A Middle-Aged Woman With Viral ARDS and Acute Establishment of Shock on Invasive Mechanical Ventilation

      A female, nonsmoker patient was admitted to the hospital because of fever, nonproductive cough, and worsening dyspnea over a 7-day period. On presentation to the ED, she was in respiratory distress (respiratory rate, 40 breaths/min), with hypoxemia (Table 1), body temperature of 39.2° C, and she was admitted to the general ward. Her laboratory results included the following: hemoglobin, 9.9 g/dL; WBCs, 2,000 cells/μL; platelets, 113,000 cells/μL; total bilirubin, 0.28 mg/dL; prothrombin time, 1.21; activated partial thromboplastin time, 37.9; fibrinogen, 479 mg/dL; lactate dehydrogenase, 1,288 IU/L; C-reactive protein, 20 mg/dL; lactic acid, 2.8 mmol/L. Her chest radiograph showed bilateral alveolar infiltrates. A throat swab turned positive for influenza A (Η1Ν1).
      Table 1Respiratory and Hemodynamic Variables
      Time of Measurements On the ED Before Intubation After Intubation After Intubation
      Respiratory Support Room Air Non Rebreather Mask Mechanical Ventilation

      PEEP: 12 cm H2O
      Mechanical Ventilation

      PEEP: 6 cm H2O
      Respiratory variables
      Pao2, mm Hg 41 60 103 106
      Paco2, mm Hg 24 33 64.5 43
      pH 7.47 7.47 7.16 7.34
      HCO3-, mmol/L 23 30 31 32
      Lactate, mmol/L 0.8 1.7 4.4 3.5
      Hemodynamic variables
      Heart rate, beats/min 98 (SR) 102 (SR) 150 (RBBB) 86 (SR)
      CVP, mm Hg NA 5 19 9
      MAP, mm Hg 74 71 65 67
      Vasopressors, μg/kg/min 0 0 2.2 0.7
      Scvo2, % NA 78 60 75
      Pa-vCO2 NA 2 10 4
      Respiratory and Hemodynamic variables of the patient at four time points:
      1. On presentation in the ED
      2. Just before intubation
      3. Immediately after intubation and mechanical ventilation initiation with PEEP 12 cm H2O
      4. After PEEP de-escalation to 6 cm H2O
      CVP = central venous pressure; DP = driving pressure measured as the difference between Pplat-PEEP; Hco3- = serum bicarbonate levels; MAP = mean arterial pressure; Pa-vo2 = arteriovenous carbon dioxide pressure difference; PEEP = positive end expiratory pressure; Pplat = plateau pressure; RBBB = right bundle brunch block; RR = respiratory rate; Scvo2 = vena caval oxygen saturation; SR = sinus rhythm; Vt = tidal volume
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