowly resolves over a couple of days with chest tube on -20 cm of water suction, but she continues to have a persistent air leak of moderate volume (about 30% of her tidal volume) consistent with a bronchopleural fistula (BPF).

Continue reading “Pulmonary “Steal” Syndrome”

Neuromuscular Weakness from an EGD?

This is a real case recently experienced in our ICU and I wanted to share it so others could also learn from it.

75 y.o. male with past medical history of atrial fibrillation (on apixaban), hypertension, obstructive sleep apnea, and gallstone pancreatitis treated with percutaneous cholecystostomy tube followed by biliary stents for stone removal presents with hematemesis and fall in his Hgb from 13 g/dL to 5 g/dL.  He is tachycardic with HR 130’s and slightly hypotensive with BP 90/45 mmHg.  He is given IV omeprazole, 2L of IV crystalloids and 2 units of matched PRBCs.  He is admitted to the MICU for further treatment and evaluation. Despite aggressive resuscitation and administration of 4-factor prothrombin complex concentrate in an attempt to reverse his apixiban, he continues to pass melena and some hematochezia and have a marginal blood pressure.  Although he is adamant about being DNR/DNI, he agrees to intubation for his EGD to evaluate his hematemesis.  He states that being intubated for the procedure is fine but that he wants to be extubated after the procedure.

He is intubated at 08:30 in the morning using 20 mg of etomidate and 100 mg of rocuronium, without difficulty.  Propofol infusion is used for sedation throughout the EGD, which is completed by 10:00 AM, also without difficulty.  EGD found a bleeding duodenal ulcer with a visible vessel in the base which was injected with epinephrine and clipped.  The patient tolerated the procedure well, and by 12:30 PM was awake and interactive.  He was placed on a spontaneous breathing trial using pressure support ventilation with 5 cm H2O PEEP and 5 cm H2O pressure support.  Having tolerated 60 minutes of these settings, he was extubated.

Within 5 minutes of extubation, the respiratory therapist, in a panic, grabbed us and asked us to go see the patient.  Upon arrival, he clearly had respiratory distress – he was hypoxic on venti mask oxygen and had shallow breathing at a rate of 50 breaths per minute.  The patient was awake and through a weak voice, asked his daughter if she could turn his head toward the other side of the bed (where we were standing) so he could see us.  She turned his head.  We asked him to squeeze our hands but he was unable.  He also was not able to lift his head off the bed, raise his arms, or wiggle his toes.  We told him that we needed to reintubate him to help him breathe but he refused, reiterating that he was only agreeable to be intubated for the procedure and would rather die than be intubated again.  We placed him on non invasive ventilation (NIV), but he did not tolerate it very well.

What is his diagnosis?  And what can we do to help him? Continue reading “Neuromuscular Weakness from an EGD?”