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P44008: In Class Test Preparation Weaning
Phillip McCracken (71 years of age) has been admitted to intensive care (ICU) with sepsis following an emergency laparotomy for a perforated caecum. During his ICU stay it was discovered that Phillip has mild right sided heart failure. He has been in ICU for 19 days and is currently weaning from mechanical ventilation. He has a tracheostomy in situ. He is being ventilated via spontaneous mode with + 10 cmH2O CPAP and a FiO2 45%. You notice that he seems to be dyspnoeic you therefore perform an assessment:
PMH: Hypertension and moderately poor exercise tolerance Social History: Smoker- 60 pack year (30 a day for 40 years) Airway: secure and patent, cuff pressure 25cmH2O Respiratory Rate: 34 bpm SpO2 84% Bilateral and equal air entry Dullness in left lower lobe upon percussion Minimal breath sounds in left lower lobe. Some coarse crackles throughout upon auscultation Thick green purulent secretions obtained on ET aspiration Tidal volumes 104 240mls (Ideal body weight 75kg) Minute Volume 7L Pulse: 65 bpm Arterial Blood Pressure: 120/70 mmHg
ABGs pH 7.15 PaCO2 10.4 kPa PaO2 7.8 kPa HCO3- 24 mM BE -4 Lactate: 0.5 mM Chlorine: 100 mEq/l Hb: 130 g/l K+: 4 mM Mg2+: 2 mEq/l BM: 7 PaO2: FiO2 128 mmHg
Sample Exam Questions:
1. Describe and discuss the mechanisms and indicators of an increased work of breathing in relation to Phillip
2. Discuss the significance of intrinsic PEEP in this patient
3. Discuss the physiology and significance of each arterial blood gas parameter and compensation mechanisms
and relate to Philip McCrakens clinical condition and suspected diagnosis
4. Describe and discuss the pathophysiological process leading to Phillips right sided heart failure.
5. What indicates a readiness to wean and how might you recognise a failure to wean?
6. Discuss and evaluate evidence based weaning strategies that may optimize success of weaning
Jack Whitley was admitted to a gastroenterology ward with suspected acute pancreatitis. He was transferred to intensive care (
ICU) last night following respiratory and cardiovascular deterioration. The patient was found to have a metabolic acidosis and was therefore sedated with propofol and fentanyl and is being ventilated via an endotracheal tube on pressure support ventilation.
Demographics:
Male
Caucasian
DOB 01/01/1960
Height: 181cm
Weight 75kg
Past Medical History:
Jack has known hypertension and hypercholesterolaemia
Family History:
Unremarkable
Social History :
Lives in house with wife
Tries to follow a low fat diet
Non-smoker
Drug History:
Captopril 50mg tds, simvastatin 40mg nocté, furosemide 40mg bd
No known allergies
Vital Signs:
Respiratory Rate: 22 breaths per minute
Air entry: Bilateral, equal, coarse crackles to the left lower lobe, dullness to left base
Oxygen saturations: 96%
Heart rate: 130 beats per minute, irregular
Arterial Blood Pressure: 75/40
EtCO2: 47mmHg
CVP: 8 mmHg
Temperature: 38.8oC
Ventilation:
FiO2: 40%
Mandatory Rate: 16
Spontaneous Rate: 6
Tidal Volume: 450 ml
Minute Volume: 9.9 l/min
Inspiratory Pressure: 25
PEEP: 12
Plateau pressure: 22
I:E Ratio 1:2
Arterial Blood Gases:
pH 7.0
pCO2: 3.5 kPa
pO2: 9.2 kPa
HCO3 2-: 15 mM
BE: -6ml/l
Lactate: 4 mM
Hb: 13 g/dl
BM: 7 mM
PaO2: FiO2 ratio: 163mmHg
1. Identify the rhythm from the strip below and briefly describe the electropathophysiology associated with this arrhythmia (5%):
2. Discuss the physiology and significance of each arterial blood gas parameter and compensation mechanisms and relate to Jack Whitleys clinical condition and suspected diagnosis (15%)
3. Evaluate the relevance of ventilation perfusion mismatch in this patient (10%)
4. Briefly describe and discuss with reference to the evidence base the ventilation strategy that you would adopt in this patient (15%)
5. Evaluate different methods of assessing fluid responsiveness in this patient (15%)
6. Critically discuss your suggested fluid management strategy providing an evidence based rationale for your plan? (40%)
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