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

Major Outcomes Expected for Patient:
Maintain patent airway
Maintain adequate ventilation
Maintain adequate tissue and cerebral perfusion
Prevent complications from mechanical ventilation, high FiO2, high PEEP, and neuromuscular blocking agents.

Questions

1. Discuss three problems or risks must be managed to achieve these outcomes?

Answer 1

One of the problems or risks which has to be managed to achieve these outcomes are

• Hypoxic state very frequently even with the support of the ventilator can detoriate patient conditions, so it has to be effectively managed with artificial ventilation with adequate oxygenation
• The patient has been prescribed lorazepam, which puts him at risk of respiratory depression which has to be managed with adequate oxygen ,positioning
• The carbon dioxide level in the body is more which can alter the tissue and cerebral perfusion ,so it has to be managed to prevent this