Icu Case Study
Once admitted to ICU, he was intubated and ventilated on bilevel ventilation and sedated with propofol and fentanyl. In theatre he received two litres of hartmanns solution as a fluid load, however in ICU was commenced on maintenance of normal saline at 100mls/hr. Feeding was ruled out on admission as it was thought that the patient would have extubated the following day. However, the patient was in ICU six days prior to extubation, therefore TPN was commenced. Noradrenaline was used for a MAP above 70mmhg rather than a fluid load. The patients clinical scenario was more in depth as outlined above.
However, these are outside the scope of this case study. The medical and nursing interventions discussed in this assignment is mechanical ventilation, total parental nutrition and vasopressors. Mechanical Ventilation Bilevel ventilation is a relatively new setting. (Mireles-Cabodevila et al, 2009) The ventilator maintains a high pressure setting for the bulk of the respiratory cycle, which is followed by a release of low pressure. (Mireles-Cabodevila et al, 2009) The release to a low PEEP is the expiration phase and aids the elimination of CO?.
The release periods are kept short to prevent derecruitment of alveoli and encourage spontaneous breathing. (Mireles-Cabodevilla et al, 2009) The advantages of bilevel include an increase in mean alveolar pressure with recruitment, haemodynamic and ventilatory benefits and reduced sedation requirements. (Putensen et al, 2006) Analgesia and sedation is not only used for pain relief and anxiety but for mechanical ventilation comfort. (Putensen et al, 2006) This level can reduced to aim of a Riker of 4, which a co-operative, responsive patient. Putensen et al, 2006) This reduces the need for more vasopressors to maintain a stable cardiovascular system. (Putensen et al, 2006) When first admitted the patients ventilatory settings were: FiO2 0. 4 Rate 12 HiPeep 22 LoPEEP 5 PS 10 CXR showed bibasal atelectasis/consolidation ABG – pH 7. 43 paCO? 33 paO? 74 HCO? 23 BE -0. 5 The pH is within normal limits, on the lower end, i. e. between 7. 35 – 7. 45. Therefore it is normal/alkalotic. The paCO? indicates an alkalotic range. This is used to assess the effectiveness of ventilation. (Coggon, 2008) PaO? is 74, which is low as normal range is 80-110, which shows hypoxemia.
PaO? is not interpreted in the patients acid-base status but indicates O? binding to haemoglobin. (Coggon, 2008) The HCO? is normal. The next step is to match the CO? , HCO? to the pH. The CO? and pH is on the alkalotic side of normal. Therefore it shows a respiratory disturbance. (Woodruff, 2009) The next step is to see if either compensation is occurring. To do this, the interpretor must look to see if either the CO? or HCO? go in the opposite direction of the pH. In which, in the ABG above, you can clearly see that it does although the HCO? is within normal range, which means no compensation is occurring. Woodruff, 2009) The full diagnosis is uncompensated respiratory alkalosis with hypoaxemia. The patient is more than likely hyperventilating with poor gas exchange in view of the CXR. In response to this ABG result ventilatory setting were changed to: FiO2 0. 4 Rate 8 HiPEEP 22 LoPEEP 8 PS 14 ABG post setting change – pH 7. 39 paO? 103 paCO? 36 HCO? 22 The rate was changed as the patient was blowing off too much CO? with the rate of 12 plus any spontaneous breaths he was doing. The patients chest was rotten with a productive secretions and bibasal consolidation at the bases, seen in a repeat CXR.
Suctioning resulted in moderate to large amounts of white sputum. The patients wife stated that he had been suffering from a cold for one week prior to admission. Therefore an increase in PEEP (Hi and Lo) was required to recruit the alveoli and aid in good gas exchange. (Dellinger at al, 2007) It is recommended that positive end expiratory pressure is set to avoid extensive lung collapse on expiration. (Dellinger et al, 2007) Maintaining pressure and spontaneous breathing resulted in an increase in arterial oxygenation and helped prevent a deterioration in pulmonary gas exchange. Putensen et al 2006) Studies have been carried out to determine whether high PEEP increases patients outcomes. These include the ALVEOLI study and the Lung Open Ventilation (LOV). These studies do not show an improvement on mortality with the increase in PEEP however show a decrease in days on the ventilator. (Mercat et al 2008) The patients right side was worse than the left on the CXR and auscultation. Therefore he was being positioned right side up and his back on pressure area cares. Repositioning patients not only protects the patients skin but it also improves gas exchange and decrease the risk of ventilator acquired pneumonia. Deutschmann and Neligan, 2010) Positioning the patient with the good lung down may improve paO? and aid in the drainage of secretion. (Deutschmann and Neligan, 2010) Elevating the head of the bed also aids recruitment of alveoli at the bases and again decreases the risk of ventilator acquired pneumonia. (Deutschmann and Neligan, 2010) All of the above interventions by nursing and medical staff were to improve the patients outcome and aid extubation once the patients chest improved and any other factors affecting the patients ability to self-ventilate. Total Parenteral Nutrition
It is seen as appropriate time-scale of 1 – 3 days that surgical patients commence normal diets. (Braga et al, 2009) As the patient was intubated and ventilated, no feeding was commenced until day three. The main goal of nutritional support is to avoid starvation in the aim to support post-operative recovery, and maintain the patients normal body functions. (Braga et al, 2009) Malnutrition decreases patients outcomes within the critical care setting. (Artinian et al, 2006) Total parenteral nutrition (TPN) was commenced at 40mls/hr as per the ICU Dr’s orders.