A 51 -year-old male has just been transferred to the ICU from the surgical ward with worsening shortness of breath five days post-oesophagectomy, and a presumed anastomotic leak.
On arrival in ICU, he is tachypnoeic and extremely agitated.
Arterial blood gas analysis on FiO2 0.6 — 0.8 via reservoir (non-rebreathing) mask shows the following:
Adult Normal Range
7.35 - 7.45
50 mmH 6.6 kPa
50 mmH 6.6 kPa *
35-45 4.6 -6.0
22 - 28
Chest X-ray shows bilateral pulmonary infiltrates.
The patient is intubated and mechanical ventilatory support is initiated.
Following intubation, there is no immediate improvement in the patient's oxygenation.
Differential diagnosis should include:
ition and patency
Answered well overall. Lack of detail and structure in some answers.
a) List the possible causes for his respiratory failure.
Tandon et al (2001) mention that this happened to over 14% of their oesophagectomy patients, with a 50% mortality. Why is this post-oesophagectomy patient so hypoxic, and what are those infiltrates? One might classify this into two broad categories:
b) Describe the ventilator settings you will prescribe, giving the rationale for your decision.
c) List the initial strategies that may be used to improve oxygenation.
Let's assume you've excluded sophomoric errors like right bronchial intubation and sputum plugging. Other strategies may include:
Additional ventilator manoeuvres to improve oxygenation:
Ventilator strategies to manage refractory hypoxia
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