James
James is a 67yo male with a long history of hypertension and recurrent polysubstance abuse, including recent crack cocaine. His home health nurse arrived to find him confused and in severe respiratory distress. On arrival in the ED he was immediately intubated, and after obtaining a CXR, baseline labs and cultures, he was transferred to the ICU. He is diagnosed with pneumonia and sepsis, and is started on broad spectrum antibiotics, along with norepinephrine for hypotension. He develops hypoxemia, poorly responsive to increased ventilator support, sedation and paralysis, and prone positioning, and is no anuric. The ICU team calls you to consider him for ECMO.
Ventilator - 100% FiO2, Rate of 24, PIP 36, PEEP 14
Pertinent Labs - WBC 3.9K (86% Segs, 5% bands), Plts 45K, BUN/CR 68/3.3, ALT/AST 1350/ 1600, CK 26,000, serum myoglobin 21,000. Albumin 1.2. Urine + cocaine.
ABG - 7.28 / 74 / 58 / 32 / 1 / 84% / Lactate 8.0
Transthoracic Echocardiogram - Severe LVH and moderate global LV dysfunction with an EF approximately 40%. Normal RV function. No TR to estimate PA pressures. No valvular stenosis or insufficiency. No pericardial effusion.