A 28-year-old man is admitted to the intensive care unit after a motor vehicle collision. The patient was intubated and received volume resuscitation at the scene. The patient sustained bladder injury, open fractures of the tibia and fibula bilaterally, a complicated pelvic ring injury, and fractures of the right 4th-7th ribs. No head or spinal injuries were detected. Over the course of 8 days, the patient undergoes laparotomy and daily surgeries to address extremity fractures, which require the patient to remain supine and intubated until all the surgeries are completed. On day 9, the respiratory therapist notes 4 hours of increasing secretions and worsening oxygenation: the patient requires an increase in FiO2 from 30% to 70% in order to maintain oxygen saturation of 92%. Vital signs reveal new-onset tachycardia. Temperature is 39.2 C (102.6 F), blood pressure is 125/80 mm Hg, pulse is 125/min, and respirations are 22/min. Portable chest radiograph reveals new right and left lower lobe infiltrates with a left-sided pleural effusion. What is the most likely diagnosis?

Question

A 28-year-old man is admitted to the intensive care unit after a motor vehicle collision.  The patient was intubated and received volume resuscitation at the scene.  The patient sustained bladder injury, open fractures of the tibia and fibula bilaterally, a complicated pelvic ring injury, and fractures of the right 4th-7th ribs.  No head or spinal injuries were detected.  Over the course of 8 days, the patient undergoes laparotomy and daily surgeries to address extremity fractures, which require the patient to remain supine and intubated until all the surgeries are completed.  On day 9, the respiratory therapist notes 4 hours of increasing secretions and worsening oxygenation: the patient requires an increase in FiO2 from 30% to 70% in order to maintain oxygen saturation of 92%.  Vital signs reveal new-onset tachycardia.  Temperature is 39.2 C (102.6 F), blood pressure is 125/80 mm Hg, pulse is 125/min, and respirations are 22/min.  Portable chest radiograph reveals new right and left lower lobe infiltrates with a left-sided pleural effusion.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d945_f478_bc81_016f7cec9c1e_MD0003_00 This intubated patient has increased respiratory secretions, worsening oxygenation, fever, tachycardia, and new pulmonary infiltrates on chest x-ray, raising strong suspicion for ventilator-associated pneumonia (VAP), a type of hospital-acquired pneumonia that occurs ≥48 hours after intubation. Most cases arise due to aspiration of oropharyngeal or gastric secretions. VAP is usually suspected when an intubated patient develops several of the following: New pulmonary infiltrates Increased respiratory secretions Signs of worsened respiratory status, such as worsening oxygenation, lower tidal volumes, and increased inspiratory pressure Systemic signs of infection, such as fever, leukocytosis, and tachycardia However, no constellation of manifestations conclusively proves VAP (eg, intubated patients often have pulmonary infiltrates on x-ray in the absence of VAP). Therefore, noninvasive (eg, endotracheal aspiration) or invasive (eg, bronchoalveolar lavage) sampling of the lower respiratory tract is required for confirmation; moderate or heavy growth of ≥1 microorganism is generally diagnostic. (Choice A) Acute respiratory distress syndrome is often seen in patients with severe trauma and frequently causes increased oxygen requirements and pulmonary infiltrates. However, most cases occur within 72 hours of the inciting event; in addition, fever and increased secretions would be atypical. (Choice B) Atelectasis due to mucus plugging is often associated with worsened oxygenation. However, high fever and pleural effusion would be less likely. (Choice C) Fat embolism is common with serious trauma to the pelvis and long bones (eg, femur). Although it frequently causes acute respiratory decompensation, it generally presents within 24-72 hours of the injury, does not usually cause lobar infiltrates, and would not be associated with increased secretions. (Choice D) Pulmonary contusion can occur in patients with blunt trauma to the chest and often causes increased oxygen requirements. However, it generally presents within the first 24 hours following the injury (not at day 9), and it is not associated with increased secretions. (Choice E) Major pulmonary thromboembolism can cause acute respiratory decompensation but is not usually associated with increased secretions or lobar infiltrates. (Choice G) Although volume overload can increase oxygen requirement and cause pulmonary infiltrates, fever and increased secretions are not commonly seen. Educational objective: Ventilator-associated pneumonia should be suspected when an intubated patient develops new pulmonary infiltrates on chest x-ray, worsened respiratory status (eg, increased oxygen requirement, increased secretions), and clinical signs of infection (eg, fever, leukocytosis). Confirmation requires the identification of an organism in a lower respiratory tract sample. References: International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). (http://www.ncbi.nlm.nih.gov/pubmed/28890434) Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. (http://www.ncbi.nlm.nih.gov/pubmed/27418577)

A 28-Year-Old Man Is Admitted to the Intensive Care Unit