Question

Mr. F., a 68-year-old man, is admitted to the critical care unit from the emergency department with respiratory failure and hypotension. His history is significant for type 2 diabetes mellitus, steroid-dependent chronic obstructive pulmonary disease, peripheral vascular disease, and cigarette and alcohol abuse. His medications at home include glipizide, prednisone, and a metered-dose inhaler with albuterol and ipratropium (Combivent). In the emergency department he received a single dose of ceftriaxone and etomidate for intubation.

            On exam he is intubated, on pressure-controlled ventilation, and receiving normal saline at 200 mL/hr and dopamine at 8 mcg/kg/min. His blood pressure is 86/50 mm Hg; heart rate, 126 beats/min; oxygen saturation, 88%; and temperature, 39.6°C. His cardiac rhythm shows sinus tachycardia and nonspecific ST-T wave changes. Arterial blood gas values are as follows: pH, 7.21; PaO2, 83 mm Hg; PaCO2, 50 mm Hg; and bicarbonate, 12 mEq/L. Other laboratory values are as follows: serum glucose, 308 mg/dL; serum creatinine, 2.1 mg/dL; and white blood cell count, 19,000/ microliter.

Questions

What disease state do you suspect this patient to experience and why?

What potential endocrine complications do you anticipate?

What further laboratory studies would you want? What results do you anticipate?

What treatment goals and strategies do you anticipate?

In providing patient and family education and support, what issues need to be addressed immediately and which can be delayed?

Answer 1

Present issues : respiratory failure, hypotension

Comorbidities: COPD, DM, PVD, alcoholism, cigarette smoking

Medications: MDI, OHA, steroid

Presently, on inotropes. Hypotensive

Mixed acidosis

Elevated blood sugars, s. Creat, WBC count

Fever

1. The patient is in septic shock. Sepsis is indicated by fever, elevated blood count. Possibly ling infection which led to acute exacerbation which explains the desaturation. The ongoing sepsis led to shock indicated by the presence of hypotension requiring inotropic support ( dopamine).

2. The sepsis can trigger diabetic ketoacidosis. Elevated counterregulatory hormones will result in increased blood sugars. Already blood sugars are elevated and metabolic acidosis ( along with respiratory acidosis due to CO2 retention) is present. This can worsen. The elevated blood sugars will lead to osmotic diuresis which will lead to severe dehydration. This is dangerous as the patient is already in shock. It can lead to hypokalemia. ECG changes can worsen further.

3. Investigations required: S. electrolytes: the patient is likely to have hypokalemia.

S.troponin : to rule out acute MI. May become positive. Patient has peripheral vascular disease so underlying coronary artery disease is also likely. The stress of septic shock may have triggered a cardiac event as well.

Echo to rule out cardiac dysfunction, so that fluids can be given.

Chest XRay - to rule out pneumonia

Serial serum creatinine and ABG- the patient is in acute renal failure and to assess progress

4. Treatment goals and strategies:

• Treat shock with inotropes and if fluids
• Treat sepis with antibiotics
• Treat DKA. Gradual blood sugar control
• Correct dyselectrolytemia
• Treat cardiac events of any
• Gradual weaning from mechanical ventilation

5. Issues to be dealt by family

Immediately:

• Requirement for mechanical ventilation.
• Need for inotropes. Chance of worsening
• Possibility of shock leading to cardiac events and even death.
• Treatment of infection

Delayed issues:

• Weaning from mechanical ventilation
• Disabilities and need for supportuve care