chbare Posted September 30, 2008 Posted September 30, 2008 Your critical care transport team is called to perform an international medical evacuation. Your patient is currently in New Deli India. You will fly him to Dubai UAE Wellcare hospital for ongoing treatment. The current working diagnosis is sepsis. You should expect at least a six hour flight. What do you want to know?
fireflymedic Posted September 30, 2008 Posted September 30, 2008 What is sepsis due to? Kidney function? Urine output? Vent dependent? Settings? ARDS an issue? Do we require vasopressors? If so how much and what? Gram negative or positive cultures? What antibiotics are we on? Current vitals? Stability of patient? Is this gonna be a happy flight or am I gonna be working my tail off here? I think I'll let you have that for the time being? Oh let's throw age, coexisting med conditions, duration of sepsis, and routine meds in addition to the boatload he's prolly on right now.
chbare Posted September 30, 2008 Author Posted September 30, 2008 He is a 42 year old male with no known pre-existing medical or significant surgical history. He sustained a shrapnel wound to his abdomen in Afghanistan, was stabilized with blood products at a small facility and transferred to Emergency hospital in Kabul. Four hours S/P injury, he was taken to theatre and his liver was packed with hemostasis achieved. After approx two hours in the OR, he was evacuated to a hospital in New Deli the same day. After evac, he was admitted to an ICU. Your team makes contact approx 48 hours S/P injury. Additional Information: The patient had a hypotensive episode in the OR and was placed on a dopamine drip following blood product administration. He was not taken off the ventilator and remains intubated and sedated. He has had continued episodes of hypotension with several episodes of non sustained ventricular tachycardia. The ICU staff suspect an intra-abdominal infection. He receives Flagyl 500mg twice a day IV and Ceftriaxone 1000 mg IV once a day. Urine output is approx 10ml/hour. Current Vital Signs: P-115, B/P- 116/088, RR- 10 Ventilator, SPO2- 98%, Temp- 98.9 F . Chest X ray looks clear, surgical wound is dry and intact, without redness or discharge. Cultures are pending. Vent Settings: Vt- 500, R- 10, FIO2- 0.6, PIP- 21, Pplat- 18, I;E- 1:2.2, Mode: what ever you want. Take care, chabre.
SANDMEDIC Posted September 30, 2008 Posted September 30, 2008 What do his labs and blood gases look like? Any CT for CHI? Any speculation from the physicians for MODS? Diprivan (Propofol) typically used for sedation could also be creating the hypotension. Pancuronium Bromide may be an alternative. My concerns: Lab values/ Blood gases Decreased urine output Runs of Vtach Hypotension
chbare Posted September 30, 2008 Author Posted September 30, 2008 Current ABG: PH: 7.3 PCO2: 28 PO2: 240 HCO3-: 15 Non Contrast CT of the head is negative. He is currently on a diprivan drip. His hypotension occurred in OR and was controlled with dopamine following blood products. He remains on a dopamine gtt at 10 mcg/kg/min. Blood pressure has been in the 110- 118 systolic range over the past 24 hours. Pancronium would be great at making him look sedated; however, there is the problem of actual sedation. Take care, chbare.
SANDMEDIC Posted September 30, 2008 Posted September 30, 2008 LMAO!! I should know better...Sheesh I was thinking too hard... With those numbers Metabolic Acidosis. :shock:
ERDoc Posted September 30, 2008 Posted September 30, 2008 LMAO!! I should know better...Sheesh I was thinking too hard... With those numbers Metabolic Acidosis. :shock: Share with the rest of the class how you came up with metabolic acidosis. What is his lactate level? Does anyone want to make any vent changes? What about his abx choices?
ERDoc Posted September 30, 2008 Posted September 30, 2008 HCO3 is toward the acid side and this matches the ph of 7.30 which is also acid; the pCO2 is alkaline; I would venture to say this is metabolic acidosis. This is the quick method I can do a step by step method, if you like Is there a better way..am I incorrect? Nope, I think you got it. I just wanted to hear the thought process so that others who were not familiar with ABGs would be able to understand how you came to the conclusions. Your pH is 7.3 which tells you that you are dealing with some form of acidosis. The pCO2 being low at 26 tells you that you have some sort of respiratory compensation for a metabolic phenomenon. How about the pO2? Sorry chbare if I am stealing your scenario. What are the other labs such as chemistry, UA, etc?
chbare Posted September 30, 2008 Author Posted September 30, 2008 As SANDMEDIC noted, the patient is clearly in an acidotic state. What if I were to thrown in a serum lactate of 6? What does this tell us? The ABG was performed about an hour ago. The patient was initially on a FiO2 of 0.8 when the ABG was drawn and the vent rate was 12. Can this relate to our ABG? Changes were performed after the ABG results. Unfortunately, the labs are missing and lab cannot seem to find copies. However, you have limited diagnostic abilities on the plane. Time to get going. Take care, chbare.
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