fireflymedic Posted September 30, 2008 Share Posted September 30, 2008 Definitely acidotic state here no arguement about that. With serum lactate of 6, he's already to the point of severe sepsis so my strongest suspicion is that he does have a septic state going on. With that info, I'm going to say that the sepsis is affecting his kidneys in some fashion and is contributing to the metabolic acidosis as renal insufficiency is a contributing factor to metabolic acidosis. Did intestine area get nicked with shrapnel and missed so this poor guy has some bowel involvement? Also, the hypotension if prolonged can compromise kidney function as well. Is this guy still on dopamine? He's also tachy (with as you said the unsustained runs of v-tach) so that makes me lean even harder towards a sepsis diagnosis. As far as antibiotic choices - you wanna go broad spectrum - vanc being first line since we don't know what bug we're dealing with yet (though I'm suspecting gram neg). Zosyn is another option to throw which is a good one for sepsis. That's as far as my brain's thinking thus far this morning. Link to comment Share on other sites More sharing options...
VentMedic Posted September 30, 2008 Share Posted September 30, 2008 How big is this patient? The ventilator is set in a volume mode at 500 x 10 which only gives a 5 L MV. CO2 of 28? What's the pt's total RR? Anion gap? SvO2? CVP? BP MAP? What's the goal for the MAP? Link to comment Share on other sites More sharing options...
chbare Posted September 30, 2008 Author Share Posted September 30, 2008 Ok, you load him and begin a long flight. You continue his infusions per the sending facility.( Dopamine and diprivan ) His liver was hit by shrapnel and bowel perforation was not really suspected. Flat plate is unremarkable. No air fluid levels, air under the diaphragm, or any indication of intestinal trauma. Your limited labs show the following: CK: 3,000, Myoglobinuria, and creatinine of 2.8. Anion gap of 22 is noted. Take care, chbare. Link to comment Share on other sites More sharing options...
chbare Posted September 30, 2008 Author Share Posted September 30, 2008 Patient is 70 kg. SvO2 is unknown. CVP is unknown. Total respiratory rate is around 22. Take care, chbare. Link to comment Share on other sites More sharing options...
p3medic Posted September 30, 2008 Share Posted September 30, 2008 Lactic acidosis, markedly elevated A-a gradient, elevated CK, and significantly decreased urinary output. This guy is in shock, the question is why. H&H? 12ld? sounds like a fun trip. Link to comment Share on other sites More sharing options...
VentMedic Posted September 30, 2008 Share Posted September 30, 2008 As SANDMEDIC noted, the patient is clearly in an acidotic state. What if I were to thrown in a serum lactate of 6? What does this tell us? The ABG was performed about an hour ago. The patient was initially on a FiO2 of 0.8 when the ABG was drawn and the vent rate was 12. Can this relate to our ABG? Changes were performed after the ABG results. The vent settings now have a rate of 10 and FiO2 of 0.6? With a serum lactate of 6 and a pH of 7.3, why decrease the Rate and FiO2 settings on the ventilator? With this being a common scenario for CCT regardless of location, do you have an established sepsis protocol or guidelines to at least initiate and maintain since you are Flight with CC capabilities? Link to comment Share on other sites More sharing options...
chbare Posted September 30, 2008 Author Share Posted September 30, 2008 Good question; however, the sending facility made the changes. Any other information we can obtain? In addition, are we sure this is sepsis? Take care, chbare. Link to comment Share on other sites More sharing options...
p3medic Posted September 30, 2008 Share Posted September 30, 2008 Good question; however, the sending facility made the changes. Any other information we can obtain? In addition, are we sure this is sepsis? Take care, chbare. I'm not convinced this is sepsis. Right now I'm concerned about his apparent V/Q mismatch. How about coags? Link to comment Share on other sites More sharing options...
chbare Posted September 30, 2008 Author Share Posted September 30, 2008 No coags available. However, you do note that he required rather high doses of sedation while in the ICU. Take care, chbare. Link to comment Share on other sites More sharing options...
VentMedic Posted September 30, 2008 Share Posted September 30, 2008 No coags available. However, you do note that he required rather high doses of sedation while in the ICU. Take care, chbare. Did I miss your Diprivan dose? It is also metabolized heavily through the liver. He is on very minimal ventilator support. I also don't see a mention of anything for pain? Fine tune pain and sedation management with the pressors and/or fluids for BP and you still have lots of room for ventilatory support. What's you BP MAP? Visual perfusion signs? HCT available? No way to monitor CVP or SvO2.... Vasopressors will be ineffective or only partially effective in the setting of hypovolemia. Good question; however, the sending facility made the changes. Any other information we can obtain? Are they still managing the ventilator "separately" while you're in flight? Was an Early Goal-Directed Therapy (EGDT) established by the hosptial post op? Link to comment Share on other sites More sharing options...
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