WebM&M: Case Studies

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done. Eight hours later, the patient became hypotensive and hypoxemic and emergent CT revealed a gastric perforation. The patient was transferred to the intensive care unit and ultimately required endotracheal intubation with mechanical ventilation. The commentary discusses the complications associated with nasogastric tube insertion, assessing and treating acute agitation secondary to delirium, and the importance of clear communication during shift changes and handoffs.

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures. During these subsequent procedures, he was found to have florid mediastinitis including multiple pockets of purulent material; the chest tissue culture collected during surgery demonstrated Aspergillus fumigatus. The patient returned to PICU with an open chest to optimize antibacterial and antifungal therapies for a hospital-acquired invasive fungal infection in an immunocompetent infant. The commentary discusses environmental factors that contribute to postoperative infections and approaches to mitigating environmental infectious disease hazards in perioperative spaces.

In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.

After removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn.

A patient with presumed small bowel obstruction undergoes a contrast-enhanced CT scan. She develops contrast nephropathy requiring dialysis.

Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.

An infant codes due to pulmonary emboli after a central line flush.

A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.