Weaning / Discontinuation of  Mechanical Ventilation

      
       

 

          
       

Clinical Scenario

A 77 year old male is admitted to ICU following a bowel perforation with fecal peritonitis, due to caecal carcinoma. His portoperative course is complicated by a perioperative anteroseptal myocardial infarction, systemic sepsis requiring insertion of a pulmonary artery catheter, volume loading and vasopressors, and moderate renal dysfunction, with serum creatinine reaching a peak of 3.3.

  • He is now at 14 days postop.

  • Currently he is difficult to arouse, with a GCS of 7 on a sedation cocktail of fentanyl 50μg/hour and lorazepam at 1mg 8 hourly.

  • His temperature is 37.8.

  • Cardiovascularly, his pulse is 76 and regular, blood pressure is 130/70 and CVP is 12.

  • His lungs are reasonably clear to auscultation, chest x-ray reveals some patchy infiltrates throughout, bibasal atelectasis and a left sided pleural effusion. He is on 35% oxygen, SIMV rate 8, spontaneous rate 6, pressure support 16 and PEEP 5 cmH2O. His blood gases are pH 7.52, PaO2 72, PaCO2 44, BE +8, SaO2 94%.

  • His abdomen remains tense, with a would closed with tension sutures and two drains, currently draining very little. His is tolerating post pyeloric feeding.

  • Liver function tests: normal except for an albumin of 1.6 (zeneth was 0.8). He has lower limb, sacral and scrotal edema.

  • His fluid balance is even over the past five days.

  • Hb 8.1, WCC 18.5, Plat 102, Na 148, K 3.1, Urea 37, Creat 1.2, MgSO4 3.2, PO4 1.5, Ca 2.0.

  • The patient is completing a 14 day course of ampicillin, gentamycin and metronidazole today, for appropriately isolated bowel organisms.

Describe how you would evaluate this patient for weaning from mechanical ventilation?

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