pulmonary-11 - laptoping

[ArchivalUser]

A 72-year-old, 90-kg (198 lb) woman who lives in an assisted living facility is evaluated after 10 days in the intensive care unit. She was admitted with severe urosepsis. She was in shock requiring pressors for several days and developed severe acute respiratory distress syndrome and acute renal failure requiring continuous venovenous hemoperfusion. She was persistently febrile until 2 days ago and is still being given piperacillin/tazobactam.

She remains intubated and is receiving ventilatory support with oxygen saturation 94% on FiO2 0.60, PEEP 8 cm H2O, and plateau pressure 30 cm H2O. The heart rate is 102/min, and blood pressure is 140/90 off pressors, and secretions are minimal. She is still oliguric and receiving hemodialysis. She has been off sedation for 3 days, but remains lethargic and confused. She cannot cooperate with the neurologic examination, but nurses have noted that she seems very weak and coughs minimally when suction is applied. Measurement of arterial blood gases on the current ventilator settings show a PO2 of 68 mm Hg, a PCO2 of 36 mm Hg, and a pH of 7.42.

The patient has a living will and has expressed the desire not to be kept on life support if there was no hope for recovery. There is no health care proxy, and family members cannot be located.

Which of the following is most likely to minimize ventilator duration, facilitate discharge from intensive care, and be in accord with the patient's desires?

A Schedule a tracheostomy and plan on transfer to a long-term acute care facility when she is sufficiently stable
B Begin corticosteroid therapy
C Begin spontaneous weaning trials and plan extubation if she succeeds for at least 30 min
D Extubate and begin noninvasive positive pressure ventilation and proceed with pressure support wean
E œTerminal wean because of medical futility

[ArchivalUser]

c.

[ArchivalUser]

a or c hmmm will go for ccccc

diff ques

[ArchivalUser]

A is the correct ans.

This patient had severe sepsis complicated by shock and multi-organ dysfunction. The normothermia is encouraging with regard to clearing of sepsis, but she remains in kidney failure, may have a critical illness neuropathy, and has not yet recovered from ARDS. Use of corticosteroids for late stage ARDS is supported by a small randomized trial, but has not been convincingly shown to be beneficial. The patient does not meet œwean screen criteria; she is receiving too much oxygen supplementation (PaO2 ≥ 60 mm Hg or SaO2 > 88% on FiO2 ≤ 60%). Thus, a spontaneous breathing trial would be premature. She is a poor candidate for NPPV because of her delirium and weak cough, and she has not demonstrated that she can sustain ventilation on settings that would be used noninvasively. Withdrawing support would be the most efficient way to minimize ventilator duration and intensive care unit stay, but it is not clear yet that her situation is futile and there is no health care proxy. Although her prospect for returning to her previous state of functioning is not good, withdrawing support at this time would conflict with the patient's stated wishes.

Defining medial futility is a matter of debate, because of different kinds of futility; inability to restore the previous quality of life, for example, as opposed to physiologic futility “ the inability to sustain vital functions. Also, patients differ on the level of futility before they would go along with withdrawing care “ many would stop if the likelihood is