Pneumonia in the critically ill hospitalized patient
Dr. Douglas Schultz: A 59-vear-old white man with a three-month history of systemic lupus erythematosus and a history of insulin- dependent diabetes mellitus was admitted to the hospital with a three-day history of fever to 38.8°C and dysuria. Evaluation revealed a urinary tract infection with E coli and benign prostatic hypertrophy. One month later, the patient underwent transurethral resection of the prostate. On the fourth postoperative day, he developed fever to 39.4°C, shortness of breath, weakness, confusion, and reported a slightly productive cough. His medications at the time included prednisone, 10 mg daily, and NPH insulin, 20 units subcutaneouslv daily.
On initial examination, the patient was found to be mildly short of breath with a respiratory rate of 32, blood pressure of 120/76 mm Hg, and a temperature of 39.3°C rectally. His only remarkable physical findings were crackles in the posterior aspect of the right lung in the upper two-thirds of the chest. The remainder of his lung examination was unremarkable and no new extrapulmonary findings were noted. Viagra Soft Tabs
FIGURE 1. Chest radiograph demonstrating right-sided pneumonia developing postoperatively.
Laboratory evaluation showed a white blood cell count of 8,600 with 85 percent polys and 10 percent bands. Blood glucose was 347 mg/dl and arterial blood gases, while breathing room air, showed a pll of 7.4, Pcx)2 38 mm Hg, and Po2 of 56 mm Hg. A chest radiograph (Fig 1) showed a right upper lobe infiltrate. Sputum was evaluated by Gram stain and showed copious white blood cells with Gram-negative rods. Sputum and blood cultures were obtained. The remainder of the laboratory data was unremarkable.
The patient was treated with a presumptive diagnosis of nosocomial Gram-negative pneumonia and therapy included intravenous hydration, oxygen via a 40 percent Venti-mask, and intravenous ceftazidime. In addition, the patient received appropriate increases in steroid therapy for stress, and insulin coverage for hyperglycemia. Two days later, the patient was found to be more short of breath and he was transferred to Winthrop-University Hospital’s intensive care unit for further care. On arrival, the patient had a blood pressure of 70 palpable. Arterial blood gases, with the patient breathing via 40 percent Venti-mask, showed a pH of 7.36, Pco2 = 22 mm Hg, and Po2 = 42 mm Hg. At that time, his blood cultures from the other hospital were reported to show two strains of Pseudomonas aeruginosa. A repeat chest radiograph (Fig 2) showed difluse infiltration of the right lung and faint infiltration at the left base.
The patient was then endotracheally intubated and placed on mechanical ventilation. Antibiotic therapy was directed towards Pseudomonas aeruginosa with amikacin added to ceftazidime. Bronchoscopy was performed with a protected specimen brush and the brush was cut into 1 ml of tryptic soy broth and cultured quantitatively, revealing greater than 104 Pseudomonas aeruginosa per ml in pure culture.
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FIGURE 2. Progression of pneumonia to a radiographic pattern consistent with ARDS.
The patient was treated with mechanical ventilation for a period of three weeks. His therapy also included supplemental oxygen, titrated to maintain oxygenation, and he had gradual improvement in his oxygenation status and control of his respiratory infection. After three weeks of mechanical ventilation, the patient was successfully extubated. His course had been complicated by diarrhea, felt to be related to antibiotic therapy and tube feedings, intermittent supraventricular tachycardia, tracheostomy for airway care, and intermittent return of fresh blood from his nasogastric tube, in spite of prophylaxis of intestinal bleeding with cimetidine. At the time of discharge from the intensive care unit, the patient was felt to have recovered from his pneumonia and all of his antibiotics were discontinued. Sputum cultures continued to reveal Pseudomonas aeruginosa, but no therapy was prescribed.