What are some specific aspects of assessment and diagnostic workup on which you would want to focus?
Apr 28, 2022, 5:05 AM
You are making rounds in the intensive care and the nurse reports the patient has spiked a fever, oxygen saturations are below 85%, tachycardia, and variant hypotension. The patient is intubated and has been treated for COVID pneumonia for 10 days. What are some specific aspects of assessment and diagnostic workup on which you would want to focus? Provide three differential diagnoses at this point and what treatment parameters you need to start while ruling out complications. What are the risk factors necessary to take into considerations as you develop treatment parameters for this patient? Think about sepsis from multiple sources of a prolonged ICU stay.
Covid is a multisystem disease that is believed to be fueled by cytokine overproduction, leading to multiorgan dysfunction. This virus has been isolated from the lungs, blood, urine, feces, liver and gallbladder and autopsy findings include vascular involvement, congestion, consolidation, hemorrhage, and diffuse alveolar lung damage that is consistent with ARDS. Additionally, SARS-CoV-2 has a strong association with hypercoagulopathy related to endothelial injury and statis, leading to increased risk of thromboembolism. Severe COVID cases are often managed in the ICU setting with mechanical ventilatory support and invasive devices, which further complicate the course of this disease (Tufan, Kayaashan, & Mer, 2021). As such, even with vigilant management, the likelihood of disease progression and unintended secondary infection is high. The patient in the scenario is experiencing symptoms for which ARDS, pulmonary embolism (PE), secondary blood/pulmonary infection/sepsis are potential differential diagnoses. The focus of the assessment and diagnostic workup for this patient would include ABG’s to rule out impending respiratory failure, CXR, CTA with d-dimer to rule out PE, evaluation of urine output to exclude ventilator induced kidney injury, and other evaluations including assessment of invasive devices to look for possible sources of infection to include blood cultures, urinalysis with culture, sputum culture and skin inspection to rule out an undetected infected pressure injury. The initiation of empiric broad-spectrum antibiotics and aggressive fluid resuscitation is warranted since the patient meets the SIRS criteria (Tufan, Kayaashan, & Mer, 2021)
Risk factors that need to be taken into consideration before implementing a treatment plan include advanced age, history of diabetes, hypertension, chronic respiratory failure, heart disease, and impaired immunity, which are all associated with greater risk of mortality. Additionally, prolonged mechanical ventilation is associated with diaphragm weakness, muscle wasting and weakness, deconditioning, recurrent symptoms, and derangement of the hypothalamic-anterior-pituitary-peripheral-hormone axis, which may be exacerbated by some changes in ventilator settings. Furthermore, mechanical ventilation for greater than 8 days is associated with a greater risk of development of pressure ulcers and the need for a tracheostomy (Ambrosino & Vitacca, 2018).
Covid is often managed with higher levels of PEEP, especially in the setting of ARDS, which has been shown to increase CVP and airway pressure, leading to higher blood pressure and tachycardia. This is most prevalent in those over the age of sixty-five and in those with hypertension or heart disease (Zhou et al, 2019). Research also indicates that keeping Covid patients on the drier side is associated with better outcomes for which the fluid resuscitation for possible sepsis may become questionable (Tufan, Kayaashan, & Mer, 2021).
Ambrosino, N., & Vitacca, M. (2018). The patient needing prolonged mechanical ventilation: A narrative review. Multidisciplinary
Respiratory Medicine, 13:6. https://doi.org/10.1186/s40248-018-0118-7
Tuftan, Z.K., Kayaashan, B., & Mer, M. (2021). Covid-19 and sepsis. Turkish Journal of Medical Sciences, 51(7), 3301-3311.
Zhou L., Cai, G, Xu, Z., Weng, Q., Ye, Q., & Chen, C. (2019). High positive end expiratory pressure level affect hemodynamics in
elderly patients with hypertension admitted to the intensive care unit: A prospective cohort study. BMC Pulmonary Medicine, 19:224.