Case Study: Fever - page 4

The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in... Read More

  1. Visit  juan de la cruz profile page
    3
    OK guys time for the update:

    So Rolando was hypotensive after intubation. You guys are right that the Propofol contributed to the drop in his blood pressure. However, many times patients who are in respiratory distress have a surge of catecholamines which artificially increases their blood pressure and once you knock off the offending stimuli (respiratory distress), the blood pressure tanks. Rolando was actually started on pressors.

    The ED continued to struggle with profound hypoxemia and transferred him to the ICU at the community hospital where his subsequent CXR showed worsening bilateral fluffy infiltrates. His pO2 remained low and he started having hypercarbia as well. He quickly presented with a septic picture and was on high doses of Norepinephrine. The community hospital decided that Rolando was too sick to be cared for in that setting and called the nearest tertiary facility for higher level of care.

    That's when we started taking care of him. Our facility has an ECMO program. Rolando was cannulated for Veno-Arterial Extracorporeal Circulatory Life Support. He was in multi-organ failure involving his circulatory system (distributive shock), respiratory system (hypoxemic and hypercarbic respiratory failure due to acute lung injury from infection requiring ECLS), and renal (acute kidney injury from acute tubular necrosis requiring continuous renal replacement therapy with CVVHD).

    The community hospital updated us of his culture results: as many of you suspected, his respiratory secretions grew Coccidiodes spp. He had Valley Fever which has progressed to Disseminated Coccidiomycosis. Valley Fever is caused by a fungus of the Coccidiodes genus.

    A note about Coccidial Infection:

    - the organism that causes this disease is endemic to Southern Arizona, Southern and Central Valleys of California, Southwestern New Mexico, and Western Texas.
    - infectious manifestations vary from very mild to severe disseminated pulmonary and extrapulmonary disease. Immunocompromised hosts are at high risk for severe infections (those with HIV, transplant recipients on immunosuppressive therapy, patient on chemotherapy, etc).
    - there are reports that people of Native American, African, and Philippine descent tend to present with severe cases. A study in California, however, did not support the evidence that people of Asian (Philippine) and Hispanic racial or ethnic background are at risk for severe cases (see link)
    - treatment with antifungals such as Fluconazole and Itraconazole are recommended. Amphothericin B may be considered in severe cases with the caveat that toxicity can be problematic. Newer antifungals such as Voriconazole or Posaconazole have not been well studied on its effectiveness in Coccidiomycosis.

    Rolando's Hospital Course:

    Perhaps owing to his healthy state prior to his infection and his age, Rolando improved clinically on ECLS and was eventually decannulated from the bulky device. He was eventually taken off pressors as well. He remained on intermittent dialysis for a period of time but subsequently had return of his kidney function. He luckily did not require a tracheotomy as his neurologic status was unaffected (his CSF was negative for cocci) and was extubated as soon as his ventilatory settings were down to minimum support.
    He was transferred to a regular hospital floor after about a couple weeks in the ICU. He went home with his mother after his hospital stay.
    Last edit by juan de la cruz on Jul 4, '13
  2. Visit  SwansonRN profile page
    0
    Wow that escalated quickly.


    Yay for Rolando!
  3. Visit  xoemmylouox profile page
    0
    Poor kid. Glad things turned out well. Great case study!
  4. Visit  FlorenceNtheMachine profile page
    0
    Quote from sarakjp
    Wow that escalated quickly.

    Yay for Rolando!
    You made me laugh at 6am with that quote. I love it.
  5. Visit  blondy2061h profile page
    0
    Really stupid question, but I have 0 experience with ECMO. Do they remain intubated and on a vent while on ECMO or is this not necessary since the ECMO system provides oxygenation?
  6. Visit  juan de la cruz profile page
    1
    Quote from blondy2061h
    Really stupid question, but I have 0 experience with ECMO. Do they remain intubated and on a vent while on ECMO or is this not necessary since the ECMO system provides oxygenation?
    It depends on the indication.

    In this case, the patient will remain intubated with as minimum vent settings as possible while ECMO does the work of providing oxygenation/ventilation and circulation/perfusion. Think of it as a portable cardiopulmonary bypass machine that is used in the OR for open heart surgery cases. As the ECMO settings are weaned, the patient is gradually taken off from ECMO support with the goal of decannulation. The patient then remains on the vent until extubation.

    In some centers, ECMO has been used as a bridge to lung transplantation. Patients who are lung transplant candidates MUST maintain a certain degree of mobility preceding transplantation. Those who decompensate with escalated oxygen requirements unable to be delivered with conventional non-invasive methods (i.e, high flow) are actually intubated, cannulated on ECMO, extubated and allowed to get out of bed (on ECMO!) - in that order while waiting for a lung donor.
    blondy2061h likes this.
  7. Visit  GrnTea profile page
    0
    Quote from juan de la cruz

    Rolando's Hospital Course:

    Perhaps owing to his healthy state prior to his infection and his age, Rolando improved clinically on ECLS and was eventually decannulated from the bulky device. He was eventually taken off pressors as well. He remained on intermittent dialysis for a period of time but subsequently had return of his kidney function. He luckily did not require a tracheotomy as his neurologic status was unaffected (his CSF was negative for cocci) and was extubated as soon as his ventilatory settings were down to minimum support.
    He was transferred to a regular hospital floor after about a couple weeks in the ICU. He went home with his mother after his hospital stay.

    See, I told ya: Lucky not to end up in a box. Valley fever is nothing to sneeze at.
  8. Visit  Lvdovicvs.Angelvs profile page
    1
    Quote from sarakjp
    [...] the eosinophilia caught my eye, which is making me think fungal/parasitic, maybe even toxin related [...]
    As a clinical laboratory technician student, it surprises me that only she paid attention to this. This was probably one of the most useful data at the start of the case study. As a CLT, we learn to interpret lab work in a basic manner.

    Greetings.
    Last edit by Lvdovicvs.Angelvs on Jul 5, '13
    LakeEmerald likes this.

Need Help Searching For Someone's Comment? Enter your keywords in the box below and we will display any comment that matches your keywords.



Nursing Jobs in every specialty and state. Visit today and find your dream job.

A Big Thank You To Our Sponsors
Top
close
close