mechanical ventilation - kallastro

[ArchivalUser]

A 65-year-old man who resides in a skilled nursing facility becomes febrile, tachycardic, dyspneic, and hypotensive 90 minutes after bladder catheterization. His past medical history is notable for Alzheimer™s disease, renal insufficiency, and anemia. His heart rate is 115 bpm, and his blood pressure is 85/55 mm Hg.

1. What is the first step in the management of this patient?

1. Administer 6% hetastarch in a 500 mL 0.9% sodium chloride injection
2. Administer 20 mL of albumin (human) 25% through a large-bore IV line
3. Rapidly administer 500 mL of normal saline through a large-bore intravenous (IV) line
4. Transfuse 1 U of packed red blood cells

The patient becomes more dyspneic. Chest radiography reveals bilateral infiltrates. The patient progresses to respiratory failure and requires intubation. He is placed on mechanical ventilation with a fractional concentration of oxygen in inspired gas (Fio2) of 100% and positive end-expiratory pressure of 8 cm H2O to maintain an oxygen saturation of 90%. He continues to be hypotensive. What is the next step in the management of this patient?

1. Administer an additional 6% hetastarch in a 500 mL 0.9% sodium chloride injection
2. Administer another 500 mL bolus of normal saline
3. Administer another 20 mL of albumin (human) 25%
4. Transfuse an additional unit of packed red blood cells

[ArchivalUser]

3. then
4 ?

[ArchivalUser]

3. dont know the next

[ArchivalUser]

3
4?

[ArchivalUser]

Hi Triplehelix and Abdalla ,I have a Small doubt. In the question It is mentioned that the patient has Renal insuffiency and anemia .In such a case is it advisable to do RAPID infusion of fluids? Please try to clarify my doubt.

Thanks,
Sriram

[ArchivalUser]

answer is 3.....

This patient is most likely in septic shock following bladder catheterization. In the early phases of fluid resuscitation in a septic patient, rapid volume expansion is the key to achieving a good outcome. Adequate and early volume expansion is generally more important than immediate insertion of a central venous catheter or a pulmonary artery catheter if adequate peripheral access is available. The choice of fluid administered is not as critical as early volume expansion.1,2 The target mean arterial blood pressure is 65 mm Hg or greater.3 Pressor therapy may be necessary later; however, adequate volume replacement would be necessary initially to �prime the pump� for more effective pressor function.

answer is 2.....

Again, the choice of fluid administered is not as critical as timely administration of fluid, even in the presence of acute respiratory distress syndrome. Rivers et al3 emphasized the importance of early goal-directed therapy for treatment of sepsis before transfer to the intensive care unit. Their approach involved adjustment of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The reported in-hospital mortality rate was 30.5% in the early goal-directed therapy group compared with 46.5% in the standard therapy group. These goals have been incorporated into the Surviving Sepsis Campaign guidelines.