A 68-year old man has undergone an esophagectomy for cancer and is on the ICU 4 hours following the surgery.
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.
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.
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.
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?