Reflective assessment of the critically ill patient - Haemodynamic monitoring: Observing and optimising appropirate parameters.

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ADEKUNLE   ENITAN

REFLECTIVE   ASSESSMENT OF THE CRITICALLY ILL PATIENT     

HAEMODYNAMIC MONITORNG: OBSERVING AND OPTIMISING APPROPIRATE PARAMETERS

INTRODUCTION

This reflective assessment is on Mr Benedict.  He was transferred to the Intensive care unit (ICU) from Operating theatre after Removal of Abdominal adhesions. GIBBS model 1988 will be used to analyse this reflection.  Continuous accurate heamodynamic measurement is vital to Mr Benedict’s treatment, and a faster pressure responsive monitoring device: Pulse contour cardiac output machine (PiCCO) was used, thus facilitated assessment and restoration of his adequate perfusion.  For data protection reason, his real name would be referred to as MR Benedict throughout this reflective assessment. Data on the caregivers and medical staff will also be concealed (Nursing and Midwifery Council UK 2002).

DESCRIPTION

Mr Benedict, aged 70 years old was admitted into Intensive Care Unit (ICU) Postoperative removal of abdominal adhesions.  He weighed approximately 80kg; he had past medical history of two episodes of Transient Ischemic Attack (TIA) three years ago and right hip replacement two years ago.

He had eight units of blood and two pools of Platelets transfused during the operation. Postoperatively, (in recovery) he developed respiratory failure and became cardiovascularly compromised; with Arterial blood pressure (ABP) of 65/35(45) mmHg, Central Venous Pressure (CVP) 15 mmHg, temperature was 38 [°C], respiratory rate of 35 breath /minute. Arterial Blood Gases (ABG) read as follows; FI02: 60%, PH: 7.2, PC02: 9.5kpa, PO2: 7.2kpa, HC03: 26.0mmol/l, Base excess: –1.4, K+ 4.3mmol/l, S02: 84%, HB: 8.6g/dl, NA: 130mmol/l.  He was cardiovascularly supported with Noradrenaline at 18mcg /minute and Dopexamine at 0.5mcg /kg/minute, he was intubated and mechanically ventilated, and transferred to our intensive care unit for Postoperative management.

Thirty minutes after his admission to our ICU, Pulse contour cardiac output (PiCCO) machine was used to ensure accurate monitoring and assessment of his haemodynamic status in order to guide Noradrenaline rate and to make further assessments on his cardiovascular status. The first PiCCO flow studies was performed by one of our Consultants Anaesthetist and read as follows:

Parameters                                       Actual                           Normal Range

Arterial Blood Pressure                    130/90  (mmHg)

Mean Arterial   Pressure                  72 (mmHg)                          70 – 90mmHg

Pulse pressure                                       40     (mmHg)                  30-50mmHg

Index of left ventricular contractility     909 (mmHg/sec)

Systemic Vascular Resistance SVRI 2    1228 (dyn-sec-cm5)       1200 – 2000dyn*s*cm-5*m2        

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Stroke volume variation SVV                   5 %                              ≤ 10        %

Cardiac Index                                           4.68 (L/min)                3.0 – 5.0l/min/m2

Stroke Volume SV                                    60 (ml)                        40 ...

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