Critical Care
The Southwest Journal of Pulmonary and Critical Care publishes articles directed to those who treat patients in the ICU, CCU and SICU including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.
November 2012 Critical Care Case of the Month: I Just Can’t Do It Captain! I Can’t Get the Sats Up!
Bridgett Ronan, MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 61 year old man was seen in consultation after undergoing a laparoscopic repeat Nissen fundoplication with mesh reinforcement. He developed worsening hypoxia postoperatively. He was initially extubated without difficulty to nasal cannula. However, he had progressive hypoxemia requiring a nonrebreathing mask, followed by BiPAP and eventually reintubation. Discussion with the surgeons revealed he had gastric contents present on intraoperative esophagogastroduodenoscopy (EGD). There was a small perforation of the fundus, with possible contamination of the peritoneum.
PMH, FH, SH
He has a long history of a paraesophageal hernia and reflux esophagitis and had previously undergone a Nissen fundoplication. There was also a history of atrial flutter and a 4.8 cm thoracic aortic aneurysm. A pre-operative echocardiogram was othewise normal. There was no remarkable family history. He was a non-drinker and non-smoker.
Physical Examination
Vital signs: Heart rate 79 beats/min, BP 95/67 mm Hg, Temperature 99.4°F, SpO2 78% on 100% FiO2.
His lungs were clear interiorly.
No murmurs or gallops were heard on cardiac auscultation.
His abdomen was post-surgical and distended but soft and nontender.
Which of the following is true regarding hypoxemia?
- Most hypoxia is secondary to alveolar-capillary block
- A normal pCO2 excludes hypoventilation as a cause of hypoxemia
- Low inspired FiO2 is a common cause of hypoxia in the ICU because of attaching air to the oxygen line on the ventilator.
- A normal chest x-ray excludes ventilation-perfusion mismatch as a cause of hypoxemia
- The patient’s age of 61 excludes a congenital heart lesion
Reference as: Ronan B. November 2012 critical care case of the month: I just can’t do it captain! I can’t get the sats up! Southwest J Pulm Crit Care 2012;5:235-41. PDF