55 year old male with a history of cardiovascular disease, diabetes, and 30 pack year history of smoking is being admitted to the Cardiovascular ICU. He underwent a CABG x 3 with a LIMA and is fully sedated. He has a pulmonary artery catheter, arterial line and intra aortic balloon pump for monitoring and treating of heart failure. Chest radiograph upon admission showed an enlarged left ventricle and estimated ejection fraction is at 21%. You are reviewing the chart as you come onto a night shift rotation and observe the following data:
Lab Values
WBC 11,300/mm3 with 48% neutrophils, 5%S lymphocytes, 11% monocytes and 25% bands
Platelet count was 127,000/mm3
Hematocrit 33%
Serum Sodium 113mmol/L, potassium 3 mmol/L, chloride 93 mmol/L, bicarbonate 24 mmol/L, BUN 12 mg/dl, serum creatinine 0.4 mg/dl and anion gap of 15.
Hospital course
After
Time | Rate (set/total) | Exh. Tidal Volume | FIO2 | PEEP | ABP | PAP | IABP Ratio | PIP | Plat |
0800 | 14/14 | 435 | 1.0 | 5 | 108/68 | 37/26 | 1:1 | 33 | 28 |
1200 | 10/15 | 435 | .80 | 5 | 111/72 | 35/24 | 1:1 | 30 | 27 |
1600 | 6/18 | 435 | .40 | 5 | 118/76 | 30/20 | 1:1 | 28 | 25 |
2000 | 2/21 | 435 | .40 | 5 | 120/78 | 24/11 | 1:1 | 24 | 12 |
Instructions:
Address the following prompts in your discussion posts and review the rubric for guidance on how you will be assessed.
- What trends in the data stand out to you?
- What do you suspect is happening to the patient?
- What recommendations would you make? Why? (consider using your protocols or published protocols as a guide)
- What would you have done differently? Why?