Trombosis Prophylaxis: A Case Study

An eighty-five year old female came in with lower abdominal pain that had persisted for a few days. This patient has a history of hypertension, gastroesophageal reflux disease (GERD), dyslipidemia, glaucoma, deep venous thrombosis prophylaxis, and is a former smoker that quit 10 years ago. She has not been diagnosed with COPD or any other respiratory problems and had not had any significant surgeries. When she came into the emergency department her vitals were as follows: blood pressure 121/57, heart rate 61, respiratory rate 24, temperature 97.4, breath sounds clear, and SpO2 99% on room air. These vitals are in normal range for a patient of her age. She was admitted to the floor for further monitoring and was given a CT of the stomach. This CT was however not read until the next morning. During the night the patient was in a lot of pain. She became severely worse and developed nausea and vomiting. The patient ultimately went into atrial fibrillation. An electrocardiogram was done and resulted in atrial fibrillation with fast ventricular response and a left bundle branch block. Once this was treated and under control the patient went for an echocardiogram and the results from this were: left ventricle ejection fraction of 62%, left ventricular hypertrophy, mitral valve calcification/thickening, and a pericardial effusion. When the stomach CT was read in the morning it stated that the patient had free air in the abdomen, small bowel obstruction, multiple diverticuli in left colon, and a small hiatal hernia. Once the results were obtained and read the patient was rushed to the ICU to get ready for surgery. If any of the bile was to escape it could be deadly. The patient was intubated with a 7.5 tube at 24cm at the lip. She was then rushed to surgery for the acute diverticulitis and perf bowel. When the patient came back from surgery she was placed in PRVC with a tidal volume of 400ml, FiO2 of 60%, PEEP of 8, and a rate of 12. …show more content…
An arterial blood gas was done thirty minutes later with a pH of 7.25, CO2 of 43, O2 of 103, and a Bicarb of 18.9 on the above settings. The FiO2 was then lowered to 50%. Diverticuli will cause a blood gas to be metabolic instead of respiratory so knowing all the values of the gas are important. A chest x-ray was done and resulted in old granulomatous disease in both lungs, and plate like atelectasis in the right lower lobe, patchy infiltrates or atelectasis in the left lower lobe. The patient needed to be monitored since the atelectasis could produce a pneumonia. On the ventilator the patient was on some medication. The list follows. Meropenem 500mg/ Sodium Chloride 50ml @ 100mls/hr IV B-lactam antibiotic Diltiazem HCL 125mg/ Sodium Chloride 125ml @ 5mls/hr IV Calcium channel blocking agent Fentanyl Citrate 30ml @ 0.5 mls/hr IV Opiate agonist Propofol 100ml @ 2.07mls/hr IV General anesthetic Norepinephrine Bitartrate 4mgl Dextrose/Water 254ml @ 19.05mls/hr IV Alpha/Beta adrenergic agonist Lactated Ringers 1000ml @ 125mls/hr IV Replacement preparations Pantoprazole Sodium Protonix inj 40mg IV Proton-pump inhibitor Sodium Chloride 1000ml @ 125mls/hr IV Replacement prep/ irrigation The next day a second blood gas showed a pH 7.35, CO2 31, O2 82, and a Bicarb 17.1 on PRVC with a tidal volume of 400ml, FiO2 of 50%, PEEP of 8, and a rate of 12. These values could be the patient's normal so nothing was changed and the patient was monitored. While on the ventilator the input and output was also monitored. 3/16 3/17 In 3250 1573 Out 1145 245 Balance 2105 1328 The patient had more input than output so this needs to be monitored closely because the patient could end up with edema that could travel to the lungs. The patient was on the ventilator for a couple of days and these are the values I obtained while on the case. 3/16 3/17 PRVC PRVC FiO2 50% FiO2 50% PEEP +8 PEEP +8 Set RR12 Set RR 12 Set Tidal Volume 400ml Set Tidal Volume 400ml Peak 14 Peak 15 Mean 8 Mean 10 RR 21 RR 20 MVe 8.4L MVe 7.9L Vte 418ml Vte 424ml TI 0.9sec Ti 0.9sec Rise 0.15 Rise