Acute Respiratory Failure

Secondary to Drug Intoxication

Medical/Surgical Major Case Study
Melissa Perry
April 16, 2014
Introduction:
S.M. is a 51 year old female who is 56 (1.676 m) and weighs 267 lbs (121 kg).
S.M. was admitted to the Medial !ntensi"e #are $nit at %rand"iew Medial #enter on
Monday& 'an(ary 27& 2)1*. +his st(dy began ,ednesday& 'an(ary 2-& 2)1*& two days
after she was admitted& and ended a week later on ,ednesday& .ebr(ary 5& 2)1*. S.M.
alled /mergeny Medial Ser"ies from her ho(se when she began to e01eriene
shortness of breath the afternoon of Monday& 'an(ary 27& 2)1*. ,hen /MS arri"ed at her
home& they fo(nd m(lti1le em1ty Sero2(el bottles in her bed aro(nd her. ,hen 1resented
to the /mergeny 3e1artment& she om1lained of hest disomfort and emesis 1rior to
int(bation. !t was also noted that S.M. had dried blood in her nostrils (1on arri"al& b(t she
o(ld not 1ro"ide any history of 1resent illness. +he reason S.M. was hosen for the ase
st(dy was d(e to her e0tensi"e 1ast medial history inl(ding 4e1atitis 5& 4e1atitis #&
#673& alohol de1endene& dr(g ab(se& de1ression& and bi1olar disorder. S.M.s
admitting diagnosis of a(te res1iratory fail(re seondary to dr(g into0iation of
Sero2(el is the 1rimary fo(s of this st(dy.
Social History:
Sine admittane to the /mergeny 3e1artment for a(te res1iratory fail(re& S.M.
o(ld not 1ro"ide any reent history. 6ne admitted to the Medial !ntensi"e #are $nit&
she was sedated and int(bated. S.M. was home alone at the time of her inident. 5ased on
S.M.s last admission notes in the hos1ital in '(ne 2)18& she li"ed with her h(sband in a
ho(se with a ram1ed entrane. S.M. had a left below9the9knee am1(tation (5:;) in
<o"ember 2)12. She mobili=ed in a wheelhair or with a walker at times and relied
hea"ily on family members for "ehile trans1ortation. S.M. was (nem1loyed and
reei"ed disability benefits. S.M.s 1ast medial history states she has had a #esarean
setion& b(t there is no reent e"idene regarding hildren. 4er h(sband assisted her with
e"erything& b(t S.M. sometimes did light hores aro(nd the ho(se& s(h as d(sting or
light leaning. S.M. was a reo"ering aloholi and 2(it drinking abo(t two years ago.
She is also a (rrent smoker who had half a 1ak of igarettes for the 1ast 2) years. S.M.
reently started taking #hanti0& a non9niotine 1resri1tion mediine& and has (t bak to
abo(t 5 igarettes 1er day. S.M. also had a history of mari>(ana and oaine (se.
;ording to her soial history& S.M. s1ent a few weeks at ;rbors /#. 1rior to
hos1itali=ation and the n(rse at the e0tended are faility was (ns(re of the last time the
1atient (sed mari>(ana or oaine.
Normal anatomy and physiology of applicable body functions:
S.M. was admitted on the diagnosis of a(te res1iratory fail(re seondary to dr(g
into0iation of the anti1syhoti dr(g& Sero2(el. /0essi"e intake of dr(gs may
1rei1itate res1iratory fail(re by either a(sing 1(lmonary 1athology or by om1romising
res1iratory 1(m1 f(ntion. ?es1iratory fail(re entails ineffeti"e gas e0hange by the
res1iratory system aross the l(ngs. ;(te res1iratory fail(re (;?.) in"ol"es s(dden
absene of res1irations& with (nres1onsi"eness or onf(sion and a failed mehanism of
1(lmonary gas e0hange. +here are se"eral different a(ses that an lead to res1iratory
fail(re (See ;11endi0 ;). (1) ;?. is a ommon om1liation of dr(g ab(se. 3r(gs may
1rei1itate res1iratory fail(re by om1romising res1iratory 1(m1 f(ntion and may lead
to as1iration 1ne(monia. ;s1iration 1ne(monia is one of the most ommon 1(lmonary
om1liations in regards to loss of onsio(sness and damage to the l(ngs from
inhalational e01os(re to dr(gs. (2)
+he 1(lmonary system is (nable to 1erform its f(ntions d(e to the om1liations
of res1iratory fail(re. +he res1iratory enter is loated at the base of the brain. +his
reg(lates breathing and determines how often and how dee1ly we breathe. 3ereased
f(ntion of the res1iratory enter will lead to res1iratory fail(re and this an be diretly
related to dr(g o"erdose. (8)
!n res1iratory fail(re& the 1atient re2(ires o0ygen that may be 1ro"ided thro(gh a
nasal ann(la or by mehanial "entilator s(11ort. (*) 60ygen le"els m(st be normali=ed
as soon as 1ossible and this an be done by 1ro"iding s(11lemental o0ygen. @entilatory
s(11ort is essential for 1atients with high arbon dio0ide le"els. +hro(gh "entilators&
1atients reei"e 1ress(re gas that inreases 1ress(re when triggered by the 1atients
ins1iratory effort. (8)
/0essi"e amo(nts of ertain dr(gs an a(se im1ro1er f(ntioning of the kidney&
whih a(ses fl(ids to be im1ro1erly filtered from the body. 7(lmonary edema is the
b(ild (1 of fl(id in the l(ngs and it an se"erely hinder the bodys res1iratory system and
an lead to res1iratory fail(re. +he kidney filters waste materials o(t of the bloodstream&
so when to0i s(bstanes reah dangero(s le"els& the kidneys fail to f(ntion. ,hen the
kidneys ant filter eno(gh aid o(t of the system it leads to metaboli aidosis& whih is
when the high le"els of aid interfere with the bodys "ital systems. Metaboli aidosis
an a(se ardia and ne(rologial om1liations. (5)
Past Medical History:
S.M. has a 1ast medial history of se"eral different diagnoses. +he ma>ority of her
medial history 1roblems are related to one another. S.M. had a history of an0iety&
de1ression& borderline 1ersonality& alohol de1endene& and nonom1liane with
mediation regimens. She also had a history of 4e1atitis 5& 4e1atitis #& M?S;
(methiillin resistant Sta1hyloo(s a(re(s)& ne(ro1athy& 1ne(monia& blood transf(sion&
hy1ertension& and ell(litis. S.M. has had ma>or 1roblems in"ol"ing the l(ngs& s(h as
#673 (hroni obstr(ti"e 1(lmonary disease) and a(te res1iratory fail(re. She had
1re"io(s om1liations that inl(ded ar1el t(nnel syndrome and a frat(re in her left
ankle. She also had a 1rior s(rgial history that inl(des abdomen s(rgery& leg s(rgery&
#esarean setion& rhino1lasty& debridement on her left ankle& and a 5:; (below the knee
am1(tation) on her left leg.
S.M. had been admitted to %rand"iew Medial #enter se"eral times before this
most reent inident. She was admitted bak in '(ne 2)18 with a hief om1laint of
sli11ing and hitting her head while trying to (se her walker at home. +his admitting
diagnosis also inl(ded se1sis and le(koytosis. 5efore this& she was admitted in May
2)18 d(e to dys1nea& inl(ding 1ne(monia and #673 e0aerbation. +he 1re"io(s
admittane 1rior to this e"ent was in 'an(ary 2)18. She was admitted d(e to fre2(ent falls
with di==iness and lightheadedness. +his was likely related to /t64 (se and her 5:;.
;nother ma>or admission to %rand"iew Medial #enter was in <o"ember 2)12. She
1resented to the hos1ital with 1rogressi"e 1ain and swelling in her left ankle. 3(ring this
admission& S.M. (nderwent s(rgery for her left 5:; d(e to osteomyelitis in her left
ankle.
Present Medical Status and Treatment:
?es1iratory fail(re o(rs when the 1(lmonary system is (nable to 1ro1erly
f(ntion (*). +he 1(lmonary system inl(des the l(ngs and the m(sles that aid in
breathing to 1(m1 air in and o(t of the l(ngs. ;(te res1iratory fail(re is a s(dden
om1liation that in"ol"es absene of res1irations and fail(re of 1(lmonary gas
e0hange. Some of the a(ses of res1iratory fail(re inl(de hroni bronhitis
(inflammation of air 1assages to the l(ngs)& em1hysema (1rogressi"e l(ng disease)&
asthma& stroke& s1inal ord in>(ry& hest wo(nd& tra(ma& obesity& and in S.M.s sit(ation&
dr(g into0iation. (1)
/0essi"e amo(nts of ertain dr(gs an a(se im1ro1er f(ntioning of the
kidney& whih a(ses fl(ids to be im1ro1erly filtered from the body. 7(lmonary edema is
the b(ild (1 of fl(id in the l(ngs and it an se"erely hinder the bodys res1iratory system
and an lead to res1iratory fail(re. +he kidney filters waste materials o(t of the
bloodstream& so when to0i s(bstanes reah dangero(s le"els& the kidneys fail to
f(ntion. ,hen the kidneys ant filter eno(gh aid o(t of the system it leads to
metaboli aidosis& whih is when the high le"els of aid interfere with the bodys "ital
systems. Metaboli aidosis an a(se ardia and ne(rologial om1liations. (5)
+reatment for a(te res1iratory fail(re (s(ally de1ends on the (nderlying a(se
and inl(des im1ro"ing the indi"id(als "entilation and inreasing their o0ygen. +here
are m(lti1le o1tions a"ailable in treating res1iratory fail(re& s(h as antibiotis&
bronhodilators (mediine that hel1s o1en the airways of the l(ngs)& ortiosteroids
(steroid (sed for anti9inflammatory thera1y and effeti"e in aelerating reo"ery from
a(te e0aerbations)& o0ygen thera1y& mehanial "entilation& and n(trition thera1y.
/nteral feedings started within 8 days of the onset of a(te res1iratory fail(re may
im1ro"e a ritially ill 1atients o(tome or red(e the length of time on a "entilator.
Some of the ma>or inter"entions are to relie"e breathlessness& derease #62 1rod(tion&
and ele"ate the 1atients head in order to 1re"ent as1iration when (sing enteral n(trition.
(1) S.M. was 1laed on enteral feedings the day right after she was admitted to the
hos1ital& sedated& and int(bated with mehanial "entilator s(11ort.
S.M. was 1resented to the hos1ital with res1iratory distress. She om1lained of
hest disomfort and "omiting when she was in the /mergeny 3e1artment. She then had
to be int(bated and sedated seondary to a(te res1iratory fail(re. S.M. was at home
when she started e01eriening shortness of breath& whih was fo(nd to be a(sed by an
o"erdose of an anti1syhoti dr(g. +here are se"eral sym1toms that an be assoiated
with dr(g o"erdose (See ;11endi0 5). (5) +he /MS (/mergeny Medial Ser"ies)
fo(nd S.M. lying in bed with se"eral em1ty Sero2(el bottles aro(nd her. Sero2(el is an
anti1syhoti dr(g (sed to treat de1ressi"e disorder& bi1olar disorder& and shi=o1hrenia
(6). S.M. did ha"e a history of dr(g ab(se& bi1olar disorder& and de1ression. 7er 7hysiian
note 1A27& S.M.s blood 1ress(re was noted to be 2))A1))s and she had res1iratory
distress with altered mentationAobt(ndation (altered le"el of onsio(sness) that led to
int(bation and sedation.
$1on admission& S.M. had se"eral laboratory "al(es o(t of the normal range& s(h
as her blood gl(ose& ammonia& lati aid& red blood ell o(nt& hemoglobin& hematorit&
;B+& and ;S+ le"els. S.M.s 1ast medial history did not state she had diabetes mellit(s&
howe"er she was 1(t on Metformin and 4(malog before eah meal while in the hos1ital.
,hen she arri"ed to the /mergeny 3e1artment on 'an(ary 27& 2)1* her blood gl(ose
le"el was ele"ated at 18* mgAdB (normal range of 7*91)6 mgAdB). /le"ated blood
gl(ose le"els are ommon in 1atients with ritial illness. S.M. had a 4emoglobin ;1#
test done on 'an(ary 27& 2)1* and it was at 5.*C (?ange DE6.5C). 4er last 4emoglobin
;1# test was done '(ne 7& 2)18 and it was at 6.2C. S.M.s ammonia le"el was also
ele"ated (1on admission at *1 (moBAB (normal range of 11982 (moBAB). ;mmonia
forms when 1rotein is broken down by bateria in the intestines. !n a normal f(ntioning
li"er& it on"erts ammonia into (rea and then the (rea is eliminated in the (rine.
;mmonia le"els in the blood rise when the li"er isnt f(ntioning 1ro1erly and ant
on"ert ammonia into (rea. +his may be a(sed by he1atitis or another infetion in the
li"er. (7)
S.M. had an ele"ated lati aid le"el of 8.5 mmolAB (normal range of ).*92
mmolAB). Most lati aid in the body is made by m(sle tiss(e and red blood ells.
/le"ated lati aid is a good indiator for metaboli aidosis& whih o(rs when the
body 1rod(es too m(h aid and the kidneys ant remo"e eno(gh of the aid from the
body. (F) 4er red blood ell& hemoglobin& and hematorit le"els were all low& whih
indiate anemia or the bodys inability to arry o0ygen thro(gho(t the body. +he red
blood ell le"el was at 8.75 millionA(B& whih is below the normal range of 8.F695.17
millionA(B. +he hemoglobin le"el was at 11.8 gAdB (normal range of 12.1915.F gAdB) and
hematorit was at 88.FC (normal range of 85.F9*6.5C). ,hen o0ygen is at a normal
le"el in the body& arbohydrate breaks down into arbon dio0ide and water. Bati aid
may inrease when the bodys o0ygen le"el is low and arbohydrates are broken down
for energy. Bati aid le"els may also rise when the li"er is damaged bea(se the li"er
breaks down lati aid. (F) ,hen S.M. alled the /mergeny 3e1artment she was
e01eriening shortness of breath and was fo(nd with em1ty bottles of Sero2(el& an
anti1syhoti dr(g (sed for bi1olar or de1ressi"e disorder. ,hen she 1resented to the
hos1ital she was sedated and int(bated seondary to a(te res1iratory fail(re.
S.M. also had ele"ated le"els of ;S+ (;s1artate aminotransferase) and ;B+
(;lanine aminotransferase). ;S+ and ;B+ are the two main li"er en=ymes. +he li"er
deto0ifies harmf(l s(bstanes& metaboli=es 1roteins& and 1erforms se"eral other
f(ntions. ,hen the li"er ells are damaged& the ;S+ and ;B+ en=ymes may leak o(t of
the ells and into the blood. (-) S.M.s ;S+ le"el was e0tremely ele"ated at 871 $AB
(normal range of 15987 $AB) and ;B+ was ele"ated at 1)- $AB (normal range of 1297F
$AB).
Lab Values upon admission: 1!"1#
$esult Value Normal $ange
Sodi(m 187 18691*5 mmolAB
7otassi(m *.1 8.595.1 mmolAB
#hloride 1)* -F91)7 mmolAB
#62 2* 21982 mmolAB
%l(ose 18* (G) 7*91)6 mgAdB
5$< - 791F mgAdB
#reatinine ).-7 ).6)91.8) mgAdB
#ali(m F.* (G) F.591).1 mgAdB
e%.? ;frian ;merian H6) H6) mlAminA1.78m2
,5# F.1 *91).5 1)G8A(B
?5# 8.75 (G) 8.F695.17 1)G6A(B
4%5 11.8 (G) 12.1915.F gAdB
4#+ 88.F (G) 85.F9*6.5 C
M#@ -).) F59-- fl
;mmonia *1 (G) 11982 (moBAB
Bati ;id 8.5 (G) ).*92.) mmolAB
;B+ 1)- (G) 1297F $AB
;S+ 871 (G) 15987 $AB
G Bab "al(es o(t of the normal range
(all other lab "al(es within normal limits)
6"ertime& S.M.s lab "al(es had either 1rogressi"ely gotten worse or stayed the
same. S.M.s ,5# (,hite 5lood #ell) o(nts& the disease9fighting ells& inreased to
18.F 1)G8A(B (normal range of *91).5 1)G8A(B). /le"ated white blood ells re"eal an
inflammatory res1onse& infetion& or 1hysial stress that is 1(t on the body. 4er ?5#&
hemoglobin& and hematorit le"els ontin(ed to derease. S.M.s 5$<& blood (rea
nitrogen& le"el ele"ated o"er time in the hos1ital to 25 mgAdB (normal range of 791F
mgAdB). 5$< is a nitrogen9ontaining waste 1rod(t generated by m(s(lar ati"ity and
an be related to kidney disease. /le"ated 5$< lab "al(es may also be an indiator of
dehydration& dr(g reations& s(rgery& or heart 1roblems. S.M.s alb(min le"el was taken
and it was at 2.1 gAdB (normal range of 8.*95.* gAdB). ; low alb(min le"el may indiate
li"er disease or infetion related to he1atitis. (6) S.M.s lati aid le"el also rose to -
mmolAB the last day of the st(dy& .ebr(ary 5& 2)1*.
Lab Values: !#1#
$esult Value Normal $ange
Sodi(m 187 18691*5 mmolAB
7otassi(m *.1 8.595.1 mmolAB
#hloride -7 (G) -F91)7 mmolAB
#62 82 21982 mmolAB
%l(ose 115 (G) 7*91)6 mgAdB
5$< 25 (G) 791F mgAdB
#reatinine ).76 ).6)91.8) mgAdB
#ali(m F.8 (G) F.591).1 mgAdB
e%.? ;frian ;merian H6) H6) mlAminA1.78m2
,5# 18.F (G) *91).5 1)G8A(B
?5# 8.)- (G) 8.F695.17 1)G6A(B
4%5 -.1 (G) 12.1915.F gAdB
4#+ 27.8 (G) 85.F9*6.5 C
M#@ FF.5 F59-- fl
S.M. remained int(bated and sedated thro(gho(t her time in the hos1ital. 4er
o0ygen sat(ration le"el dro11ed to F5C on .ebr(ary 5& 2)1*. She was immediately 1(t
on 1))C o0ygen s(11ort with 7//7 of 1*. 7//7 (1ositi"e end9e01iratory 1ress(re) is a
method of mehanial "entilation that is meant to im1ro"e gas e0hange. (1)
$1on admission to the hos1ital on 1A27& S.M. was 1(t on the following mediationsI
nal6Jone ).* mg 6<#/
/tomidate 2) mg 6<#/
?o(roni(m 1)) mg 6<#/
;ti"ated haroal9sorbitol 5) g 6<#/
7ro1ofol 2) mg 6<#/
7i1eraillin9ta=obatam in <S *.5 g 6<#/
#i1roflo0ain in 35, *)) mg 6<#/
@anomyin in de0trose 1))) mg 6<#/
7ro1ofol 1*.186 mgAkgAmin #ontin(o(s inf(sion
3(e to S.M.s admitting diagnosis& <alo0one was gi"en to her (1on admission to
the hos1ital. <alo0one is a s1eial naroti dr(g (sed to treat naroti dr(g o"erdose.
/tomidate is (sed to ind(e general anesthesia and ?o(roni(m is gi"en before
anesthesia to hel1 rela0 the m(sles. ;ti"ated haroal9sorbitol is an adsorbent and it is
(sed to treat o"erdose or 1oisoning by binding with the 1oison in the stomah to derease
absor1tion into the body. 7ro1ofol red(es an0iety and tension by 1romoting loss of
onsio(sness or rela0ation. 7i1eraillin9ta=obatam& #i1roflo0ain and @anomyin are
all antibiotis. ;ll three of these dr(gs are (sed to kill bateria. (6) S.M. was immediately
gi"en these mediations to hel1 1re"ent ertain side effets from her aidental o"erdose
of Sero2(el and a(te res1iratory fail(re.
6ne S.M. was admitted to the !ntensi"e #are $nit& she was 1(t on the followingI
7otassi(m #hloride 2) m/2 +wo times daily
7anto1ra=ole *) mg 3aily at )6))
#hlorhe0idine 15 mB +wo times daily
!ns(lin lis1ro 291) (nits /"ery * ho(rs
@anomyin 1))) mg /"ery 12 ho(rs
#lona=e7;M 1 mg +wo times daily
7i1eraillin9ta=obatam 8.875 g /"ery F ho(rs
Be"oflo0ain 75) mg /"ery 2* ho(rs
+hiamine (591) 1)) mg 3aily
4e1arin (7orine) 5))) (nits /"ery F ho(rs
;lb(terol 2.5 mg <eb(li=ationI e"ery 6 ho(rs
!1ratro1i(m ).5 mg <eb(li=ationI e"ery 6 ho(rs
7ro1ofol *) mgAkgAmin !nf(sion
7otassi(m #hloride is (sed to treat or 1re"ent low blood le"els of 1otassi(m.
7otassi(m is an essential mineral that is needed for se"eral f(ntions& es1eially the
beating of yo(r heart. 7otassi(m le"els an be low after a 1rolonged illness& whih is
1robably why S.M. was 1(t on this mediation >(st to make s(re her blood le"els stay
within the normal range. (6) 7anto1ra=ole is a 1roton 1(m1 inhibitor (sed to derease the
amo(nt of aid 1rod(ed in the stomah. #hlorhe0idine is an oral rinse (sed to red(e
bateria in the mo(th. Sine S.M. was not eating anything by mo(th& this rinse was
neessary to (se. !ns(lin lis1ro is a fast9ating ins(lin ty1ially (sed to treat 1eo1le with
diabetes by hel1ing to lower their blood s(gar le"els. ;ording to S.M.s 1ast medial
history& it did not state that she had diabetes& yet her gl(ose le"els were ontin(o(sly
ele"ated. 5lood gl(ose le"els an inrease d(e to illness. !t is "ery im1ortant to (se the
fast9ating ins(lin within 15 min(tes of eating& b(t S.M. did not ha"e to worry abo(t that
sine she was on a ontin(o(s t(be feed. She ontin(ed to reei"e antibioti mediations&
s(h as @anomyin& 7i1eraillin9ta=obatam& and Be"oflo0ain. #lona=e7;M is (sed to
treat se"ere 1ani disorder. !t affets the hemials in the brain that a(se an0iety and
hel1s to red(e these (nbalaned hemials. (6)
+hiamine is @itamin 591 and as a mediation it is (sed to 1re"ent @itamin 591
defiieny. #hroni alohol ons(m1tion an lead to +hiamine defiieny and sine S.M.
had a long history of /t64 de1endene& she was 1laed on this mediation. 4e1arin is
an antioag(lant (blood thinner). +his 1re"ents the formation of blood lots. S.M. was
also 1(t on ;lb(terol and !1ratro1i(m& whih are bronhodilators that rela0 the airway
m(sles and inrease air flow to the l(ngs. +his was an essential mediation to be 1(t on
sine S.M. (nderwent a(te res1iratory fail(re. +hese mediations sho(ld not be taken
with alohol bea(se that will interat with the mediation and may lead to sym1toms of
di==iness& headahe& and 1ossible hanges in heart rate (6).
S.M. was sedated and int(bated the entire time in the hos1ital. +he third day S.M.
was in the hos1ital& 'an(ary 2-& 2)1*& she beame agitated and nearly e0t(bated herself.
+he t(be was ad"aned and the "entilator was ad>(sted to im1ro"e o0ygenation. !n order
to red(e tension and 1romote sedation& the 7ro1ofol was inreased to a high rate of *)
mgAkgAmin. She was also 1(t on Basi0 thro(gho(t her hos1itali=ation bea(se she had
edema and they were trying to inrease di(resis.
3(e to S.M. being sedated and int(bated the entire time while hos1itali=ed& she
o(ld only be obser"ed sine she was (nable to be inter"iewed. $nfort(nately&
thro(gho(t the time of her stay in the hos1ital& S.M. did not ha"e any "isitors& whih
eliminated the o11ort(nity to ask family members or friends 2(estions abo(t her history
or 1resent sit(ation. S.M.s <(rse noted if there were any 1hysial or 1syhologial
hanges while in the hos1ital. 7er ?< note 1A2-& S.M. beame agitated and fre2(ently
attem1ted to 1(ll at the endotraheal t(be and was 1(t in bilateral soft wrist restraints and
gi"en 7ro1ofol that almed her down. 7er ?< note 1A8)& S.M. was tahy1nei (ondition
of ra1id breathing) and had tahyardia (inreased heart rate) at times. !t was 1art of
n(rsing 1rotool to t(rn S.M. e"ery 2 ho(rs to 1re"ent skin breakdown& b(t as of 2A2 she
was fo(nd to ha"e a Stage 2 oy0 (ler.
+reatment for a(te res1iratory fail(re (s(ally onsists of antibiotis&
bronhodilators& ortiosteroids& o0ygen thera1y& mehanial "entilation& and n(trition
thera1y. Sine admission to the hos1ital& S.M. reei"ed antibiotis& s(h as 7i1eraillin9
ta=obatam& #i1roflo0ain and @anomyin. She was also treated with ;lb(terol and
!1ratro1i(m& whih are bronhodilators that rela0 the airway m(sles and inrease air
flow to the l(ngs. S.M. was then treated with o0ygen thera1y and mehanial "entilation
thro(gh /ndotraheal int(bation. She was 1(t on #M@ with 62 sats 1))C. !n order to
red(e tension and 1romote sedation& S.M. was gi"en 7ro1ofol that ranged between 1*9
*) mgAkgAmin.
7er 7hysiian note 1A2-& S.M. was gi"en a #@S (#ardio"as(lar) /0amination
and a #hest J9?ay. +he #@S e0am is essentially an e0amination of the heart& b(t it also
inl(des e0amination of other 1arts of the body& s(h as nek& fae& and hands. +he
1(r1ose of the e0am is to 1ik (1 any ardio"as(lar 1athology that o(ld be a(sing the
1atients sym1toms that wo(ld inl(de hest 1ain or breathlessness. (1)) +he #hest J9
?ay re"ealed abilateral basilar o1aities s(ggesti"e of ateletasis "ers(s infiltrate 1er
radiology. !t also re"ealed a onern for as1iration 1ne(monitis seondary to emesis with
int(bation. ;n /hoardiogram was 1erformed on S.M. on 'an(ary 81& 2)1*. !t was
1erformed to im1ro"e assessment of B@ (left "entri(lar) f(ntion and fo(nd sin(s
tahyardia rhythm (ele"ated heart rhythm).
S.M. was also gi"en a $rea <itrogen $rine +est& whih meas(res a 1ersons
1rotein balane and the amo(nt of food 1rotein that is needed. !f the nitrogen balane is
negati"e& then that 1ersons 1rotein intake needs to be inreased. S.M.s 2* ho(r $$<
test from 2A8 to 2A* re"ealed a negati"e *.* <9balane. +his res(lted in S.M. needing an
additional 27.5 grams 1rotein on to1 of her 65 grams 1rotein she was already reei"ingK
making it a total of -2.5 grams 1rotein needed daily.
!t was deided that S.M. did in fat aidentally o"erdose on Sero2(el& whih led
to her a(te res1iratory fail(re. +he a(te res1iratory fail(re& along with all of S.M.s
other 1ast medial history 1roblems& (ltimately led to her bodys fail(re to f(ntion any
longer.
Medical Nutrition Therapy:
Sine S.M. was int(bated and sedated and there were no family members 1resent
to inter"iew thro(gho(t her hos1itali=ation& information abo(t her n(trition history ame
from 1ast admissions to the hos1ital. S.M. was admitted se"eral times before to
%rand"iew Medial #enter. 4er 1ast admissions show her to be on a reg(lar diet most of
the time. She was 1(t on a 4eart 4ealthy diet d(ring her last admission in '(ne 2)18. ;
dietitian was ons(lted bea(se she had a Stage 2 1ress(re (ler and needed to ha"e her
alorie and 1rotein needs inreased. +hro(gho(t this "isit by the ?3& S.M. re2(ested to
ha"e her diet hanged from 4eart 4ealthy to a ?eg(lar diet. .rom all 1ast admissions to
the hos1ital& it was noted that S.M. ons(med 7591))C of all meals.
5ased on 1re"io(s admissions& S.M. was to follow a 4eart 4ealthy diet bea(se
she had hy1ertension& b(t it is (nlear whether she followed that diet at home or not. S.M.
had no food allergies listed& whih leads to the belief that she did not s1eifially a"oid
any foods& (nless they were ones she had disliked.
3(e to S.M. being int(bated and sedated thro(gho(t her hos1itali=ation& she was
not a11ro1riate to be inter"iewed. +he st(dy began when n(trition are was ons(lted on
'an(ary 2-& 2)1*. S.M. was 1laed on t(be feeding on 'an(ary 2F& 2)1*& whih was the
day right after she was admitted to the hos1ital. 3(e to S.M.s ondition& she was not
a11ro1riate for oral feedings& whih was why her 7hysiian ordered enteral n(trition right
away. S.M.s 7hysiian ordered t(be feeding of <(tri4e1 at 8) mB 1er ho(r on 'an(ary
2F. <(tri4e1 at 8) mB 1er ho(r 1ro"ides a total of 1)F) alories& 2- grams 1rotein& and
5*7 free water. <(tri4e1 is an enteral n(trition form(la (sed for he1ati 1atients. !t is
a form(la rih in branhed9hain amino aids& alorially dense& and it 1ro"ides a high
alorie9to9nitrogen ratio. (11) !t is likely that the 7hysiian hose <(tri4e1 as the first
hoie for S.M. bea(se of her dr(g into0iated li"er and ele"ated ;S+ and ;B+ lab
"al(es. ;S+ and ;B+ are the two main li"er en=ymes.
Bab 1A27 1A2F 1A2- <ormal range
;B+ 1)-G --G F8G 1297F $AB
;S+ 871G 278G 17)G 15987 $AB
S.M. was gi"en 1*.186 mgAkgAmin 7ro1ofol on 'an(ary 27& 2)1* to sedate her.
+he 7ro1ofol was then sto11ed on 'an(ary 2F. ;s of 'an(ary 2-& 2)1*& the day the st(dy
began& S.M. was not (rrently on 7ro1ofol. She did not restart 7ro1ofol (ntil the morning
of 'an(ary 8) and it was 1(t at 85 mgAkgAmin. +he 7ro1ofol was at 85 mgAkgAmin (ntil
it was sto11ed again on .ebr(ary 1& 2)1* d(e to ha"ing to re1lae a 7!## line. +he
7ro1ofol started bak (1 the morning of .ebr(ary 2 and it was at *) mgAkgAmin (ntil the
last day of the st(dy& .ebr(ary 5& 2)1*.
+he afternoon of 'an(ary 2-& 2)1*& S.M.s 7hysiian aneled the order for the
<(tri4e1 t(be feeding form(la and 1(t in a new order for .iberso(re 4< at *) mB 1er
ho(r. .iberso(re 4< at *) mB 1er ho(r 1ro"ides 1152 alories& 52 grams 1rotein& and
77F free water. +here was no 7ro1ofol r(nning at this time to deli"er e0tra alories
from fat. .iberso(re 4< is a high 1rotein& fiber ontaining t(be feeding form(la. !t is
1ossible that the 7hysiian hose to hange the enteral n(trition form(la from <(tri4e1
to .iberso(re 4< bea(se her ;B+ and ;S+ lab "al(es were slowly im1ro"ing and
.iberso(re 4< is higher in 1rotein and ontains fiber.
Nutrition %ssessment: &anuary !'( !)1#
$ecommendations: #ontin(e (rrent +(be .eed regimen as tolerated. !f warranted&
reommend .iberso(re 4< be inreased as tolerated to a goal rate of 6) mB 1er ho(r to
1ro"ide 172F alories& 7F grams 1rotein& and 1166 free water daily (-6C of alorie
needs and 1)FC of 1rotein needs).
*stimated Nutritional Needs:
25 #alories 1er kg 1 gram 7rotein 1er kg .l(id needs if on +(be .eed
17-F alories 72 grams 1rotein (1 mB 1er kal )
17-F mB
<(tritional needs based onI ad>(sted body weightI 71.- kg
Nutrition +iagnosis: 7atient with inade2(ate energy intake related to t(be feeding
1ro"iding less than estimated n(tritional needs as e"idened by (rrent t(be feed regimen
1ro"iding 6*C of alorie needs and 72C of 1rotein needs.
Nutrition Inter,ention:
Beft reommendation for 7hysiianI .iberso(re 4< at a goal rate of 6) mB 1er ho(r.
,ill ro(tinely monitor n(trition 1arameters and follow for tolerane.
Nutrition -oals:
1. +olerate t(be feed at goal rate to meet 1))C of 1atients estimated n(tritional needs.
+he day after& 'an(ary 8)& 2)1*& S.M.s t(be feed order was inreased to
.iberso(re 4< at 5) mB 1er ho(r& whih 1ro"ides 1**- alories& 65 grams 1rotein& and
-72 water. 7ro1ofol was also restarted at 85 mgAkgAmin.
+he 7ro1ofol was at 85 mgAkgAmin (ntil it was sto11ed again on .ebr(ary 1&
2)1* d(e to S.M. ha"ing her 7!## line re1laed. +he 7ro1ofol started bak (1 the
morning of .ebr(ary 2 and it was inreased to *) mgAkgAmin. 6n .ebr(ary 2& 2)1* her
t(be feeding form(la was hanged to <(tren 7(lmonary at *) mB 1er ho(r& whih
1ro"ides 1**) alories& 65 grams 1rotein& and 7*- free water. <(tren 7(lmonary is an
enteral n(trition form(la for 1atients with res1iratory iss(es. !t has a modified
arbohydrate and balaned fat 1rofile for better tolerane and designed with a
arbohydrate le"el to hel1 red(e 1rod(tion of #62 and res1iratory 2(otient. (12)
Bab 1A27A1* 1A8)A1* 2A2A1*
#62 (<ormal range
21982 mmolAB)
21 81 8*G
6n .ebr(ary 1& 2)1*& it was diso"ered that S.M. had a Stage 2 oy0 1ress(re
(ler. 4a"ing a Stage 2 wo(nd inreases a 1atients energy and 1rotein needs. +herefore&
when S.M. was reassessed on .ebr(ary 8& 2)1*& her 1rotein and alorie needs inreased.
Nutrition $eassessment: .ebruary /( !)1#
$ecommendations: !f warranted& reommend <(tren 7(lmonary at a goal rate of 5) mB
1er ho(r to 1ro"ide 1F)) alories& F2 grams 1rotein& and -86 free water daily (1))C of
alorie needs& 11*C of 1rotein needs).
*stimated Nutritional Needs: ?eassessed d(e toI Stage 2 oy0 1ress(re (ler
0Nutrition Prescription1
2592F #alories 1er kg 191.2 gram 7rotein 1er kg .l(id needs if on +(be .eed
17-F92)18 alories 729F6 grams 1rotein (1 mB 1er kal )
17-F92)18 mB
<(tritional needs based onI ad>(sted body weightI 71.- kg
$e,ised Nutrition +iagnosis Statement: 7atient with inreased energy and 1rotein
needs related to wo(nd healing as e"idened by stage 2 oy0 1ress(re (ler.
Nutrition Inter,ention:
Beft reommendation for 7hysiianI <(tren 7(lmonary at goal rate of 5) mB 1er ho(r.
,ill monitor n(trition 1arameters and follow for tolerane.
Nutrition -oals:
1. +olerate t(be feed at goal rate to meet 1))C of 1atients estimated n(tritional needs.
S.M.s t(be feeding of <(tren 7(lmonary remained at *) mB 1er ho(r with
7ro1ofol at *) mgAkgAmin (ntil .ebr(ary *& 2)1*& and this 1ro"ided a total of 2*-6
alories& 65 grams 1rotein& and 7*- free water.
+he afternoon of .ebr(ary *& 2)1*& the 7hysiian ad"aned S.M.s t(be feed of
<(tren 7(lmonary to 65 mB 1er ho(r to 1ro"ide 28*) alories& 1)6 grams 1rotein& and
1217 free water daily. +he t(be feed of <(tren 7(lmonary ran at 65 mB 1er ho(r&
along with the 7ro1ofol at *) mgAkgAmin (ntil the last day of the st(dy& .ebr(ary 5&
2)1*. ;ording to S.M.s ?< and do(mented notes& S.M. tolerated eah t(be feeding
"ery well with minimal resid(als. !t was ina11ro1riate to inter"iew S.M. at any time
d(ring her hos1itali=ation& whih 1re"ented the n(trition ed(ation 1roess.
Prognosis:
S.M. had a long list of 1roblems in her 1ast medial history& inl(ding
hy1ertension& #673& se1sis& alohol and s(bstane ab(se& 4e1atitis #& 4e1atitis 5& as
well as her most reent admittane to the hos1ital for a(te res1iratory fail(re& ;?3S&
and dr(g o"erdose. S.M. remained sedated& int(bated& and reei"ed her n(trition thro(gh
t(be feeding the entire time while she was in the hos1ital. 6n .ebr(ary 1& 2)1*& S.M. had
some e1isodes of what was desribed as "tah. @entri(lar tahyardia ("tah) is a ra1id
heart beat that originates in one of the lower hambers ("entriles) of the heart.
@entri(lar tahyardia is (s(ally a(sed by other heart 1roblems& s(h as high blood
1ress(re or oronary artery disease. !t an also de"elo1 in 1eo1le who do not ha"e heart
disease& and it may be a(sed by ertain mediations& e0essi"e alohol ons(m1tion& or
dr(g ab(se. (18) /0essi"e intake of Sero2(el has been fo(nd to a(se tahyardia&
somnolene& hy1erglyemia& and L+ 1rolongation (1*).
7er 7hysiians note 2A5& it was s(s1eted the 1atient had a loss of onsio(sness
seondary to her o"erdose& whih res(lted in a large9"ol(me as1iration. ;s of .ebr(ary 5&
2)1*& S.M.s left l(ng infiltrate had worsened and her white blood ell o(nt ontin(ed to
inrease. ;bo(t one ho(r after the 7hysiian had "isited with S.M.& her o0ygen sat(ration
dro11ed to F5 and she was 1(t on 1))C o0ygen s(11ort with 7//7 of 1*. She was also
ordered a bariatri bed so she o(ld be 1ronated. S.M. de"elo1ed 1rogressi"e hy1o0emia
(low o0ygen in the blood) and did not res1ond well to amb(9bag "entilation. +his was
followed by bradyardia (slow heartbeat)& where she res1onded to e1ine1hrine for a
brief moment& and then into 7/; (7(lseless eletrial ati"ity) arrest. ?es(sitation with
good92(ality hest om1ression was gi"en for abo(t 5 min(tes witho(t a ret(rn of
s1ontaneo(s ir(lation. +he n(rse tried to reah her family b(t was (ns(essf(l as all
n(mbers were disonneted. +he res(sitation attem1t was then sto11ed.
Summary and 2onclusion:
S.M. had a long list of 1ast medial 1roblems that (ltimately led to her healths
deline in the end. ;t age 51& her body o(ld no longer 1ro1erly f(ntion d(e to all of the
stress and harm it had been 1(t thro(gh. ! ha"e learned a lot thro(gh doing this e0tensi"e
researh ase st(dy. ! ha"e beome "ery familiar with a(te res1iratory fail(re seondary
to dr(g into0iation& the key risk fators& ommon mediations (sed for 1eo1le with
1(lmonary infetions and heart9related medial 1roblems& dr(g9n(trient interations& and
1ro1er n(trition 1resri1tions for 1eo1le trying to reo"er from res1iratory fail(re or a
similar health iss(e. +his has gi"en me the o11ort(nity to 1ratie e0tensi"e
do(mentation in the medial reords. ! ha"e also had a great e01eriene in >(stifying the
orret Medial <(trition +hera1y for 1atients& along with great 1ratie with the
<(trition #are 7roess thro(gh assessing& diagnosing& 1lanning inter"entions& monitoring
and e"al(ating 1atients and setting n(trition thera1y goals for their o(tome. +his ase
st(dy has >(stified the im1ortane of taking 1re"entati"e meas(res in order to ha"e a
healthy lifestyle.
%ppendi3 %
2auses of $espiratory .ailure
Sym1tom #a(se
;irway 6bstr(tion #hroni bronhitis
/m1hysema
5ronhietasis
#ysti fibrosis
;sthma
5ronhiolitis
!nhaled 1artiles
7oor breathing 6besity
Slee1 a1nea
3r(g into0iation
+ra(ma
<e(rom(s(lar disease M(s(lar dystro1hy
7olio
5ot(lism
Stroke
S1inal ord in>(ry
;bnormality of l(ng tiss(e ;(te res1iratory distress
3r(g reation
7(lmonary fibrosis
,ides1read t(mors
?adiation thera1y
Saroidosis
5(rns
;bnormality of hest wall :y1hosoliosis
#hest wo(nd
%ppendi3 4
2ommon Symptoms from +rug 5,erdose
+o0i s(bstanes an reah dangero(s le"els and may a(se se"ere damage to the body.
#ommon side effets may inl(deI
7rolonged na(sea and "omiting
Metalli taste in the mo(th
!nessant hi(1ing
!thing all o"er the body
.l(id retention
6ther sym1toms may be more se"ereI
7(lmonary /demaI the b(ild (1 of fl(id in the l(ngs& whih an serio(sly ham1er
the bodys res1iratory system& and may e"ent(ally a(se res1iratory fail(re
9;ssoiated sym1tomsI o(ghing (1 blood& an0iety& and diffi(lty breathing
Metaboli aidosisI when the kidneys are not filtering eno(gh aid o(t of the
system& the aid may reah e0tremely high le"els
94igh le"els of aid interfere with the bodys "ital systems
4y1erkalemiaI 1otassi(m reahed an e0essi"ely high le"el in the blood
94igh le"els of 1otassi(m lead to abnormal heart rhythms and an a(se ardia
arrest and s(dden death
$*.*$*N2*S:
1.) /sott9St(m1 S. Nutrition and Diagnosis-Related Care. 7
th
/d. 7hiladel1hiaI
,olters :l(werK 2)11.
2.) Megarbane 5& #he"illard B. +he large s1etr(m of 1(lmonary om1liations
following dr(g (seI feat(res and mehanisms. Science Direct Journals. 2)18K
2)6I***9*51.
8.) <a"a S& 4ill <. <on9in"asi"e "entilation for a(te res1iratory fail(re. Banet
2))-K 87*I25)M25-.
*.) Mahan B:& /sott9St(m1 S. Krauses Food and Nutrition Therapy. 18
th
/d. St.
Bo(isI Sa(nders /lse"ierK 2)11.
5.) Bi"eStrong .o(ndation. ;(te ?enal .ail(re Sym1toms from 6"erdose.
;"ailable at htt1IAAwww.li"estrong.omAartileA28F65*9a(te9renal9fail(re9
sym1toms9from9o"erdoseA. ;essed Marh 2)& 2)1*.
6.) 3r(gs.om. 3r(gs ; to N. ;"ailable at htt1IAAwww.dr(gs.omAdr(gOinformation.
html. ;essed Marh 2*& 2)1*.
7.) ,ebM3. 3igesti"e 3isorders. ;"ailable at htt1IAAwww.webmd.omAdigesti"e9
disordersAammonia9test. ;essed Marh 2*& 2)1*.
F.) ,ebM3. Bati ;id 5lood +est. ;"ailable at htt1IAAwww.webmd.omAa9to9=9
g(idesAlati9aid9blood9test. ;essed Marh 2*& 2)1*.
-.) ,ebM3. Bi"er .(ntion +est. ;"ailable at htt1IAAwww.webmd.omAa9to9=9
g(idesAli"er9f(ntion9test9lft. ;essed Marh 2F& 2)1*.
1).) 6S#/ Skills. #ardio"as(lar /0amination. ;"ailable at
htt1IAAwww.oseskills.omAe9learningAs(b>etsAardio"as(lar9e0aminationA.
;essed Marh 2F& 2)1*.
11.) 74#. <estle <(tri4e1 <(trition. ;"ailableat htt1IAAwww.1h9
online.omA<estlesO<(tri4e1O1An(trihe1.htm. ;essed Marh 2-& 2)1*.
12.) 74#. <estle <(tren 7(lmonary <(trition. ;"ailable at
htt1IAAwww.nestlehealthsiene.(sA1rod(tsA7agesA<$+?/<C#2C;/9
7$BM6<;?P.as10. ;essed Marh 2-& 2)1*.
18.) #le"eland #lini. @entri(lar +ahyardia. ;"ailable at
htt1IAAmy.le"elandlini.orgAheartAdisordersAeletriA"entri(lar9
tahyardia.as10. ;essed ;1ril 2& 2)1*.
1*.) M(ller #& ?e(ter 4& 3ohmen #. !nto0iation after e0treme oral o"erdose of
L(etia1ine to attem1t s(iideI 1harmaologial onerns of side effets. Case
Reports in Medicine. 2))-K 21)I 1912.