Question

Brief Patient History

Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery

for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated

bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during

resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously

(IV) to achieve hemodynamic stability.

Clinical Assessment

Within 24 hours of admission to the unit, Mr. A becomes extremely short of breath with an increase in respiratory

rate of 44 breaths/min. Crackles, rhonchi, and bronchial breath sounds are heard bilaterally, whereas on

admission, breath sounds were clear with a few crackles in the bases. Arterial blood gas (ABG) analysis reveals a

PaO

2

of 56 mm Hg, PaCO

2

of 33 mm Hg, pH of 7.52, HCO

3

-

level of 34, and O

2

saturation of 84%. Mr. A was

intubated and placed on synchronized intermittent mandatory ventilation (SIMV) with an FiO

2

(fraction of

inspired oxygen) of 60%, tidal volume (VT) of 400 mL, and 5 cm of positive end-expiration pressure (PEEP).

Despite sedation, Mr. A becomes extremely restless, diaphoretic, and tachypneic at 36 to 44 breaths/min. His

breathing is not synchronous with the ventilator, which is causing him to fight, or “buck,” the ventilator. The

high-pressure alarm on the ventilator sounds frequently, and he steadily becomes more hypoxic. His FiO

2

is

increased to 80%, and PEEP is increased to 10 cm to keep his PaO

2

above 60 mm Hg. Mr. A is started on a

Norcuron (vecuronium) and Ativan (lorazepam) IV infusion.

Diagnostic Procedures

The current chest radiograph reveals complete opacity or a “white-out” appearance of the lungs. The chest

radiograph in the emergency department was clear, and the chest radiograph immediately after surgery revealed

bilateral patchy infiltrates that had a “ground-glass appearance.” ABG analysis: pH of 7.48, PaO

2

of 60 mm Hg,

PaCO

2

of 65 mm Hg, HCO

3

-

level of 28 mEq/L, and O

2

saturation of 90% on an FiO

2

of 80%. Current vital signs

are blood pressure of 118/76 mm Hg, heart rate of 112 beats/min (sinus tachycardia), respiratory rate of 16

breaths/min, and temperature of 100.8F. Urine output is 30 mL/h, and peripheral pulses are palpable. Hematocrit

is 24%, hemoglobin is 8 g/dL, lactate level is 3 mmol/L, and white blood count is 12,000/mcL.

Medical Diagnosis

• Gunshot wound to abdomen; bowel resection

• Splenectomy

• Acute respiratory distress syndrome (ARDS)

• Patient-ventilator dyssynchrony

Questions

1. What major outcomes do you expect to achieve for this patient?

Answer 1

The patient is in critical condition and needs ICU stay and mechanical ventilation support for at least 96 hours.

The priorities and outcomes at this point include:

• Care of surgical wound and prevention of secondary infection.
• If a significant portion of bowel has been removed, then total parenteral nutrition has to be continued. Adequate protein intake is important for recovery.
• Hemoglobin is 8gm/dl. Since, he is young, he will tolerate this Hb. But if further drop in Hb occurs he may need transfusions. But this is a problem. Because most likely his ARDS is due to Transfusion associated lung injury. TRALI
• Treatment big ARDS. If the ARDS is due to TRALI, then it might resolve in 4- 5 days with mechanical ventilation and supportive therapy. ARDS ventillation ( low tidal volume, increased PEEP, proning and de- proning) will help. But ARDS is very difficult to manage and patient's condition can deteriorate due to milultisystem involvement. Presently FiO2 is 80% and saturation is 90%. Target saturation for next few days is 90 percent. Gradual reduction of FIO2 should be done. Patient ventillator dysynchrony should be prevented by continuous neuromuscular blockade till patient's lungs improve and he becomes capable of spontaneous ventillation.
• Splenectomized patients are vulnerable for infections by capsulated organisms. Hence patient should be on broad spectrum antibiotic coverage.
• His total count is already elevated and he has fecer. So, he might already have underlying infection. He can go into septic shock. Broad spectrum antibiotics and inotropic support may become necessary.
• His urine output is inadequate. Kidneys can fail and he may need supportive hemodialysis.
• He is presently vitally stable. And saturation has improved compared to previous state. ABG is also better. Gradual improvement is possible with TPN, antibiotics, wound care, mechanical ventilation and muscle relaxation.