Background
On July 22
nd, 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
th, 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.
