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?

1. Most hypoxia is secondary to alveolar-capillary block
2. A normal pCO2 excludes hypoventilation as a cause of hypoxemia
3. Low inspired FiO2 is a common cause of hypoxia in the ICU because of attaching air to the oxygen line on the ventilator.
4. A normal chest x-ray excludes ventilation-perfusion mismatch as a cause of hypoxemia
5. 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