Page 100 - JSOM Summer 2024

• IV fluids rate: LR at 125mL/h. (Note: norepinephrine not available on DDG); or initiate
• Epinephrine: 8μg/min. stress dose steroids. Hydrocortisone is the preferred steroid
• UOP improved after initiation of vasopressors. in vasopressor refractory shock; however, it is typically not
• Cumulative total UOP: 135mL (dark), approximately available to Role 1 medical departments at sea. Dexameth-
20mL/h after initiating vasopressors. asone may be useful and is available. Decision: Dexameth-
• Nasogastric tube (NGT) output: 2L out after initial place- asone 8mg IV daily.
ment. Since placement 200mL. (Note: NGT is not available • IV fluids rate: LR at 75mL/h.
on a DDG). • Goal UOP: 0.3–0.5mL/kg/h.
• Patient is complaining of severe abdominal pain. Morphine • Titrate vasopressors with a SBP goal >90mmHg or MAP
4mg IV was given, but he developed hypotension with >60mmHg.
a systolic BP (SBP) of 82mmHg and confusion a few min • Continue NGT to low continuous or intermittent suction.
later. • Continue antibiotics and chemical VTE prophylaxis.
• The antibiotics may need to be re-dosed, depending on the
The recommended interventions include: type. Ertapenem and ceftriaxone are re-dosed every 24h;
• Consider the PLR test to correlate other signs indicating the metronidazole is re-dosed every 8h.
need for further resuscitation.
• LR or NS fluid bolus 30mL/kg. Recommended Nursing Care:
• Titrate vasopressors with a SBP goal >90mmHg or MAP • Maintain head of bed elevation >30 degrees.
>65mmHg. • Check BP readings hourly or more frequently if frequent
• Goal UOP: 0.3–0.5mL/kg/h. titration of vasopressors is needed.
• NGT to low continuous or intermittent suction (if available). • Cleanse the NGT site.
• Check the IV site that is infusing vasopressor hourly.
Recommended Nursing Care: • Flush any IV line not being used every 12h.
• Maintain head of bed elevation >30 degrees. • Perform Urinary Catheter care.
• Check BP readings hourly or more frequently if frequent • Document strict intake and output (I&Os) to track the pa-
titration of vasopressors is needed. tient’s fluid status.
• Check the IV site that is infusing vasopressor hourly. • Ensure the patient is being repositioned or ambulated every
• Document strict intake and output (I&Os) to track the pa- 2h.
tient’s fluid status. • Encourage coughing and deep breathing hourly when awake.
• Ensure patient is being repositioned or ambulated (if able) • Assist patient with oral/dental care.
every 2h.
• Encourage coughing and deep breathing hourly. Time: +48h
• Assist patient with oral/dental care. The patient was given one 30mL/kg fluid bolus 18h ago with
a good response. IV fluids rate turned down to 50mL/h at
Time: +24h Time+26h. Over the last 12h, HR, UOP, and BP improved; how-
The patient was given three 30mL/kg fluid boluses over the ever, RR and respiratory distress increased. Eight hours ago, you
16h with an initial good response. IV fluids rate turned down started supplemental O by nasal cannula for a SpO of 88%.
2
2
to 75mL/h at Time+12h. Over the last 6–8h, HR, and RR have • HR 97bpm; SBP 112/78mmHg; RR 35 breaths/min; O sat-
2
increased and UOP and BP have decreased, causing you to in- uration 94% on 8L; temp 38.5°C.
crease the norepinephrine drip rate approximately hourly. • Norepinephrine: 4μg/min (20 drops/min).
• HR 119bpm; BP 84/60mmHg; RR 25–30 breaths/min; O • IV fluids rate: LR at 50mL/h.
2
saturation 94% on room air; temp 38.8°C. • Cumulative total IV fluid input: 15,112.5mL (~15.1L);
• Epinephrine: 24μg/min. 3,350mL over 24h.
• IV fluids rate: LR at 75mL/h. • Cumulative total UOP: 1,035mL; 670mL over 24h. 35mL/h
• Cumulative total IV fluid input: 11,762.5mL (11.8L). over the last 6h; yellow.
• Cumulative total UOP: 375mL over 24h. 10mL/h over the • Cumulative NGT output: 5.3L; 1.5L over 24h.
last 6h; brown. • Unable to run more laboratory data.
• Cumulative NGT output: 3.7L over 24h; green, bilious. • Abdominal pain is well controlled with scheduled acet-
• Unable to run more laboratory data. aminophen and as needed IV morphine.
• Abdominal pain is well controlled with scheduled acet- • No flatus, frequent burping.
aminophen and as needed IV morphine. • No change or increase in BP with PLR test.
• No flatus, frequent burping.
• No change or increase in BP with PLR test. Assessment:
Pulmonary edema from resuscitation versus sepsis-induced
Assessment: lung injury. Still with ileus/small bowel obstruction secondary
• Likely appropriately resuscitated. to intra-abdominal infection.
• Still with ileus/small bowel obstruction secondary to intra-
abdominal infection. Recommended Interventions:
• Consider the possibility of refractory shock and possible • Monitor airway and breathing closely. 21
adrenal insufficiency. • Telemedicine consultation.
• IV fluid rate: LR at 50mL/h.
Recommended Interventions: • Goal UOP: 0.3–0.5mL/kg/h.
• Telemedicine consultation. Options: Add a second vasopres- • Titrate vasopressors with a SBP goal >90mmHg or MAP
sor (epinephrine) if the initial vasopressor is norepinephrine >60mmHg.

98 | JSOM Volume 24, Edition 2 / Summer 2024