Acute Respiratory Distress Syndrome (ARDS) following septic shock with acute kidney injury, metabolic acidosis, and post-intubation rehabilitation

Anna Maria Jonathan1*, Dhamodharan. S2

1Physiotherapist, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

2Senior Physiotherapist and Head of Department, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Patient Information

The patient is a 33-year-old male

Chief Complaints

  • Fever for 8 days
  • Bradycardia for 4–5 days
  • Nausea
  • Breathing difficulty

History of Present Illness

The patient developed fever on 1st July, followed by breathing difficulty on 2nd July. Investigations were conducted on 3rd July, and he was admitted to Indira Gandhi Government Hospital, Puducherry from 4th to 6th July.

Initial findings suggested

  • Enteric fever
  • Malaria
  • Thrombocytopenia

Management included

  • 20 units of platelet transfusion
  • 4 units of Fresh Frozen Plasma (FFP)

During hospitalization, the patient developed

  • Hematuria
  • Behavioral changes
  • Hallucinations

On 7th July, the patient became unresponsive and was shifted to Kauvery Hospital, Vadapalani Chennai.

During transport

  • Oxygen saturation dropped to 88% despite oxygen support
  • Unresponsive for approximately 15 minutes
  • Cardiac arrest occurred

Emergency Department Findings

General Examination

  • Temperature: 106.2°F
  • Severe hypotension (~70 mmHg systolic BP)
  • Immediate intubation required

Neurological Status

  • Unresponsive
  • GCS: 3/15
  • Bilaterally sluggish pupils
  • Pupillary dilatation (<5 mm)

Laboratory Findings

Sodium148 mEq/L
Potassium5.2 mEq/L
Chloride118 mEq/L
Creatinine3.8 mg/dL
Hemoglobin13.3 g/Dl

Imaging Findings

CT Brain: Mucosal thickening in bilateral ethmoid and sphenoid sinuses

CT Chest

Features suggestive of

  • Aspiration pneumonitis
  • Acute Respiratory Distress Syndrome (ARDS)
  • Bilateral basal air-space opacities
  • Bilateral apical involvement (right > left)

CT Abdomen

  • Mild hepatosplenomegaly
  • Bilateral bulky kidneys with perinephric fat stranding
  • Minimal ascites

Chest X-ray: Initially normal

Cardiac Evaluation

ECG

  • Sinus tachycardia
  • Features suggestive of acute myocardial injury/STEMI

Echocardiography

  • Ejection Fraction (EF): 54%
  • Adequate left ventricular function
  • Tachycardia due to shock state

Final Diagnosis

  • Septic shock secondary to severe infection (likely enteric fever/malaria)
  • Acute Respiratory Distress Syndrome (ARDS)
  • Acute Kidney Injury requiring hemodialysis
  • Metabolic acidosis

Clinical Progress

  • Trial extubation successful
  • Vital parameters stable
  • ABG within normal limits
  • Persistent hypercalcemia noted
  • Physiotherapy initiated
  • Continued on non-invasive ventilatory support

Physiotherapy Management

ICU Phase (9th July)

  • Positioning to optimize ventilation
  • Airway clearance techniques
  • Chest physiotherapy
  • Early mobilization
  • Passive Range of Motion (ROM) exercises

 

Post-Extubation Phase (11th July)

  • Breathing exercises
  • Active-assisted exercises
  • Incentive spirometry
  • Bed mobility training.
  • Sitting balance training
  • Edge-of-bed sitting.
  • Supported standing.
  • Progressive ambulation with minimal assistance

General Rehabilitation

  • Functional mobility training
  • Muscle strengthening exercises.
  • Endurance training
  • Activities of Daily Living (ADL) retraining

Discharge Advice

  • Practice diaphragmatic and deep breathing exercises regularly.
  • Use incentive spirometer consistently.
  • Perform prescribed upper and lower limb strengthening exercises.
  • Gradually increase walking distance as tolerated.
  • Avoid overexertion and conserve energy.
  • Avoid prolonged bed rest; maintain frequent position changes.
  • Maintain proper posture during daily activities.

Conclusion

This case highlights the importance of early recognition and multidisciplinary management of septic shock complicated by ARDS and acute kidney injury. Timely physiotherapy intervention played a crucial role in improving respiratory function, functional mobility, and overall recovery following prolonged critical illness and mechanical ventilation.

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