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You have just arrived at work in the Surgical Intensive Care Unit (SICU).You receive report on William Bennett, 34 years old, admitted to the Emergency Department (ED) after a motorcycle accident. He is expected from the Operating Room (OR) shortly. On arrival in the Emergency Department (ED), Mr. Bennett was in shock. He had multiple lacerations on his face and extremities. His airway was cleared of blood and debris. He was confused, although his eyes opened spontaneously and he was able to follow commands. PERRL at 4 mm bilaterally. His neck was aligned and immobilized. An x-ray of the cervical spine was negative for injury. An x-ray of a swollen and ecchymotic left thigh showed a fractured femur. Fluid resuscitation was initiated with Lactated Ringer’s. Mr. Bennett’s abdomen was bruised but there was no penetrating trauma. Diagnostic peritoneal lavage (DPL) revealed a grossly bloody return. After DPL, Mr. Bennett went into respiratory arrest and was intubated. He was transferred to the Operating Room (OR) stat. Mr. Bennett was in shock when admitted to the Emergency Department (ED). You know that shock is a state of inadequate circulation and perfusion with subsequent tissue hypoxia. Mr. Bennett was experiencing hypovolemic shock, due to blood loss from his injuries. Identification of hypovolemic shock is critical. When shock is present, signs of shock are assessed to monitor its progression and evaluate the patient’s response to therapy. Besides bleeding into the peritoneal cavity, Mr. Bennett was also bleeding from a fractured femur. An exploratory laparotomy revealed a severely lacerated liver and a ruptured spleen. Mr. Bennett’s liver was repaired and his spleen was removed. The left femur fracture was immobilized with internal fixation devices. During surgery, Mr. Bennett received 25 units of packed red cells, 10 units of fresh frozen plasma, and 20 liters of crystalloid solution. Normal saline (0.9% sodium chloride) and Lactated Ringer’s are isotonic crystalloid solutions used for fluid replacement during shock states.

Mr. Bennett arrives in the Surgical Intensive care Unit (SICU). An initial assessment is done. Mr. Bennett is on mechanical ventilation with synchronized intermittent mandatory ventilation (SIMV).

Several hours after admission to the Surgical Intensive care Unit (SICU), Mr. Bennett becomes tachypneic and starts fighting the ventilator. Peak airway pressures rise from 30 to 50 cm H2O. Stat arterial blood gases (ABGs) on 0.6 FiO2 are drawn from the arterial line, and reveal hypoxemia and hypocapnia. FiO2 is increased.

A pulmonary artery catheter is inserted and hemodynamic readings are obtained.
Cardiac output (CO), cardiac index (CI), right atrial pressure (RAP), and pulmonary artery occlusion pressure (PAOP/ PCWP) are normal.

Mr. Bennett’s PaO2 drops further from 60 mm Hg to 55 mm Hg. Chest auscultation reveals scattered crackles throughout.
Permissive hypercapnia ventilation strategy is being used with Mr. Bennett. However, PaO2 above 60 mm Hg cannot be maintained with an FiO2 (oxygen concentration) below 0.6.
Although a heated humidifier provides 100% humidity with Mr. Bennett’s ventilator, to keep secretions from thickening, Mr. Bennett still needs periodic suctioning.

Four days have passed. Mr. Bennett’s condition has improved. Chest x-ray shows improvement, and PaO2 and SaO2 are maintained at normal levels with decreasing oxygen concentrations. It is determined that Mr. Bennett is ready to be weaned from the ventilator.
Mr. Bennett is periodically removed from ventilator assistance and allowed to breathe spontaneously with T-piece oxygen delivery. Over a two-day period, the amount of time off the ventilator is increased.

Mr. Bennett is successfully extubated, and steadily improves over the next few days. His abdominal wound is healing without complication. He is transferred to a step-down unit to continue his recovery.

Mr. Bennett is discharged. As an ARDS survivor, he may or may not have residual pulmonary function abnormalities because of ARDS.

 

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SCIENCE
HEALTH SCIENCE
NURSING

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