June 6, 2012
Case Study: Pneumonia and Sepsis in an Elderly MICU Patient
L.M. is a 75-year-old female who suffers from severe dementia and lives in a SNF. She was diagnosed with lung cancer in 2005 and as a result had a right upper and middle lobectomy. She also has a history of severe emphysema. L.M. has had several pneumonic infections and has an allergy to Pneumovax. She has a recurrent aspiration risk and received a tracheostomy and a PEG tube in January 2012.
On Aril 25, 2012, L.M. was found to be increasingly fatigued, somnolent, and had shortness of breath accompanied with tachycardia as witnessed by the staff at the SNF. When she arrived at the emergency department, she was tachycardic with a heart rate in the 130-140’s and tachypnic with a respiration rate in the 30-40’s. L.M., who normally depends on 2 liters of oxygen at home, desaturated to 88% requiring oxygen support increased to 4 liters. Her baseline systolic blood pressure is 100-110 and it was measured in the low 90’s in the ED. She also had an increased temperature of 38.2 degrees Celsius.
As a result of L.M.’s increase in temperature, heart rate, and respiratory rate accompanied with pneumonia, the emergency department treated her for sepsis. Labs drawn showed an increase in white blood cells and lactic acid, as well as an increase in PC02 and a decrease in PO2. She was aggressively resuscitated with IV boluses as necessary followed by maintenance normal saline. She was also administered Vancomycin, Cefepime, Azithromycin, and Metronidazole. In addition, her chest x-ray illustrated a near complete opacification of the right lung field. She was diagnosed with sepsis secondary to pneumonia complicated by a right lower lung collapse due to mucus plugging.
I assumed care of L.M. in the MICU ten days after her admission in the ED. She had been intubated and put on a mechanical ventilator. She was put on pressure support mode at a rate of 10, PEEP of 5, Fi02 of 40%, and her tidal volumes averaged around 230. She had three bronchoscopies, however, there was still evidence of mucous plugs and L.M. was unable to clear lung secretions. Respiratory therapy attempted to decrease the pressure support on the ventilator but L.M. showed increased signs of respiratory distress. At the point that I took over care for the patient, my goals were: prevent aspiration and further spread of infection and improve ventilation and perfusion.
Interventions for my patient to prevent aspirations and decrease risk of further infection included suction contaminated secretions, raise the head of the bed, and use of Chlorexidine wash. Protocol for suctioning an intubated patient in the MICU is every 4 hours or more frequently if necessary depending on the patient. L.M. had a history of recurrent aspirations and was at risk for increased infection because she was on a ventilator. “Closure of the glottis prevents aspiration of oropharyngeal secretions. When a patient is intubated with an endotracheal tube, the glottis remains open, leaving only the inflated cuff for protection against aspiration (Bennett, Bertrand, Penoyer, Sole & Talbert, 2011).” Therefore, routine suctioning helps to eliminate the pooling of secretions above the cuff of the endotracheal tube, where aspiration is most likely to occur. In addition, raising the head of the bed to 30-45 degrees decreases aspiration and the risk of ventilator-associated pneumonia. “The single most cost-free intervention found to reduce the incidence of VAP is elevation of the HOB (Stonecypher, 2010).” Although my patient was already diagnosed with pneumonia, it was important to prevent the spread of the infection to the healthy portion of her lungs or have a recurrence of sepsis. Chlorehexidine is an antiseptic that has been proven to inhibit dental plaque formation and gingivitis. I swabbed my patient’s mouth with...