respi 3 - showman

[ArchivalUser]

A 64-year-old man requires endotracheal intubation
and mechanical ventilation for chronic obstructive pulmonary
disease. He was paralyzed with rocuronium for intubation.
His initial ventilator settings were AC mode,
respiratory rate 10 breaths/min, FIO2 1.0, Vt (tidal volume)
550 mL, and PEEP 0 cmH2O. On admission to the intensive
care unit, the patient remains paralyzed; arterial blood
gas is pH 7.22, PaCO2 78 mmHg, and PaO2 394 mmHg. The
FIO2 is decreased to 0.6. Thirty minutes later, you are called
to the bedside to evaluate the patient for hypotension. Current
vital signs are: blood pressure 80/40 mmHg, heart rate
133 beats/min, respiratory rate 24 breaths/min, and SaO2
92%. Physical examination shows prolonged expiration
with wheezing continuing until the initiation of the next
breath. Breath sounds are heard in both lung fields. The
high-pressure alarm on the ventilator is triggering. What
should be done first in treating this patient™s hypotension?
A. Administer a fluid bolus of 500 mL
B. Disconnect the patient from the ventilator
C. Initiate a continuous IV infusion of midazolam
D. Initiate a continuous IV infusion of norepinephrine
E. Perform tube thoracostomy on the right side

[ArchivalUser]

AA??

[ArchivalUser]

d?

[ArchivalUser]

bbbbbb
Patients intubated for respiratory failure due to obstructive
lung disease (asthma or chronic obstructive pulmonary disease) are at risk for the development
of intrinsic positive end-expiratory pressure (auto-PEEP). Because these
conditions are characterized by expiratory flow limitation, a long expiratory time is required
to allow a full exhalation. If the patient is unable to exhale fully, auto-PEEP develops.
With repeated breaths, the pressure generated from auto-PEEP continues to rise and
impedes venous return to the right ventricle. This results in hypotension and also increases
the risk for pneumothorax. Both of these conditions should be considered when
evaluating this patient. However, because breath sounds are heard bilaterally, pneumothorax
is less likely, and tube thoracostomy is not indicated at this time. Development of
auto-PEEP has most likely occurred in this patient because the patient is currently agitated
and hyperventilating as the effects of the paralytic agent wear off. In AC mode ventilation,
each respiratory effort will deliver the full tidal volume of 550 mL and there is a
decreased time for exhalation allowing auto-PEEP to occur. Immediate management of
this patient should include disconnecting the patient from the ventilator to allow the patient
to fully exhale and decrease the auto-PEEP. A fluid bolus may temporarily increase
the blood pressure but would not eliminate the underlying cause of the hypotension. After
treatment of the auto-PEEP by disconnecting the patient from the ventilator, sedation
is important to prevent further occurrence of auto-PEEP by decreasing the respiratory
rate to the set rate of the ventilator. Sedation can be accomplished with a combination of
benzodiazepines and narcotics or propofol. Initiation of vasopressor support is not indicated,
unless other measures fail to treat the hypotension and it is suspected that sepsis is
the cause of hypotension.

[ArchivalUser]

very nice q thanks alot

[ArchivalUser]

showman ru an intensivist?

[ArchivalUser]

no harryputtar.....
i am an mbbs grad from rgmc bombay

[ArchivalUser]

bumping