Page 675 - Clinical Application of Mechanical Ventilation

Case Studies 641

V T 800 mL
F O 2 100%
I
PEEP 5 cm H O
2
Twenty-five minutes later, the patient remained in critical but stable condition
while continuing to bleed into the chest tube. The endotracheal tube position was
noted to be at the 24 cm mark at the lip and secured in the airway, awaiting confir-
mation of tube position on the chest radiograph. Blood gases were drawn to evalu-
ate his acid-base status and to quantify the degree of blood loss from the tension
hemothorax. These were outlined as follows:

pH 7.40
Change in the hemo- PaCO 33 mm Hg
globin level (from 15.8 to 2
10.7 g %) greatly diminishes PaO 2 196 mm Hg
the patient’s arterial oxygen HCO 19.6 mEq/L
-
content (from 20.9 to 3
15 vol %), confirming the B.E. 24.2 mEq/L
presence of tissue hypoxia. Hb 10.7 g %
CaO 2 15 vol %
SaO 2 96%
SpO 2 95%
Mode A/C
f 16/min
V T 800 mL
F O 2 100%
I
PEEP 5 cm H O
2
The F O was reduced to 60% to lower the PaO while being mindful of the low
I
2
2
The F I O 2 was reduced to oxygen content. A chest radiograph confirmed proper placement of the endotra-
60% because the PaO 2
(196 mm Hg) was excessive. cheal tube and noted a tension hemothorax on the right side. He was taken to the
operating room for an emergency thoracotomy and relief of the tension hemothorax
resulting from a lacerated intercostal vessel.
By the end of the thoracotomy and repair of the bleed, he received 11 units of blood
prior to returning to the ICU. Later, he received 9 more units of blood in the ICU.

Patient Monitoring

Upon return from the operating room (OR), the patient was placed back on me-
chanical ventilation at 1,000 mL tidal volume (approx. 11 mL/Kg) on assist/control
(A/C) with a frequency of 12/min, F O of 60%, and 5 cm H O of PEEP. Peak
2
I
2
inspiratory pressures returned to 36 cm H O. The patient’s hemodynamic status
2
was stable and he was allowed to awaken from the anesthesia. Blood gases 10 min
after returning from surgery revealed the following:
pH 7.41
PaCO 2 39 mm Hg
PaO 2 55 mm Hg
-
HCO 24.1 mEq/L
3

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