Problem
Introduction:
The patient is a 76-year-old man who presented to the emergency room after being struck by a car. After being stabilized in the emergency room he was transferred to the medical intensive care unit. He has been hospitalized for 8 days and remains in the medical ICU due to several fractures sustained in the motor vehicle accident. The patient has been intubated and on mechanical ventilation since admission 8 days ago. As you assess him during rounds you note he has had increased, yellow/green secretions overnight.
Current Medications
1) Sodium chloride 0.9% (NS) @ 150 mL/hr
2) Heparin 5000 units subcutaneously q8 h
3) Insulin infusion titrated to maintain BG 80-110
4) Fentanyl intravenous infusion at 25 mcg/hr
5) Dexmedetomidine intravenous infusion titrated to RASS 0 to -2
Allergies
NKDA
Home Medications
1) Lisinopril 20 mg PO daily
2) Metformin 1000 mg PO BID
Vital Signs
Temp 101.3°F, BP 100/70 mm Hg, HR 110 bpm, RR 21 breaths per minute, SpO2 92% on mechanical ventilation.
Ht 6'1" Wt 98 kg
Laboratory Findings
WBC 12.2 ×103/μL, platelets 156 ×103/μL, AST/ALT 54/32 units/L, SCr 1.7 mg/dL, lactate 1.3 mmol/L, albumin 2.0 g/dL, INR 1.3, blood glucose (3 most recent q4h finger pocs = 120, 70, 85 mg/dL) and all other laboratory values are WNL
Ventilator Settings
1) FiO2: 70% (increased from 40% yesterday)
2) PEEP: 10 cm H2O (increased from 5 cm H2O yesterday)
Answer these questions:
A. What signs/symptoms are consistent with the presentation of pneumonia?
B. What diagnostic procedures are indicated?
C. A portable CXR is obtained which shows a new infiltrate in the right lower lobe. Which infectious syndrome would be highest on the differential diagnosis?
D. Which antibiotic regimen would be most correct for empiric treatment?
E. If the patient was not ventilated, what empiric antibiotic regimen would be recommended?
F. What total duration of antibiotic therapy would be recommended for VAP?