Correct!
2. Right lower lobe atelectasis and subsequent pneumonia

This patient likely developed right lower lobe atelectasis secondary to splinting from his abdominal pain. This, in turn, led to the development of pneumonia. Most of the morbidity and mortality of atelectasis is due to the primary disorder. Hypoxemia, which is usually transient, is the main complication. Within 24 to 48 hours, blood is shunted away from atelectatic areas. If the atelectasis is extensive, it may cause enough hypoxemia to require supplemental oxygen or ventilator support.

Case continued:
Neostigmine was administered on admission to the intensive care unit. Broad spectrum antibiotics for health care associated pneumonia (vancomycin and piperacillin-tazobactam) were administered. Chest percussive therapy, incentive spirometry, and bronchodilators were administered to improve the atelectasis. A CT scan of the chest, abdomen and pelvis was obtained (Figure 4).

AFigure 4. Panels A and B: Coronal views of CT demonstrating right lower lobe posterior segment consolidation. Panels C and D: CT demonstrating marked distention of the colon with large amount of fecal matter.

CDespite these measures, the patient continued to require more supplemental oxygen. Bilevel (bipap) was initiated with improvement in hypoxemia. Intubation was discussed with the patient, however the patient adamantly declined. His code status was changed to do not resuscitate/do not intubate (DNR/DNI). The patient had some improvement in abdominal distention with conservative measures.

If you are a member of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic and wish to receive 0.25 AMA PRA Category 1 Credit(s)™, click here.

References

  1. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med. 1999;341:137-41. [CrossRef] [PubMed] 
  2. Jetmore AB, Timmcke AE, Gathright JB Jr, Hicks TC, Ray JE, Baker JW. Ogilvie's syndrome: colonoscopic decompression and analysis of predisposing factors. Dis Colon Rectum. 1992;35(12):1135-42. [CrossRef] [PubMed] 
  3. Johnston G, Vitikainen K, Knight R, Annest L, Garcia C. Changing perspective on gastrointestinal complications in patients undergoing cardiac surgery. Am J Surg. 1992;163(5):525-9. [CrossRef] [PubMed]
  4. Delmer A, Cymbalista F, Bauduer F, Martin A, Rio B, Fenaux P, Marie JP, Zittoun R. Acute colonic pseudo-obstruction (Ogilvie's syndrome) during induction treatment with chemotherapy and all-trans-retinoic acid for acute promyelocytic leukemia. Am J Hematol. 1995;49(1):97-8. [CrossRef] [PubMed] 
  5. Xie H, Peereboom DM. Ogilvie's syndrome during chemotherapy with high-dose methotrexate for primary CNS lymphoma. J Clin Oncol. 2012;30(21):e192. [CrossRef] [PubMed] 
  6. Rausch ME, Troiano NH, Rosen T. Use of neostigmine to relieve a suspected colonic pseudoobstruction in pregnancy. J Perinatol. 2007;27(4):244-6. [CrossRef] [PubMed]
  7. Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005;22(10):917-25. [CrossRef] [PubMed] 
  8. Bonacini M, Smith OJ, Pritchard T. Erythromycin as therapy for acute colonic pseudo-obstruction (Ogilvie's syndrome). J Clin Gastroenterol. 1991;13(4):475-6. [CrossRef] [PubMed] 
  9. Weinstock LB, Chang AC. Methylnaltrexone for treatment of acute colonic pseudo-obstruction. J Clin Gastroenterol. 2011 Nov;45(10):883-4. [CrossRef] [PubMed] 
  10. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbaugh J, Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Acute colonic pseudo-obstruction. Gastrointest Endosc. 2002;56(6):789-92. [CrossRef] [PubMed]
  11. Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome): an analysis of 400 cases. Dis Colon Rectum 1986;29:203-10. [CrossRef] [PubMed] 
  12. Simon M, Duong JP, Mallet V, Jian R, MacLennan KA, Sandle GI, Marteau P. Over-expression of colonic K+ channels associated with severe potassium secretory diarrhoea after haemorrhagic shock. Nephrol Dial Transplant. 2008;23(10):3350-2. [CrossRef] [PubMed] 
  13. Sandle GI, Hunter M. Apical potassium (BK) channels and enhanced potassium secretion in human colon. QJM. 2010;103(2):85-9. [CrossRef] [PubMed] 

Home/Critical Care