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 possible learning needs do you anticipate for this patient?

Answer 1