Critical Case Discussion
Monthly online case based discussion
Case 2
December 2023
A 10-month-old infant known to have acute lymphoblastic leukemia presented with fever, cough and fast breathing. He does not have any cardiac issue or fluid overload. Clinical examination revealed: T: 39, HR: 160 b/m, RR: 60 b/m, BP: 80/50, Spo2: 85% in room air. Chest exam: accessory muscle use with b/l crepitations. He was started on full face mask NIV, and after 6 hours, his saturation raised to 92 % on the following settings: IPAP: 14, EPAP: 7, FiO2: 50%. ABG showed: PH: 7.30, PCO2: 50, PO2: 60, HCO3: 24.
CXR is attached.
Q1:
Which one of the following is true about this patient?
A: He does not have ARDS
B: He has mild-moderate ARDS
C: He has severe ARDS
D: With above information, we cannot define ARDS
After 24 hours, the patient clinical condition has worsened and became more hypoxic and got intubated. Ventilatory settings are as following:
SIMV-PC/PS: PEEP: 5, PIP: 24, Rate: 30, inspiratory time: 0.6, Fio2: 80%, Mean Airway Pressure: 15. Saturation is 91%.
Chest x-ray is attached. ABG: pH: 7.32, PCO2: 52, PO2: 50, Bicarb: 25.
Q2:
Which one of the following is the best option at this stage?
A: Increase PEEP to 8-10
B: Increase PIP to 28
C: Give surfactant
D: Start inhaled nitric oxide (iNO)
Q3:
On day 3 and during the clinical round, you observed that the patient was on the following ventilatory settings: SIMV-PRVC: PEEP: 10, TV: 12ml/kg, PIP: 32, rate: 30, Fio2: 40%. Based on the Second International Guidelines for the Diagnosis andManagement of Pediatric Acute Respiratory
Distress Syndrome (PALICC-2), Which one of the following is correct?
A: HFOV and APRV mode are superior modes for pediatric ARDS patients and they improve patient’s outcome.
B: It is recommended to limit inspiratory plateau pressure to less than or equal to 36 cm H2O.
C: Cuffed endotracheal tubes should be used when ventilating a patient with PARDS
D: Keep the patient on tidal volumes between 10 and 12 mL/kg
Case 1
October 2023
Noor is an 8-month-old baby born at term, she was found to have a heart murmur at the post-natal examination. The ECHO confirmed the diagnosis of VSD for which she was started on oral diuretics and now she is waiting for corrective cardiac surgery. Noor’s mother tells you that she has been struggling to gain weight, has become more breathless over the last 24 hours, and cannot complete feeds.
On Assessment:
She was lethargic, pale in color with respiratory distress.
HR:180, RR: 60, BP:100/60, Temp: 39, Saturation 87% in RA,
Capillary refill time: 4 sec.
Chest: bilateral crepitation
Herat: pan-systolic murmur best heard in the left lower sternal border.
Abdomen: soft with hepatomegaly 3cm below the costal margin.
Lab investigations: WCC:22, Hb:11, platelets:250, CRP: 90, RFT & LFT normal.
CXR: bilateral haziness with obliteration of right heart border.
Questions:
-
What is the most likely diagnosis?
-
What is the rule of lung point of care ultrasound (POCUS) in confirming or excluding the diagnosis?
-
The linear ultrasound probe is best used to scan which of the two following structures:
A. Vessels
B. Heart
C. lung in neonates/infants
D. lung in adolescent
4. Which two of the following lung ultrasound features are normal findings during lung POCUS:
A. Pleural sliding
B. A-lines
C. Multiple B-lines
D. Shred sign
E. Barcode sign
5) Which one of the following ultrasound features suggests lung consolidation:
A. Barcode sign
B. Absence of a lung pulse
C. A-lines
D. PLAPs point
E. Tissue-like sign