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M, LWrc Rodgers; &MC; ,k*S,N, CCRN, C.'NR.nf, ACNV.BC
JohnBudd, a 7Z-year-old, arrived in the emergency department unconscious, with stab
wourids to the upper-right abdomen and lower-right chest that were sustained in his home
while fighting off a burglar. The paramedics secured two large-bore intravenous (IV)
catheters in his right and left antecubital spaces and infused lactated Ringer,s solution wide
open in both sites. An endotracheal tube was inserted, and ventilation w-ith a resuscitation
bag at 1000/o oxygen was begun. Medical antishock trousers (MAST) were in place. pressure
dressings to both wounds were secured.
A S-cm (Z-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab
wound to his upper-right abdomen were inspected. Chest tubes were inserted into the
upper-right and lower-right midaxillary regions. Immediatety, 500 ml of red drainage
returned via the lower chest tube. His heart rate (HR) was 125 bpm, and the monitor showed
sinus tachycardia without ectopy. His blood pressure (BP) was TOIS0 mm Hg. Inserting a
Fo1ey catheter resuited in drainage of 400 ml clear, dark yellow urine. After infusion of more
than 2000 mi of lactated Ringer's solution, Mr. Budd was sent to surger)4, still in a hypotensive state. Preoperative body weight was 74 kg (1651b).
During surgery/ a right thoracotomy and dght abdominal laparotomy were performed. The
right chest wound was explored, and a lacerated intercostal artery was ligated. Exploration
of his upper-right abdominal wound revealed more extensive damag". the livei and the
duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were
apparent after opening the peritoneum. Mr. Budd's injuries were repaired, the peritoneal
cavity was irrigated with antibiotic solution, and incisional sump drains were plaied in the
During the 4-hour surgery, Mr. Budd received 6 U of biood and an additional 3 L of
lactated Ringer's solution. A pulmonary artery catheter (PAC) and right radiai arterial line
lntensive Care Unit: Immediately after Surgery
When Mr. Budd arrived in the surgical intensive care unit (ICU), he was receiving ventilatory support. Ventilator settings were as follows:
immediately after surgery
Vital signs and
c (97.2 F)
cetl (WBC) count
normal. Except for a white blood
Arterial blood gas values were ^i."Li
rr ro g7at, Mr' Budd's other laboratory values
of 13.6 x 103/mm3 and a hemoglobin
were within normal limits'
ICU: PostoPerative DaY
;il#ffi fi *T"ilil,['*,T""1iie"iyq:4**"}iffi
oo -rir,,. His abdomen was slightrv
no bowel sounds'
u.rJ aitt""aed, and he had
Postoperative DaY 2
his second postoperative day' At this time
Mr. Budd's condition remained stable until
to commanai' Hls respirations were 28
became difficult to arouse but did respond
output dropped to 20 ml/hr' His skin became
breaths/min, shallow, and labored' His urine
included the following:
warm, dry, and flushed' Other clinical data
80/50 mm Hg
36.2' C (97.2 T)
7417 mm Hg
indicated gram-negative bacilli'
Culture and sensitivity repolts from wound drainage
we11 as"IV hvdrocortisone and
Appropriate IV antibiotics were iA*f,iri.t.d, ;;
(Narcan). A pharmaciconsuitation to formulate and calculate
i; prepareto' the suspected hvperdvnamic
and total parenteral tl"Hl#fi;;;,;;'
was inicreased to 150 ml/hr' and
of septic shock, infusion of lactated Ringer;s ,ol.,tion
of ZOOmglZSO ml of 5olo
dopamine at 5 pg/kg/min was started *itf. u concentration
dextrose in water (DSW)'
Inc All rights reserved
O 2004, 2001,1996 Elsevier'
ICU: Postoperative DaY 6
dramatically. His skin
B_v-- the sixth postoperative day, Mr. Budd's condition had deteriorated
r,r;as cool, ,rrotttea, and moist. His sclerae were yellow tinged. He no longer responded to
stimuli. A norepinephrine (Levophed) drip infused at 6 Fg/min with a concentration of
lmglZlO ml of D5W, along with a dopamine drip at 2 ptgikg/min was begun. His monitor
showed sinus tachycardia with short runs of ventricular tachycardia. ST-segment elevation,
T-wave inversion, and the development of Q waves over most of the anterior V leads on
his electrocardiogram (ECG). A 75 mg bolus of lidocaine was given followed by a continuous intusion atimglmin with a concentration of 2 gl5OO ml of D5W. His breath sounds
revealed crackles throughout his chest. Urinary output was only 3 to 5 ml/hr and was grossly
bloody. His abdomen was enlarged and flrm. His abdominal suture lines had dehisced, and
the peritoneum could be seen. The duodenal sump and NGT drainage started to turn red.
AII irterial and venous puncture sites began oozing blood. Further clinical data included
70152 mm Hg
35.8' C (96.4'F)
44126 mm Hg
24 mm Hg
Other abnormal laboratory results included the following:
49 mm Hg
46 mm Hg
Despite attempts to reduce afterload with sodium nitroprusside (Nipride) and increase contraciility with dobutamine (Dobutrex), Mr. Budd's hemodynamic status failed even further.
When his cardiac rhythm deteriorated into ventricular fibrillation, resuscitation efforts were
unsuccessful. An autopsy revealed several small abscessed areas in the lung, acute hepatic
failure, multiple hemorrhagic ateas, and an acute myocardial infarction (MI).
O 2004, 2001, 1996 Elsevier, lnc. All rights reserved.
and the rerationship
in hospirarized patienrs
the masnitude of
between these two diagnoses'
of septic shock? Identify
what are the risk factors
aPPlied to Mr' Budd'
Discuss the rationale
for use of a PAC in monitoring
volume' and pump?
processes on the
lnc' All rights reserved'
O 2004, 2001,1996 Elsevier'
is the rationale for each of
the following therapeutic modalities ordered for Mr. Budd
on the second postoperative day?
lV rate increased to .l50 ml/hr
Dopamine 5 pglkg/min
Naloxone lV infusion
Total parenteral nutrition
Discuss the clinical changes that occurred
during Mr. Budd's sixth postoperative day.
what is the rationale for each of the following therapeutic
modalities ordered on the sixth
postoperative day? How many milliliters pur liou,
should be infused for each drug listed?
Norepinephrine 6 pglmin
Dopamine 2 p"glkg/min
Lidocaine 2 mglkg/min
10. What are the reasons for the changes in the following
hemodynamic parameters noted on the
sixth postoperative day?
Interpret Mr. Budd's blood gas levels on the
sixth postoperative day.
why are the renal, liver, and pancreatic laboratory values reported
on the sixth postoperative
@2004,2001,1996 Elsevier, lnc. AII rights reserved,
what complications do the hematorogic raboratory varues suggest?
What would account for the ECC changes described?
Mr. Budd's liver was lacer:ated during the stabbing. What effect, if any,
did this have on his
Describe the differences in the parameters below between hyperdynamic
or warm septic
shock and hypodynamic or cold septic shock.
How do elderly patients manifest symptoms of sepsis?
What antimicrobial and antiendotoxin therapies should be instituted in
What does the future hold for therapy in septic shock?