Case Studies

August 16, 2017 • Male, 37

Background

On July 22, 2017, a 37-year-old male was admitted as a transfer from an outside hospital. His initial complaints included acute onset abdominal pain that rapidly progressed to vomiting and then hematemesis. He went into septic shock, was coded and intubated at the outside hospital. He was started on low dose levophed. The patient developed a blanching rash over his torso, cyanotic discoloration of feet and large bilateral ecchymosis on bilateral knees. He was transferred with concerns for vasculitis. Admitting diagnosis upon admission included:

  • Sepsis
  • Acute Respiratory Failure with concern for ARDS
  • Renal Failure requiring CRRT
  • Small Bowel Obstruction
  • Multifocal Pneumonia

The patient was admitted to the MICU with catastrophic illness. Rheumatology, hematology, infectious disease, palliative care and vascular were consulted. On August 6, 2017, the patient underwent Bilateral BKA. Patient was deemed difficult to wean. Barriers to weaning included severe critical illness myopathy, peripheral vascular disease s/p bilateral amputations, renal failure requiring dialysis and not able to understand English (patient spoke only Vietnamese).

Special Care Unit

The clinical review team was consulted and it was determined that the patient met Special Care Unit criteria. On August 16, 2017, the patient was admitted for aggressive ventilator weaning on the following setting:

  • Mode:  SIMV
  • Ventilator Rate:  10
  • FIO2:  30-40%
  • PEEP:  5

During his stay in the SCU, with quality nursing care and multidisciplinary treatment from Physical Therapy, Occupational Therapy and Respiratory Therapy, the patient was successfully weaned in 17 days. The patient made functional gains by progressing from minimal ability to lift extremities off the bed with assistance from therapy to being able to perform bed mobility with min to mod assistance and transfers from bed to chair with mod to max assist using a sliding board. He transitioned to inpatient rehab with his trach capped and plans to decannulate within the week. He was able to propel himself in a wheelchair 50 ft prior to transition. The patient continues to make improvements and is continuing his rehab in an outpatient setting with plans to be fit for prosthesis.

April 5, 2017 • Female, 59

Background

Patient is a 59-year-old white female initially admitted to hospital on December 12, 2013. Her medical history included complications from sarcoidosis and a recent hospitalization for hypercapnia. She was evaluated by the lung transplant team and a bilateral lung transplant was performed on January 10, 2014.

Patient’s hospital stay was complicated by sepsis, subglottic stenosis, acute blood loss anemia, multiple fractures, respiratory failure, depression, pulmonary hypertension, PTE, deconditioning and a new ESRD diagnosis. She remained hospitalized, with two LTAC discharges and subsequent readmissions to STAC, since her December 31, 2013, admission. Her last readmission to STAC was on November 23, 2016, to the lung transplant service.

Patient was deemed as one of the most difficult to attempt vent weaning. The Special Care Unit was consulted. On April 5, 2017, nearly 3½ years after admission, the patient was admitted to the Special Care Unit for vent weaning with a goal of trach capping during the day and Trilogy/ventilator at night. This goal would have allowed her to possibly qualify for an outpatient dialysis chair. She was admitted to SCU on the following vent setting:

Mode:  SIMV
Ventilator Rate:  20
FiO2:  35%
Inspiratory Pressure:  15

Special Care Unit

She was admitted to Special Care Unit on April 26, 2017, with the agreement that this would be the last attempt at ventilator weaning. If unsuccessful the transplant team would resume primary care for this patient. On April 31st, 2017, the patient was successfully weaned from the vent. She was able to tolerate trach collar with 40% oxygen during the day and pressure support ventilation at night to her trach. Trials for trach capping with nasal cannula oxygen during the day and BiPAP per face mask at night were started on June 2, 2017. The patient was able to be decannulated on June 20, 2017.

On June 27, 2017, with comprehensive treatment from Nursing, Physical Therapy, Occupational Therapy, Speech and Language Pathology and Respiratory Therapy she was discharged to Inpatient Rehab. The patient took her first steps in four years while in the SCU. Shorlty after her transfer to inpatient rehabilitation, she was successfully discharged home.

December 16, 2016 • Male, 62

Background

A 62-year-old male was admitted to Level I Trauma Center on November 25, 2016, reporting fevers for 3 days. On initial assessment he was noted to have tachypnea and tachycardia, as well as the following co-morbidities:

  • Sepsis
  • Hypertension
  • Type II Diabetes Mellitus

He was admitted to MICU due to h/o Myastenia Gravis and high risk for decompensating. Exam on November 26th was consistent with Myestenia exacerbation. He was treated with antibiotics and IVIg. He was intubated and placed on ACVC ventilation. He failed extubation on December 4th due to hypoxia accompanied by atrial fibrillation with RVR. A trach and PEG was placed on December 9th. Patient was deemed difficult to vent wean, and the Special Care Unit was consulted.

Special Care Unit

Clinical information was reviewed by the Special Care Unit Team and the patient was accepted on December 16, 2016. He was on the following ventilator setting:

  • Mode:  ACPC
  • Ventilator Rate:  16
  • FiO2:  50%
  • PEEP:  5
  • PIP:  23

In addition to his Nursing care, the patient received comprehensive treatment from Respiratory Therapy, Physical Therapy, Occupational Therapy, Speech and Language Pathology. He was successfully weaned from ventilator on December 26th. He was also de-cannulated on December 26th. Pt made exceptional functional gains and was able to discharge home on December 28th ambulating 200ft moderately independent. The SCU team maintained communication and the patient to ensure that he functioned well once home.

November 7, 2016 • Male, 65

Background

On October 27, 2016, a very active 65-year-old male who suffered a witnessed cardiac arrest while swimming at the YMCA was transferred to a Level I Trauma Center in Alabama from an outside hospital for ECMO consideration. He was positive for Enterobacter and Pseudomonas before transfer as well as the following co-morbidities:

  • Acute Hypoxemia Respiratory Failure
  • Lactic Acidosis
  • Leukocytosis
  • Encephalopathy
  • Pneumonia
  • S/P Cardiac Arrest

The patient was admitted to CICU orally intubated and ventilated on ACPC settings. He was sedated on propofol and had a Fentanyl PCA. During his initial hospital course, three (3) Bronchoscopies were performed with findings of scattered sanguineous secretions. Extubation was attempted on November 3, 2016, however failed and required re-intubation. Tracheostomy performed November 4, 2016, due to prolonged ventilator support. Nutrition was provided by enteral feeds through nasal Dobhoff Feeding Tube. Patient had history of Anxiety and failed multiple PSV trials due to tachypnea. At this time the CICU team felt that the patient would benefit most by transferring to the Special Care Unit for comprehensive ventilator weaning.

Special Care Unit

Clinical information was reviewed by the Special Care Unit Team and the patient was accepted for aggressive ventilator weaning on November 7, 2016. He was on the following ventilator settings:

  • Mode:  ACPC
  • Ventilator Rate:  6
  • FIO2:  40%
  • PEEP:  6

On November 12, 2016, after 7 days in SCU the patient was successfully weaned from the ventilator. With quality high touch nursing care coupled with comprehensive multi-disciplinary treatment modalities from Respiratory Therapy, Physical Therapy, Occupational Therapy and Speech and Language Pathology, the patient progressed well enough to discharge to Acute Inpatient Rehabilitation on November 17, 2016. Prior to discharge from the Special Care Unit the patient was tolerating a speaking valve and a regular diet with thin liquids. At discharge the patient was capped, on room air, speaking clearly and tolerating well.

Post Discharge follow up showed patient was successfully decannulated during his first few days at the Inpatient Rehabilitation Unit.

October 19, 2016 • Female, 47

Background

On October 4, 2016, a 47-year-old morbidly obese female was transferred to an Alabama Level 1 Trauma Center from an outside hospital with cellulitis to her left lower extremity. Prior to her emergent transfer the patient had become acutely hypoxic and required intubation with maximal ventilator settings. Upon arrive she was febrile with an oral temperature of 102.3 with Acute Respiratory Failure along with the following co-morbidities:

  • Left Lower Extremity Cellulitis
  • Bilateral Opacities/ ARDS
  • Sepsis
  • Non-oliguric Acute Kidney Injury
  • HTN
  • Morbid Obesity
  • Elevated Troponins
  • Possible Pulmonary HTN
  • Possible combined systolic and diastolic CHF

The patient was admitted to the MICU orally intubated and ventilated on ACVC settings with 100% FIO2 and on Nitric Oxide. She was continuously agitated and unable to wean off sedation, therefore a tracheostomy was placed on October 13, 2016, to help ease weaning from ventilator and sedation. During her hospital course the patient was placed on intermittent hemodialysis due to acute tubular necrosis from sepsis, rhabdomyolysis and hypoxia. The patient was considered a complicated ventilator wean and the Special Care Unit was consulted.

Special Care Unit

Clinical information was reviewed by the Special Care Unit Team and the patient was accepted for aggressive ventilator weaning on October 19, 2016. She was on the following ventilator settings:

  • Mode:  ACVC
  • Ventilator Rate:  16
  • FIO2:  75%
  • Tidal Volume:  360
  • PEEP:  8

The patient received quality high touch nursing care along with comprehensive treatment modalities from Respiratory Therapy, Physical Therapy, Occupational Therapy, and Speech and Language Pathology and was successfully weaned from ventilator November 1, 2016, and de-cannulated on November 11, 2016. She was discharged home with Home Health Care and the support from her family on November 12, 2016. Upon discharge the patient was able to perform bed mobility, transfers and ambulate 20 feet with a rolling walker and supervision. The SCU team has maintained communication with her and she is currently thriving at home.

August 16, 2017 • Male, 37

Background

On July 22nd, 2017, a 37-year-old male was admitted as a transfer from an outside hospital. His initial complaints included acute onset abdominal pain that rapidly progressed to vomiting and then hematemesis. He went into septic shock, was coded and intubated at the outside hospital. He was started on low dose levophed. The patient developed a blanching rash over his torso, cyanotic discoloration of feet and large bilateral ecchymosis on bilateral knees. He was transferred with concerns for vasculitis. Admitting diagnosis upon admission included:

  • Sepsis
  • Acute Respiratory Failure with concern for ARDS
  • Renal Failure requiring CRRT
  • Small Bowel Obstruction
  • Multifocal Pneumonia

The patient was admitted to the MICU with catastrophic illness. Rheumatology, hematology, infectious disease, palliative care and vascular were consulted. On August 6, 2017, the patient underwent Bilateral BKA. Patient was deemed difficult to wean. Barriers to weaning included severe critical illness myopathy, peripheral vascular disease s/p bilateral amputations, renal failure requiring dialysis and not able to understand English (patient spoke only Vietnamese).

Special Care Unit

The clinical review team was consulted and it was determined that the patient met Special Care Unit criteria. On August 16th, 2017, the patient was admitted for aggressive ventilator weaning on the following setting:

  • Mode: SIMV
  • Ventilator Rate: 10
  • FIO2: 30-40%
  • PEEP: 5

During his stay in the SCU, with quality nursing care and multidisciplinary treatment from Physical Therapy, Occupational Therapy and Respiratory Therapy, the patient was successfully weaned in 17 days. The patient made functional gains by progressing from minimal ability to lift extremities off the bed with assistance from therapy to being able to perform bed mobility with min to mod assistance and transfers from bed to chair with mod to max assist using a sliding board. He transitioned to inpatient rehab with his trach capped and plans to decannulate within the week. He was able to propel himself in a wheelchair 50 ft prior to transition. The patient continues to make improvements and is continuing his rehab in an outpatient setting with plans to be fit for prosthesis.

2016 • Female, 18

Background

An 18-year-old female was admitted from an outside hospital. She was found in her college dorm room incontinent of urine and febrile up to 104. She was sent to hospital for further evaluation of presumed autoimmune demyelinating disease. Her admitting diagnosis included:

  • Encephalopathy
  • Acute Respiratory Failure
  • Urinary Tract Infection

The patient was intubated and mechanically ventilated and was unresponsive. Per Neurology, diagnosis was likely viral encephalitis. She received feedings through a nasogastric tube. She was started on trach collar trials but had significant anxiety. Her parents wanted her to return home to New York for further care, however there were many uncertainties regarding the safety of the patient flying with a ventilator and a trach. They were considering a $20,000 trip by air ambulance for transfer to an LTACH.

Special Care Unit

Fifteen days after initial admission, transfer to Special Care Unit was recommended, clinical review team consulted and she was transferred. At the time of transfer she had been on trach collar at 40% FiO2. She was able to follow commands but had material cognitive deficits and was unable to swallow anything safely.

During her stay in SCU, with multidisciplinary treatment from Physical Therapy, Occupational therapy, Speech and Language Pathology and Respiratory Therapy, the patient was able to make exceptional functional gains. She was decannulated just 6 days after transfer. Her nasogastric feeding tube was discontinued and she was able to eat a regular diet. Cognition improved and she assisted with booking her flight on her laptop computer. She was able to walk a total of 100 feet with seated rest breaks.

After only 17 days in the SCU, the patient was discharged to an Inpatient Rehab facility in New York for further recovery. She was able to safely travel on a commercial flight. The patient continues to make improvements and was able to return to her university for the fall semester.