A 32-yrs-old man undergoes a distal pancreatectomy

Discussion in 'MRCS Forum' started by Lona., Nov 29, 2007.

  1. Lona.

    Lona. Guest

    Items 1-3
    A 32-yrs-old man undergoes a distal pancreatectomy, splenectomy, and partial colectomy for a gunshot would to the left upper quadrant of the abdomen. One week later he develops a shaking chill in conjunction with a temperature spike to 39.44°C (103°F). His blood pressure is 70/40 mmHg, pulse is 140/min, and respiratory rate is 45/min. He is transferred to the ICU, where he is intubated and a Swan-Ganz catheter is placed.

    1. Which of the following is most consistent with this patient’s pre-intubation arterial blood gas measurement?
    pH Paco2 Pao2
    a- 7.31 48 61
    b- 7.52 28 76
    c- 7.45 40 77
    d- 7.40 30 72
    e- 7.40 48 94


    2. Which of the following is consistent with the expected initial Swan-Ganz catheter readings?
    a- Cardiac output: 7.0 L/min
    b- Peripheral vascular resistance; 1660 dyn
    c- Pulmonary artery pressure: 50/20 mmHg
    d- Pulmonary capillary wedge pressure: 16 mmHg
    e- Central venous pressure: 18 mmHg


    3. Initial therapy for this patient should include -
    a- Furosemide
    b- Propranolol
    c- Sodium nitroprusside
    d- Broad-spectrum antibiotics
    e- Laparotomy
  2. Lona.

    Lona. Guest

    Answer: 1-b, 2-b, 3-d. (Schwartz, 7/e, pp 115-120) The case presented is most consistent with septic shock from a postoperative intraabdominal abscess. In the early phase of septic shock, the respiratory profile is characterized by mild hypoxia with a compensatory hyperventilation and respiratory alkalosis. Hemodynamically, a hyperdynamic state is seen with an increase in cardiac output and a decrease in peripheral vascular resistance in the face of relatively normal central pressures. Initial therapy is aimed at resuscitation and stabilization. This includes fluid replacement and vasopressors as well as antibiotic therapy aimed particularly at gram-negative rods and anaerobes for patients with presumed intraabdominal collections, especially after bowel surgery. Laparotomy and drainage of a collection is the definitive therapy but should await stabilization of the patient and confirmation of the presence and location of such a collection.

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