JudgeChimpanzee3104
Presenting history: Lisa Walters, 59 years, presented to the…
Presenting history: Lisa Walters, 59 years, presented to the emergency department with 15-day
history of worsening dyspnoea, fever and cough. Lisa was transferred to a medical ward where she
was administered oxygen at two litres per minute, which resulted in an oxygen saturation of 92 –
94%. The next day Lisa had increased respiratory effort and the nurse on the ward initiated a rapid
response call due to vital signs exceeding the threshold criteria and after consultation with the
medical consultant Lisa was transferred to the ICU.
Past medical history: Lisa has been a healthy woman who presented to her GP for a cough 2 1/2
weeks ago. She ceased smoking in 1998 and is on no regular medications.
Lisa works as an optometrist and lives alone and has two adult daughters.
On admission
On arrival to the ICU Lisa was speaking in short sentences her respiratory rate was 45 breaths per
minute temperature 39.6 and her SpO2 two was 80% on room air and Lisa appeared to have an
increased respiratory effort and was using accessory muscles ported no pain.
Lisa had a regular pulse rate 105 beats per minute when the ECG trace was reviewed her rhythm was
identified as sinus tachycardia. BP was 150/70 mmHg and the nurse noted no pedal oedema but
Lisa’a peripheries were cold up to her knees and her capillary refill time was more than five seconds.
The were bilateral bronchial breath sounds over the bases and a mild exploratory wheeze.
Initial management: non-invasive ventilation with high flow nasal cannula FiO2 0.45 was
commenced. The team ordered a CT of the thorax and an arterial blood gas after insertion of an
arterial line. The suggested target saturation range was >90%.
Other assessment findings: C reactive protein 28 mg/L (normal range is less than 5 mg/L).
Arterial blood gas:
? pH 7.3
? Pa02 56mmHg
? PaCo2 45 mmHg
? Base Excess 3
? HCO3 25mmHg
Chest imaging showed “ground glass” opacities in both lungs
Assessment plan: More Blood cultures were ordered to look for Legionnaires human
immunodeficiency virus or pneumococcal antigen. A sputum sample was collected for culture and
sensitivity testing. Hourly urine measures and daily weight was commenced.
Lisa was assessed as having multifactorial type one respiratory failure including nonspecific
pneumonia. Lisa was commenced on a broad-spectrum intravenous antibiotic.
Day 1
During the first night in the ICU Lisa deteriorated further, while her FiO2 was increased, this did not
improve her oxygen saturation. Her respiratory rate was 40 and an increased work of breathing was
noted despite increasing non-invasive ventilation parameters. Her temperature was 40 degrees and
she was sinus tachycardiac 140 bpm, BP 100/50mmHg. Lisa’a feet remained cold with no oedema.
She had widespread wheezes and reduced air entry at the bases.
During the morning, Lisa was intubated and IV propofol and fentanyl initiated. She was commenced
on volume – controlled mandatory mechanical ventilation with FiO2 0.8 respiratory rate of 16 and
peep 5.
1. On admission, Lisa’s peripheries were cold up to her knees and her capillary refill time was
more than 5 seconds. While poor tissue oxygenation from respiratory failure is one
probable cause, what is the second possible cause considering she is febrile? Explain the
pathophysiological basis for your answer
2. On admission, Lisa’s C reactive protein was elevated – a marker for inflammation. What
are the possible consequences of serious pulmonary inflammation?
3. Review Lisa’s ABG on admission, what does this tell us about her oxygenation, ventilation
and compensatory mechanisms?
