Question

Part II It has now been 24 hours since Sam has been intubated and in the ICU. His parents are at his bedside. Both Sam and his parents are practicing Buddhists. Sam has a living will that states he does not want to be on the ventilator longer than 4 days without improvement. Sam’s parents have asked to have the sedation to be discontinued because of their religious beliefs.

Assessment: Vital Signs: B/P 80/40, HR 120, T 102, RR 20, Pulse Ox 88% Ventilator: Vent: Assist Control (AC), TV 550, FiO2 90%, RR 20, PEEP 15 ABG: pH 7.30, PaCO2 46, Bicarb 24, PaO2 60 PaO2/FiO2 ratio: 150 Neuro: Patient is sedated Resp: Lungs with rhonchi bilaterally in all lobes Cardiac: CO 3.5, CVP 3, SVR 800 dynes/sec/cm-5, GI: Bowel sounds absent, NG tube to low continuous suction GU: Foley in place with Urine output <20 ml/hr Lab Values: Lactic Acid 40 mg/dL, Potassium 5 meq/L, Sodium 140 meq/L, Platelets 50,000, Creatinine 4 mg/dL, WBC 20,000 mm3, Doctor’s Orders: Begin Dobutamine at 3 mcg/kg/min (IV bag is supplied with 500 mg Dobutamine mixed in 250 ml D5W). Begin Levophed at 1.5mcg/kg/min (IV bag is supplied with 1000 mg Levophed in 500 ml D5W). Sam is now in septic shock.

What information can you use to come to this conclusion?

Calculate the Mean Arterial Pressure (MAP), and ml/hr for the Dobutamine drip and Levophed drip What are your top three priorities, with rationale, at this time?

Discuss one ethical dilemma you identify in relation to Sam’s parents request. Use either beneficence or non-maleficence to justify our answer.

Answer 1

Sam is in Septic Shock and it is understood from the signs mentioned in the question paragraph.

1. Lactic acid increased levels to 40 mg / dl indicates severe sepsis

2. Urine output is reduced in septic shock

3. Low BP, Increased HR, increased temperature , decreased RR indicates the patientis septic shock.

4. Ratio of Pa O2 : Fi O2 being 150 indicates Acute respiratory distress syndrome.

5. Decreased WBC count indicates infection.

6. Creatinine increase indicates Sepsis

7. ABC results indicates respiratory distress

All the above indicates Sam is in Septic Shock

MAP is calculated by the formula = SBP + 2* DBP / 3

80 +2*40 /3 = 53.

Dobutamine is infused at 0.09 ml per hour

Levophed is infused at 0.045 ml per hour.

Top 3 priorities are as follows

1. Antibiotic therapy to reduce sepsis

2. IV fluids

3. Vasopressors to stabilise blood pressure

4. pain killers and sedatives

Sam parents are practicing buddhism which states that sedation need to be stopped but this will cause him to collapse as the intubation cannot be done and as we know 50% septic shock will lead to death. So we should convince his patents to wait for 2 more days to improve.