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.

What possible learning needs do you anticipate for this patient?

Answer 1

The possible learning needs to anticipate for this patient includes:

1) keep a track on ventilator settings and modes based on patient effort of breathing. Check all ventilatory parameters like Respiratory rate, Tidal volume, Fraction of inspired oxygen FIO2 , Peak inspiratory pressure (PIP). Count respiratory rate manually to detect spontaneous breath of patient. Target PIP is 30 cm of water. Elevated PIP indicates excess secretions and need for suctioning, kinked tubes, bronchospasm ,pulmonary edema.

2) To maintain patient airway suctioning is essential. Provide endotracheal suctioning as per need of the patient. Preoxygenate before rending suctioning. Apply suction pressure of 100 - 150 mmHG to prevent injury to normal mucus tissues. Apply suction only after entering catheter.

3) Prevent infection by following universal precautions like hand hygiene, proper oral care using chlorhexidine solution .Proper oral hygiene to patient will prevent Ventilator associated pneumonia. Elevate patient head to 45 degree to prevent aspiration. Follow stress ulcer prophylaxis. Mobilize the patient every hour to prevent pressure ulcer and DVT prophylaxis must initiated by providing compression bandages and promoting passive exercises.

3) Coordinate the care with all health professionals like doctors, respiratory therapist, physiotherapist to Foster quality care. Communication with in departments about patient progress should be done on daily basis.

4) Hemodynamic stability should maintained by monitoring vitals and central venous pressure. Mechanical ventilation increases intrathoracic pressure leads to decrease blood circulation and a drop in blood pressure. To maintain blood pressure stability administer adequate IV fluids and supportive cardiac inotropes like dopamine and dobutamine.

5) Increased PEEP value will end up with barotrauma. To prevent this auscultate breath sounds and oxygenation status.

6) Meet nutritional demand of patient by providing Rules tube feeding as prescribed.