*Please critical care plan and drug study for this case*

The patient who is described in the vignette satisfies the diagnostic criteria for the
acute respiratory distress syndrome (ARDS), since he has severe sepsis (a recognized
risk factor for ARDS), bilateral alveolar infiltrates, and a PaO2:FiO2 (P:F) ratio of
less than 200 mm Hg; the hemodynamic data suggest that he does not have
cardiogenic pulmonary edema. In recent years, there has been a broad consensus that
mechanical ventilation of patients with ARDS should focus on preventing ventilator-
induced lung injury through the avoidance of excessive lung stretching and high
airway pressures rather than on normalizing gas exchange. Such strategies have been
shown to reduce mortality.

In a seminal study, the ARDS Network investigators found that a low-tidal-volume

strategy targeting a tidal volume of 6 ml per kilogram of predicted body weight and a
plateau airway pressure of 30 cm of water or less reduced mortality, as compared with
a control strategy using a tidal volume of 12 ml per kilogram. This study confirmed
previously published observational data and the findings of a smaller randomized
trial. Early ARDS is characterized by atelectasis affecting the dependent portions of
the lung, with the delivered tidal volume distributed to a smaller-than-usual volume of
still aerated lung.2 At least some of the atelectatic-dependent lung is “recruitable,”
meaning that it can potentially be reaerated, resulting in better gas exchange and
reducing the stress placed on ventilated lung units. As a result, other ventilation
strategies, such as the used of higher levels of PEEP,3,4 recruitment maneuvers,4 or
the placement of patients in the supine position alternating with the prone position,5
have been investigated both to recruit atelectatic lung and to reduce mortality.
Currently, there are no consistent outcome data to support the use of levels of PEEP
that are higher than those used in the ARDS Network study of low tidal volumes or to
support the routine use of lung-recruitment maneuvers.

The patient should undergo mechanical ventilation with the use of a strategy designed
to minimize ventilator-induced lung injury. In this patient, it would be reasonable to
target a tidal volume of 440 ml, since although his actual weight is 60 kg, his
predicted body weight is 73 kg (the size of the lungs is proportional to the predicted
body weight); a slight decrease in tidal volume would be reasonable to limit the
plateau airway pressure to 30 cm of water and to increase the PEEP to 10 cm of water
in view of the severity of the hypoxemic respiratory failure.

A recent trial showed a marked reduction in mortality among patients with severe
ARDS (defined as a P: F ratio of 6.

*HOW WOULD YOU PROVIDE THIS PATIENT WITH SEDATION?*

Intermittent intravenous lorazepam. Continuous intravenous infusions of propofol to

facilitate daily cessation of sedation to assess the ongoing need for sedation and
analgesia.

An intravenous infusion of alpha-2-adrenoceptor agonist such as dexmedetomidine

with daily cessation to assess the ongoing need for sedation.

*As a critical care nurse what is your suggestions to change it to add

for this case*

The immediate priority is to secure the patient’s circulation.

The patient should be placed in a monitored area, and blood collected for typing and
cross-matching. Venous access should be established with two large-bore intravenous
catheters, and volume resuscitation initiated with crystalloid Puids.

1- It is important to recognize a suspected variceal bleed because this may

necessitate a different management strategy.
2- Several bedside variables are associated with an increased likelihood of a
variceal source of upper gastrointestinal bleeding: history of liver disease
(odds ratio [OR] 6.7), excessive alcohol use (OR 2.3), hematemesis (OR 2.7),
hematochezia (OR 3.0), and stigmata of chronic liver disease (OR 2.5).