D.V., age 42, has a history of HIV infection with the development of
AIDS 2 years ago. He has been hospitalized and treated twice for
Pnuemocystis jiroveci pneumonia and is now admitted to ICU with a
suspected cryptococcal meningitis. ICP monitoring is instituted, and an
arterial line and flow directed pulmonary artery catheter are inserted.
Endotracheal intubation with assist-control mechanical ventilation at 12
breaths/min, 15 cm H20 PEEP, and FI02 of 50% is established. (Note:
this patient is very critically ill and requires you to review ICP,
septic shock, multiple organ dysfunction syndrome (MODS), and
respiratory failure).
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Subjective Data: Friend relates that D.V. had two generalized tonic-clonic seizures in the 2 hours before admission.
Objective Data:
GCS score: 6
ICP: 22 mm Hg
Vital signs: T 102.2 F (39C); HR 80; RR 26/min; BP 100/46 mmHg
ABGs: Pa02 65 mm Hg; PaC02 32 mm HG; HC03 -16mEq/L; ph 7.26
Other laboratory results: Glucose 228 mg/dL (12.6 mmol/L); lactate 3 mEq/L (3mmol/L); WBC 18, 500/uL
Hemodynamic monitoring values: CO 6L/min; PAP 8mm Hg; PAWP 15 mm Hg; SVR 530 dyne sec/cm5; Sv02 90%; Sa02 92%
Skin warm and dry
Foley catheter inserted with 30 mL urine return
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Clinical Decision Making Questions
1. What are the best indicators to use in D.V.’s case to monitor his hemodynamic status?
2. What effect might the use of PEEP have on D.V.’s intracranial pressure?
3. What is D.V.s MAP/ What MAP would be necessary to promote tissue and cerebral perfusion and yet not increase ICP?
4. What drugs and fluids would be indicated for D.V.’s treatment?
5. How may D.V.’s condition be complicated by gastrointestinal ischemia?
6. Explain the processes that account for the abnormal assessment findings in D.V.
7. Based on the assessment data presented, what are the priority diagnoses? What are potential complications?
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