Morbidly obese male

Morbidly obese male

WEEK: 6 Case Scenario (SPRING 2015) Respiratory Failure (RF)
Arthur M., a 57-year-old morbidly obese male, has just been transferred to the Surgical Intensive Care Unit (SICU) from the post-op recovery room following bariatric surgery. The recovery room nurse informs you that Mr. M. self-extubated and the decision was made by the physician to allow him to remain extubated.  He is awake but very drowsy and is currently receiving oxygen 5 LPM via face mask (FM).
Past Medical History: hypertension, type 2 diabetes, and of sleep apnea with a cpap machine used at home. He quit smoking 2 years ago following a 26 year history of smoking 1 1/2 pack of cigarettes a day.
Current Medications:  hydrochlorothiazide, glucovance, and oxygen at night with is cpap machine.
Vital Signs and ABG upon admission to the SICU:
RR    10 breaths/min
BP    150/90
HR    86 bpm
SpO2    92%  5/L FM
Temp    96.2 oral
PaO2    94 mm Hg
SaO2    96%
pH    7.40
PaCO2    42 mm Hg
HCO3    26 mEp/L

Content: Wagner and Hardin-Pierce (2014): Chapters 6 and 33

1.    What risk factors does Mr. M have that decreases his oxygen consumption and places him at risk for respiratory failure  Explain the rationale for each risk factor. (1. point)

2.    In your report from the recovery room nurse, you remember that Mr. M extubated himself too early and he is still drowsy at this time.  In your post extubation follow up assessment, what will you pay particular attention to  (.75 points)

Scenario Continued:  You have been monitoring Mr. M for 8 hours now and he is starting to show signs of respiratory deterioration including extreme somnolence.  You call the physician to report the following vital signs and he orders: ABGs and PFTs:  The results are as follows:

RR    38 shallow and labored
BP    160/94
HR    112
SpO2    82%
Temp    97 oral
PaO2    55 mm Hg
SaO2    90%
pH    7.29
PaCO2    55 mm Hg
HCO3    26 mEq/L

Respiratory rate (f)    38 breaths/min
Vital capacity (VC)    12 mL/kg
Maximum inspiratory pressure (MIP)    -14 cm H2O

3.    Interpret the ABGs.  (1 point)

4.    What is acute ventilatory failure (AVF), how is it diagnosed  What are the criteria for ventilatory support and what are Mr. M’s critical values that meet this criteria(1.25 points)

5.    The physician tells you that he wants to use an endotracheal tube for intubation.   You grab all the supplies, the physician successfully intubates Mr. M., and now you are performing your post intubation assessment.  Explain what will be included in this assessment. (1 point)

Mr. M. has been sedated on a propofol drip and the physician has ordered the settings below.
Ventilator Settings
Tidal Volume    500 mL
Fio2    0.40 or 40%
PEEP    5 cm
Ventilation Mode: PRVC    Setting Only
Respiratory Rate    12 Breaths/min
6.    Please explain (thoroughly) Tidal Volume, Fio2, and PEEP. (1 point)
TIDAL VOLUME:

Fio2:

PEEP

7.    Mr. M. is at high risk for ventilator-associated pneumonia (VAP).  Explain, in detail, what this is, how it happens, and what measures can be taken to prevent VAP (.75 points)

8.    What interventions will you perform to prevent common complications of mechanical ventilation  (1.25 point)

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