Mr. J, a 44-year-old man with no previous medical history, presents to the emergency department with a chief complaint of severe abdominal pain, fever, and chills. He is subsequently admitted to the critical care unit after an open exploratory laparotomy where it was found that he had a perforated appendix and diffuse peritonitis. Intraoperatively he had an estimated blood loss of 200 mL, and he received 2.5 L of crystalloid solution. He arrives at the critical care unit intubated and sedated with an arterial line, subclavian triple-lumen catheter, indwelling urinary catheter, and esophageal Doppler monitor in place. He is placed on mechanical ventilation with the following settings: assist/control mode at 12 breaths/min; tidal volume, 700 mL; fraction of inspired oxygen, 1.0 (100%); and positive end-expiratory pressure, 5 cm H2O. His initial vital signs are:
The provider orders administration of a 250-mL infusion of 5% albumin and to prepare to replace the triple-lumen catheter with an ScvO2
catheter. You administer the albumin and assist with the placement of the ScvO2
catheter. After these interventions, his vital signs are now:
Questions
1. The 2.5 L of crystalloid solution the patient received during surgery should have provided adequate volume resuscitation. What was the rationale for the albumin bolus?
2. Discuss which hemodynamic parameters you would monitor to assess efficacy of the bolus and why. 3. What advantage would the ScvO2
catheter provide over the traditional triple-lumen catheter?
4. What technical factors would you need to consider to ensure accuracy in the hemodynamic parameters that you are monitoring?
5. Discuss the significance of the ScvO2
value.
6. Recently, you attended an in-service workshop on the esophageal Doppler monitoring device that your unit uses. The representative stated that the best way to evaluate preload optimization was to assess FTc before and after each intervention. He provided a journal article outlining a study that suggested that you should continue to administer boluses of albumin to the patient until you no longer see an increase in the FTc by 10% after each intervention. Given that information, what would you suggest to the provider?