- 42 year old female housemaid presented with 3 days of fever and dry cough, and worsening shortness of breath. - On examination, she was febrile, tachypneic, and had bilateral crackles on lung auscultation. - Chest X-ray showed bilateral infiltrates consistent with severe ARDS. She was intubated and required multiple vasopressors and renal replacement therapy due to refractory shock. Her condition continued to deteriorate despite ECMO and she passed away on the third day.

1. Case presentation

2. Data:
• Mrs. Renuka
• 42/F
• Occupation :House maid

3. Chief complaints: HOPI
- Fever * 3 days
- Dry cough * 3 days
- Breathlessness since yesterday night.
Patient was apparently normal three days back & she developed fever which is low
grade, continuous type associated with cough which is dry not continuous not blood
stained and not associated with chills/rigor. After that She developed
breathlessness[MMRC III] since the night before ER Presentation, which was
progressive in nature and worsened since today morning. No relieving factor. H/o
generalized tiredness (+). H/o decrease urine output (~ 100 -200 ml)since yesterday
night.
HOPI:

4. Negative history:
• No h/o vomiting ,loose stools, chest pain, burning
micturation,hematuria abdominal pain, giddiness, altered sensorium.
• No recent travel history.
• TB contact/loss of weight/loss of appetite/bleed/rashes/ joint
pain/swelling
Adayar clinic – initially presented to adayar kmh treated with
inj.hydrocortisone, nebulisers, IV fluids 1.5 litres and NIV support and
shifted with inotropes support

5. PAST HISTORY:
• RA FACTOR positive - 1 MONTH back. PATIENT started ON
T.ETORICOXIB & T.PREDINISOLONE DAILY.
• Routine neg.

6. GENERAL EXAMINATION:
• CONSCIOUS,ORIENTED. GCS – 15/15.
• FEBRILE – 101.2 F
• TACHYPNEIC
• NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA
• VITALS: BP -100/80 MMHG with 3ml/hr noradrenaline support .(taken on right
arm sitting position)
• PR- 124/MIN
SPO2 – 85 -92 @ 15 L 02
RR – 31/MIN

7. Systemic examination: Respiratory system
• Inspection: Trachea is in midline, Chest is symmetrical, no chest wall
deformity,movement of chest is equal in both sides &
normal,Abdominal thoraco breathing,Tachypneic,using accessory
muscles for respiration. No dilated or engorged veins, No
scars,swelling & visible pulsation seen.
• Palpation: Not done.
• Auscultation: bilateral extensive crepitation in all areas of chest.
• Percussion: Dull in all areas of chest..

8. SUMMARY:
• 42 YR/F CAME WITH C/O FEVER(D3), BREATHLESSNESS AT REST , DECREASE URINE
OUTPUT, GENERALISED TIREDNESS. WHILE RECEIVING PATIENT WAS FEBRILE &
TACHYPENIC , WHEEZE + .
• PATIENT WAS INTIALLY EVALUATED AT KMH ADAYAR . STARTED ON
NIV.WORSENING SHORTNESS OF BREATH AND DIFFICULTY IN LYING DOWN FLAT.
PATIENT WAS COUNSELLED FOR ICU ADMISSION AND SHIFTED TO KAMAKSHI ER
FOR FURTHER MANAGEMENT.
• INITIALLY STARTED WITH NEBULISERS 2 CYCLES, IV PARACETAMOL 1GM IV,
INJ.HYDROCORT 100 MG IV, IV FLUIDS 1000ML IV BOLUS F/B 200ML/HR.
• NIL URINE OUTPUT .
• BP WAS NOT MAINTAINED.STARTED INJ.NORADRENALINE 8ML/HR.
• PATIENT DEVELOPED B/L CREPTS+.

9. Investigations:
• ABG: PaO2/FIO2 RATIO  < 100
• ECG –
• XRAY – B/L UPPER & MIDDLE ZONE INFILTRATES +. F/S/O SEVERE
ARDS.
• ECHO – LVEF 65% ,NO RWMA, NORMAL LV, IVC – COLLAPSING.

11. Provisional DIAGNOSIS:
• Influenza like illness / CAP
• Severe ARDS
• Septic shock
• RA positive on Steroid tx

12. Treatment:
• IN VIEW OF IMPENDING RESPIRATORY DISTRESS , PATIENT INTUBATED WITH
7MM ET TUBE FIXED AT LIP LEVEL 22 CM WITH
• PREMEDICATION: INJ.SCOLINE 100MG, INJ.KETAMINE 100MG, INJ.FENTANYL
100MG. 5 POINTS AUSCULATION CHECKED.
• VCV MODE : FIO2 100 % PEEP -12 TV – 420
• POST PROCEDURE VITALS: SPO2 – 92 % BP – 130/70 MMHG PR – 120/min
• INJ.NORADRENALINE 5 ML/HR
• ANTIBIOTICS : INJ.MEROPENAM 2GM IV STAT.
• Catheterization :10ML URINE OUTPUT.
• IV fluids 100ml /hr
• Right ijv central line secured.

13. BUFALO

14. Summarize : only positibe

16. ICU CARE:
• PATIENT REVIEWED BY ICU TEAM  IN VIEW OF Refractory HYPOXIA(84-87%) - PRONE
VENTILATION.
• Repeat ABG - ?? RESPIRATORY ACIDOSIS WITH HIGH LACTATE.
• A LINE secured at right radial
• I/V/O PERSISTENT HYPOTENSION  INJ.NORADRENALINE uptitrated AND VASOPRESSIN
SUPPORT STARTED.
• BLOOD REPORTS REVIEWED  leukocytosis
• Antibiotic :INJ.MEROPENAM 1GM TDS , INJ.TEICOPLANIN 400MG BD, T.AZITHROMYCIN
5OOMG 1-O-O , T.OSELTAMAVIR 75 MG 1-0-1 .
• INJ.HYDROCORTISONE 50MG 1-0-1
• INJ.CLEXANE 60MG S/C O for prophylaxis.

17. DAY 2:
• I/V/O PERSISTANT HYPOTENSION AND LACTIC ACIDOSIS . PATIENT
ATTENDERS WAS EXPLAINED IN DETAIL ABOUT ECMO TO IMPROVE
OXYGENATION.
• CTVS OPINION OBTAINED  PATIENT WAS UNPRONED AFTER 16HRS
OF PRONE VENTILATION AND VenoVenous ECMO WAS PLACED
UNDER ASPETIC PRECAUTION.
• VCV MODE FIO2 : 100% SERIAL ABG WAS MONITORED
WORSENING ACIDOIS AND LACTATE LEVELS.
• PATIENT ON MAXED OUT INOTROPES LEVELS.

19. DAY 2:
• PATIENT WAS ANURIC WITH SERIAL INCREASE IN LACTATE LEVELS.
CONTINUOUS RENAL REPLACEMENT DIALYSATE 800ML/POST 600ML)
THERAPY WAS INITIATED.( AT EFFLUENT RATE OF 1800 ML, PRE
400ML

21. • DAY 3 PATIENT ON MAX INOTROPES SUPPORT UNDER SEDATION &
PARALYSIS SHE WAS HYPOTENSIVE,BRADYCARDIA AND HYPOXIA.
• DESPITE ALL RESUSCIATIVE MEASURE WITH ALL SUPPORTIVE
MEDICATION.
• PATIENT DETORIATES AND DECLARED DEAD.

22. ARDS /Prone ventilation/ECMO

23. ON ARRIVAL: @ ER:
• SHE IS TACHYPNEIC,GCS- 15/15.
• RR- 36/MIN
• BP- 100/60 @ 3ML INJ.NORADRENALINE 3ML/HR.
• SPO2 – 85 @ 15 L O2
RS:
• Inspection/palp -
• ON AUSCULTATION B/L CREpTS – areas , nvbs/bronch, accessory muscle usage, other
added sounds
• Percussion
• cvs