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 FiO2 is increased to 80%, and PEEP is increased to 10 cm to keep his PaO2 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, PaO2 of 60 mm Hg, PaCO2 of 65 mm Hg, HCO3- level of 28 mEq/L, and O2 saturation of 90% on an FiO2 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

2. What problems or risks must be managed to achieve these outcomes?

Answer 1

2.The problems or risk which has to be managed to to achieve those outcomes are

• Increased serum lactate can be because of severe infection in blood or sepsis ,so it has to be corrected. Oxygen administration with rebreathing mask and correction of increased carbon dioxide and bicarbonate level to be done in order to correct acute uncompensated respiratory alkalosis with metabolic alkalosis. This can be corrected by administering the acidic agents
• There is very high risk for metabolic acidosis when treatment is provided .So if on ventilator decrease the respiratory rate and tidal volume
• Hyperventilation syndrome to be managed with beta adrenergic drugs
• Hypertension has to be reduced with appropriate antihypertensive drugs in 9rder to prevent severe complications
• The problem of anemia has to be managed with blood transfusions
• The problem of infection has to be treated with antibiotics, antipyretics to reduce body temperature