Case Study Case Study PresentationPresentation

Michelle PryceMichelle Pryce

July 13, 2005July 13, 2005

IntroductionIntroduction

Biographical DataBiographical Data

General AppearanceGeneral Appearance

Social/Family HistorySocial/Family History

Prior Medical HistoryPrior Medical History Former premature infant (33 weeks)Former premature infant (33 weeks)

Cardiac abnormalitiesCardiac abnormalities

Pulmonary AbnormalitiesPulmonary Abnormalities

Developmental AbnormalitiesDevelopmental Abnormalities

Metabolic AbnormalitiesMetabolic Abnormalities

Ventricular Septal DefectVentricular Septal Defect VSD is the most VSD is the most

common cardiac common cardiac abnormalityabnormality

Small VSD can close Small VSD can close on their own; large on their own; large ones require surgeryones require surgery

If serious and If serious and uncorrected, VSD can uncorrected, VSD can increase pulmonary increase pulmonary artery pressures and artery pressures and cause a reversal of cause a reversal of blood flow.blood flow.

Cleft lip and palateCleft lip and palate 44thth most common birth most common birth

defectdefect can affects feedings can affects feedings

which in turn affect which in turn affect growth and developmentgrowth and development

At higher risk for At higher risk for aspiration during feedingaspiration during feeding

More difficulty breathing More difficulty breathing due to oral cavity due to oral cavity malformationmalformation

Later can have problems Later can have problems with speech, ear with speech, ear infections, and tooth infections, and tooth developmentdevelopment

AsthmaAsthma Asthma is characterized Asthma is characterized

by airway inflammation, by airway inflammation, smooth muscle smooth muscle constriction, and constriction, and accumulation of accumulation of secretions.secretions.

Can result in mucus Can result in mucus plugging and/or plugging and/or atelectasis if not properly atelectasis if not properly controlledcontrolled

Management of Management of symptoms include use of symptoms include use of anti-inflammatory and anti-inflammatory and bronchodilator for bronchodilator for immediate symptomsimmediate symptoms

Hospital CourseHospital CourseMay 27, 2005-presentMay 27, 2005-present

May 27, 2005 to June 15, 2005May 27, 2005 to June 15, 2005

June 16, 2005 to June 24, 2005June 16, 2005 to June 24, 2005

June 25, 2005 to July 12, 2005June 25, 2005 to July 12, 2005

Mechanical VentilationMechanical Ventilation Servo 300 ventServo 300 vent 3.5 cuffed ETT @ 3.5 cuffed ETT @

11cm11cm PRVC, rate 40, Vt 60, PRVC, rate 40, Vt 60,

peep 7, FiO2 35%peep 7, FiO2 35%

Attempting to deliver Attempting to deliver an adequate tidal an adequate tidal volume to correct volume to correct atelectasis with as atelectasis with as little risk of little risk of barotrauma as barotrauma as possible possible

Servo 300 ventServo 300 vent

Weaning: decrease Weaning: decrease rate by 2 breaths rate by 2 breaths every 12 hours to every 12 hours to maintain adequate pH maintain adequate pH level and EtCo2 levelslevel and EtCo2 levels

Extubated June 15Extubated June 15 Re-intubated an Re-intubated an

placed in SIMV (P) placed in SIMV (P) modemode

No changes madeNo changes made

Mechanical VentilationMechanical Ventilation

Flow curve decelerating ramp for better gas Flow curve decelerating ramp for better gas distributiondistribution

Diagnostic TestsDiagnostic Tests

BronchoscopyBronchoscopy Performed 06/20 to Performed 06/20 to

determine severity determine severity of airway softeningof airway softening

Determined to be Determined to be very severevery severe

Even with Even with ventilatory support ventilatory support airway caliber only airway caliber only 60%60%

EEGEEG Performed June 7Performed June 7thth

to determine cause to determine cause of seizure activityof seizure activity

Results—abnormal Results—abnormal EEG, but no EEG, but no definitive cause for definitive cause for seizure activityseizure activity

Diagnostic TestsDiagnostic Tests

Chest X RayChest X Ray

ETT positionETT position

Resolution of Resolution of atelectasisatelectasis

Artificial devicesArtificial devices

Labs and Blood GasesLabs and Blood Gases

Lab valuesLab values K—6.6 (3.5-5)K—6.6 (3.5-5) Na—136 (139-146)Na—136 (139-146) Cl—98 (98-107)Cl—98 (98-107) Glucose 113(50-80)Glucose 113(50-80) BUN 5 (4-9)BUN 5 (4-9) Creatinine 0.2 (0.2-0.4)Creatinine 0.2 (0.2-0.4) Calcium 9.2 (9.0-11.0)Calcium 9.2 (9.0-11.0) Anion gap 3 (7-16)Anion gap 3 (7-16)

Lab valuesLab values WBC—23,600WBC—23,600 RBC—3.82RBC—3.82 HBg—11.3HBg—11.3 Hct—33.1Hct—33.1 Plt ct--388Plt ct--388 Bands--34Bands--34 Segs--48Segs--48

Labs and Blood GasesLabs and Blood Gases

FINGER STICK BLOOD GAS FINGER STICK BLOOD GAS RESULTSRESULTS

pH-7.30pH-7.30 PO2-71PO2-71 Pco2-51Pco2-51 HCO3-25.1HCO3-25.1

Surgeries and Special Surgeries and Special ProceduresProcedures

Tracheotomy performed June 23Tracheotomy performed June 23

Insertion of central line June 18Insertion of central line June 18

Medications and their Medications and their actionsactions

Respiratory Respiratory MedsMeds

Albuterol/XopenexAlbuterol/Xopenex

Ipratropium bromideIpratropium bromide

FluticasoneFluticasone

Racemic epinephrineRacemic epinephrine

Other MedsOther Meds

Propranolol (regulate bp)Propranolol (regulate bp) Morphine/ativan/versed/ Morphine/ativan/versed/

fentynal-pain, anti-fentynal-pain, anti-anxietyanxiety

Methylprednisone-Methylprednisone-steriodsteriod

Tegretol-anagelsicTegretol-anagelsic Tylenol-pain reliefTylenol-pain relief Ciprofloxacin and Ciprofloxacin and

rocephin –antibioticsrocephin –antibiotics Lansoprazole –tx of acid Lansoprazole –tx of acid

refluxreflux

EKGEKG

Shows attempted pacing during a run of Shows attempted pacing during a run of non sustained V-tachnon sustained V-tach

Hr reached as high as 225Hr reached as high as 225 Also see the 2Also see the 2ndnd degree heart block degree heart block

Hemo valuesHemo values Normal 100d/5.2kg Normal 100d/5.2kg

infant valuesinfant values

Cardiac Output 1.0-2.0LCardiac Output 1.0-2.0L CVP—0-8CVP—0-8 Rt vent press—22/4Rt vent press—22/4 PAP—22/9PAP—22/9 Wedge—4-12Wedge—4-12 Left vent press—87/53Left vent press—87/53 SVR/PVR—20-30SVR/PVR—20-30

Predicted Values Predicted Values for this patientfor this patient

Cardiac Output--normalCardiac Output--normal CVP –normalCVP –normal Rt vent press- incr Rt vent press- incr

(65/9)(65/9) PAP-increased (60/20)PAP-increased (60/20) Wedge –normalWedge –normal Left vent press-dec Left vent press-dec

(75/10)(75/10) SVR/PVR both increasedSVR/PVR both increased

How is he now?How is he now?

As of July 12, he is stable.As of July 12, he is stable. He may be able to go home soon on He may be able to go home soon on

a home ventilator if he has adequate a home ventilator if he has adequate family supportfamily support

He has consultation orders for He has consultation orders for corrective surgeries after discharge corrective surgeries after discharge from GMHfrom GMH

Sources ReferencedSources Referenced

Darovic, Gloria. Darovic, Gloria. Hemodynamic Monitoring.Hemodynamic Monitoring. 3 3rdrd edition.edition.

www.heartpoint.comwww.heartpoint.com www.hemosapiens.com/normnpv.htmlwww.hemosapiens.com/normnpv.html www.marchofdimes.orgwww.marchofdimes.org www.plasticsurgery.orgwww.plasticsurgery.org www.rxlist.comwww.rxlist.com Whitiker, Kent. Whitiker, Kent. Comprehensive Perinatal and Comprehensive Perinatal and

Pediatric Respiratory CarePediatric Respiratory Care. 3. 3rdrd edition. edition.