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 PaO₂ of 56 mm Hg, PaCO₂ of 33 mm Hg, pH of 7.52, HCO₃^- level of 34, and O₂ saturation of 84%. Mr. A was intubated and placed on synchronized intermittent mandatory ventilation (SIMV) with an FiO₂ (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

Question:

1. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

Answer 1

Mr.A 18 years old have suffering with conditions like Gun shot injury and also he has ARDS.

• He Should be put on mechanical ventilator for supportive care (oxygenation for prevent further damage of cells of body)

• Proper positioning of patients should be done
• Patients should be sedated and then Giving proper medications to patients.
• fluid management is key
• ECMO

there are some important things when manage this patient with ARDS is by maintaining proper proper perfusion ,protective lung ventilation, and prevent complications like

•deep vein thrombosis

•pressure ulcer,

•Deep Vein Thrombosis

•Ventilator Associated Pneumonia

For prevention of complication:

DVT(Deep Vein Thrombosis): warm and moist compressesions, elevation of affected leg,anticoagulants,analgsics etc.

Pressure Ulcer: proper adequate nutrition , skin care, pressure relieving devices(air mattress)

Ventilator Associated Pneumonia: Broad-spectrum antibiotics , Airway Management, Frequent Suctioning , Use of Aseptic techniques.

MECHANICAL VENTILATION is lung protective ventilation is only supportive therapy that can clearly improve survival in patient with ARDS however mechanical ventilation can lead to lung injury by different mechanisms , according to the mode of ventilator patient becomes stabilized but if there is no progress in patients there may be need to put patients on ECMO if there is more damage in the Lungs.

ECMO is extracorporeal membrane oxygenation which providing prolong cardiac and respiratory support to patient whose heart and lungs are unable to provide an adequate amount of O2 to sustain life.

Indication and uses are:

• hypoxemic respiratory failure
• hypercapnic respiratory failure with an arterial Ph <7.20
• cardiogenic shock
• cardiac arrest

So in condition of Mr.A the best technology useful after mechanical ventilator is ECMO and also according his critical condition continuous observation is also Important.