A 68-year old man has undergone an esophagectomy for cancer and is on the ICU 4 hours following the surgery.
History:
He has a 30-pack year smoking history, drinks 2 beers a day, and a history of coronary artery disease with stable angina. He snores at night and falls asleep during the day; he probably has undiagnosed obstructive sleep apnea. His home medications include aspirin, metoprolol and simvastatin. He lost about a liter of blood during his surgery and received 5 liters of crystalloid.
Examination:
He weighs 95 kg and is 1.8m tall. He is intubated on the ICU and is receiving propofol for sedation and fentanyl for analgesia. The CVP is 9 mmHg, the HR is 95/min, the BP is 105/60 and the temperature is 37.4 degrees Celsius. The ventilation mode is volume control ventilation; the respiratory rate is 12/min, the tidal volume = 800 ml, the I:E ratio is 1:3, the FiO2 is 0.6, and the PEEP is 5 cmH2O. Cardiorespiratory examination reveals distant heart sounds, bilateral breath sounds, faint crackles in the lower zones with a soft wheeze. Urine output has been 50 and 45 ml/hr for the last two hours.
Special Investigations:
Blood results reveal a hemoglobin of 8.2 g/dL, platelet count of 210 x 1000/mcL and white blood count of 12.3 x1000/mcL. There are no electrolyte abnormalities, the BUN is 19 mg/dL, the creatinine is 1.3 mg/dL and the blood glucose is 170 mg/dL. The arterial blood gas shows a pH = 7.37, PO2 = 78 mmHg, a PCO2 = 38 mmHg, and bicarbonate = 23 mmol/L. The CXR shows the tracheal tube and the central line appropriately positioned. There are bilateral patchy opacifications. The ECG is unchanged compared with the preoperative ECG, and troponin I is not elevated.
Questions:
Based on the information presented and the most up to date evidence, decide on the following management conundrums for this particular patient, critically citing peer reviewed literature to support your decisions. When you cite evidence, comment on its validity, its importance, and its applicability to this patient.
1) Would you give a blood transfusion?
2) Would you give a fluid challenge?
3) Would you target a blood sugar range of 80-120 mg/dL?
4) Would you promote diuresis?
5) Would you start low dose dopamine or use another pressor, such as phenylephrine?
6) Would you give a beta-blocker?
7) Would you give aspirin and a statin, and via what route?
8) Would you alter mechanical ventilation?
9) What steps would you take to prevent pneumonia?
10) Would you sedate this patient?
11) Would you try to extubate this patient to a CPAP mask?
12) Would you plan to do a tracheostomy?
13) What thrombosis prophylaxis would you use?
Sunday, January 13, 2008
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12 comments:
1) Yes I would give a blood transfusion for the following 4 reasons. The patient has a history of coronary artery disease. Large estimated blood loss from surgery. Received a large volume of crystalloid during the case. Will need more volume expansion through out the night and blood would be the most beneficial expander.
2) Yes I would give a fluid challenge, most likely 5% Albumin. The urine output is marginal but in the presence of volume still low so more volume is likely needed. The primary goal at this time is to protect the grafted tissues perfusion status.
3) Yes I would target the 80 to 120 blood sugar but before that I would take alcoholic precautions. That would include thiamine along with a daily banana bag with multiple vitamins and folic acid.
4) No I would not promote diuresis. Again graft perfusion is the most important factor the fluid overload in the lung will be an issue later.
5) No pressor should be used in this patient population due to the single vessel perfusion on the graft. Epidrine might be useful of duramorph was the cause of the hypotension.
6) No I would not use a beta blocker at this time but I would be mindful of reflex tachycardia. If need an IV dose of lopressor could be used.
7)No po meds can be given at this time but a rectal asprin might be useful for cardiac reasons.
8) Yes I would change the mechanical ventilation. If not already SIMV would be the ideal choice for this patient. Changes would increase the peep to 7.5 to increase PO2. Decrease the tidal volume to 600. Increase the respiratory rate to 14. Decrease the FIO2 to 40 due to existing COPD history.
9) The only steps in this case would be early rotation therapy and low tidal volume approach.
10) Yes I would sedate this patient pain control, fluid volume, and oxygenation will be goals to control in the first 12 to 24 hours.
11) No I would not extubate this patient to CPAP. The patient is in a class where CPAP/BIPAP are of questionable use. The patient should remain on the vent until the team arrives in the am. Patient has a strong history of smoking and sleep apnea dont rock the boat.
12) Trachestomy is an option but a trail wean and even trail extubation used be attemp prior to trach.
13) The heparin subcutaneous should start at 24 hours post op. The SCD should start on arrival to unit. Early extubation the following day along with up to chair and aggressive pulmonary toilet.
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