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3. Penicillin exposure
The differential diagnosis of a military pattern on chest x-ray does not typically include medication side effects. The differential is extensive including 1) Infectious: disseminated fungal disease, tuberculosis and viral pneumonias due to cytomegalovirus (CMV) and varicella; 2) Inhalational diseases such as silicosis, extrinsic allergic alveolitis, and other pneumoconioses; 3) Malignancy from bronchoalveolar carcinoma as well as hematogenous lung metastasis from lung, thyroid, renal cancers; and 4) Others including sarcoidosis and pulmonary hemosiderosis (1).
The patient was transferred to the ICU and was intubated and placed on mechanical ventilation. Initial basic metabolic panel (BMP), arterial blood gases (ABG), and ventilator settings are as follows:
BMP: Na+ 135 meq/L, K+ 4.2 meq/L, Cl− 111 meq/L, CO2 14 mmol/L, blood urea nitrogen (BUN) 46 mg/dL, glucose 132 mg/dL, albumin 1.5 g/dL
ABG: pH 7.16, pCO2 38 mm Hg, pO2 95 mm Hg, HCO3− 13 meq/L, SaO2 95%.
Ventilator settings: Assist control/volume control (ACVC) with respiratory rate (RR) set at 20 with actual rate of 40, positive end expiratory pressure (PEEP) 8 cm H20, FiO2 50%, tidal volume (TV) 400 ml with ideal body weight 76 kgs.
What is the acid-base status and how might you adjust the ventilator to improve this acid base status? (click on correct answer to move to next panel)