ED: John Budd, a 72-year-old, arrived in the emergency department unconscious, with stab wounds to the upper right abdomen and lower right chest that were sustained in his home while fighting off a burglar. The paramedics secured two large-bore intravenous catheters in his right and left anticubital spaces and infused lactated Ringer's solution wide ope in both sites. An endotracheal tube was inserted, and ventilation with resuscitation bag at 100% oxygen was begun. Medical antishock trousers (MAST) were in place. Pressure dressings to both wounds were secured. A 5-cm (2 inch) stab wound to his right lower chest and a 7.5-cm (3 inch) stab wound to his upper right abdomen were inspected. Chest tubes were inserted into the upper-right and lower-right midaxillary regions. Immediately, 500 ml of red drainage returned via the lower chest tube. His heart rate was 125 bpm, and the monitor showed sinus tachycardia without ectopy. His blood pressure was 70/50 mmHg. Inserting a Foley catheter resulted in drainage of 400 ml clear, dark yellow urine. After infusion of more than 2000 ml of lactated Ringer's solution, Mr. Budd was sent to surgery, still in a hypotensive state. Preoperative body weight was 74 kg (165 lb). Surgical intervention: During surgery, a right thoracotomy and right abdominal laparotomy were performed. The right chest wound was explored, and a lacerated intercostal artery was ligated. Exploration of his upper-right abdominal wound revealed more extensive damage. The liver and the duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were apparent after opening the peritoneum. Mr. Budd's injuries were repaired, the peritoneal cavity was irrigated with antibiotic solution, and the incisional sump drains were placed in the duodenum. During the 4-hour surgery, Mr. Budd received 6 U of blood and an additional 3 L of lactated Ringer's solution. A pulmonary artery catheter and right radial arterial line were inserted. ICU, Immediate Post-op: When Mr. Budd arrived in the surgical ICU, he was receiving ventilation support. Ventilator settings were as follows: Assit - mode Rate 12 FiO 60% Vt 800 ml 2 Vital signs and hemodynamic parameters immediately after surgery were: o o BP 92/52 HR 114 Resp 12 Temp 36.2 C (97.2 F) PAP 20/8 mmHg PCWP 6 mmHg CVP 4 2 mmHg CO 5L/min CI 2.9 L/min/m SVR 1040 dynes/sec/cm Arterial blood gas values were normal. Except for a WBC of 13.6 and a hemoglobin of 10 g/dl, Mr. Budd's other laboratory values were within normal limits. ICU, PO Day1: Mr. Budd remained drowsy and received ventilatory support for 24 hours. His pain was controlled by IV morphine sulfate. The nasogastric tube continued to drain large amounts of green fluid, and an incisional duodenal sump tube drained large amounts of greenish brown fluid. His chest and abdominal dressings remained dry. Breath sounds were diminished on the right side but clear on the left. His chest tubes continued to drain small amounts of bloody fluid.

1. ED: John Budd, a 72-year-old, arrived in the emergency department unconscious, with stab
wounds to the upper right abdomen and lower right chest that were sustained in his home while
fighting off a burglar. The paramedics secured two large-bore intravenous catheters in his right
and left anticubital spaces and infused lactated Ringer's solution wide ope in both sites. An
endotracheal tube was inserted, and ventilation with resuscitation bag at 100% oxygen was
begun. Medical antishock trousers (MAST) were in place. Pressure dressings to both wounds
were secured. A 5-cm (2 inch) stab wound to his right lower chest and a 7.5-cm (3 inch) stab
wound to his upper right abdomen were inspected. Chest tubes were inserted into the upper-right
and lower-right midaxillary regions. Immediately, 500 ml of red drainage returned via the lower
chest tube. His heart rate was 125 bpm, and the monitor showed sinus tachycardia without ectopy.
His blood pressure was 70/50 mmHg. Inserting a Foley catheter resulted in drainage of 400 ml
clear, dark yellow urine. After infusion of more than 2000 ml of lactated Ringer's solution, Mr. Budd
was sent to surgery, still in a hypotensive state. Preoperative body weight was 74 kg (165 lb).
Surgical intervention: During surgery, a right thoracotomy and right abdominal laparotomy were
performed. The right chest wound was explored, and a lacerated intercostal artery was ligated.
Exploration of his upper-right abdominal wound revealed more extensive damage. The liver and
the duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were
apparent after opening the peritoneum. Mr. Budd's injuries were repaired, the peritoneal cavity
was irrigated with antibiotic solution, and the incisional sump drains were placed in the duodenum.
During the 4-hour surgery, Mr. Budd received 6 U of blood and an additional 3 L of lactated
Ringer's solution. A pulmonary artery catheter and right radial arterial line were inserted.
ICU, Immediate Post-op: When Mr. Budd arrived in the surgical ICU, he was receiving ventilation
support. Ventilator settings were as follows:
Assit - mode Rate 12 FiO
2
60% Vt 800 ml
Vital signs and hemodynamic parameters immediately after surgery were:
BP 92/52 HR 114 Resp 12 Temp 36.2
o
C (97.2
o
F) PAP 20/8 mmHg PCWP 6 mmHg CVP 4
mmHg CO 5L/min CI 2.9 L/min/m SVR 1040 dynes/sec/cm
2
Arterial blood gas values were normal. Except for a WBC of 13.6 and a hemoglobin of 10 g/dl, Mr.
Budd's other laboratory values were within normal limits.
ICU, PO Day1: Mr. Budd remained drowsy and received ventilatory support for 24 hours. His pain
was controlled by IV morphine sulfate. The nasogastric tube continued to drain large amounts of
green fluid, and an incisional duodenal sump tube drained large amounts of greenish brown fluid.
His chest and abdominal dressings remained dry. Breath sounds were diminished on the right side
but clear on the left. His chest tubes continued to drain small amounts of bloody fluid. Urine output
was 40 to 60 ml/hr. His abdomen was slightly firm and distended, and he had no bowel sounds.
ICU, PO Day2: Mr. Budd's condition remained stable until his second PO day. At this time he
became difficult to arouse but did respond to commands. His respirations were 28 breaths/min,
shallow, and labored. His urine output dropped to 20 ml/hr. His skin became warm, dry, and
flushed. Other clinical data included:
BP 80/50 HR 132 Temp 36.2
o
C 997.2
o
F) PAP 14/7 mmHg PCWP 4 mm Hg CVP 2 mmHg CO 8
L/min CI 4.7 L/min/m
2
SVR 560 dynes/sec/cm
2
WBCs 22.0 Glucose 270 mg/dl
Culture and sensitivity reports from wound drainage indicated gram-negative bacilli. Appropriate IV

2. antibiotics were administered as well as IV hydrocortisone and naloxone (Narcan). A pharmacy
consultation to formulate and calculate nutritional needs was done and total parenteral nutrition
was started. Infusion of lactated Ringer's solution was increased to 150 ml/hr and dopamine at
5mcg/kg/min was started with a concentration of 200 mg/250 ml of D5W.
ICU, PO day 6: By the sixth postoperative day, Mr. Budd's condition had deteriorated dramatically.
His skin was cool, mottled, and moist. His sclerae were yellow tinged. He no longer responded to
stimuli. A norepinephrine (Levophed) drip infusion at 6 mcg/min with a concentration of 4 mg/250
ml D5W along with a dopamine drip at 2 mcg/kg/min was begun. His monitor show sinus
tachycardia with short runs of VT. ST-segment elevation, T-wave inversion, and the development
of Q waves over most of the anterior V leads on his ECG. A 75 mg bolus of lidocaine was given
followed by a continuous infusion at 2 mg/min with a concentration of 2 g/500 ml D5W. His breath
sounds revealed crackles throughout his chest. Urinary output was only 3 to 5 ml/hr and was
grossly bloody. His abdomen was enlarged and firm. His abdominal suture line had dehisced, and
the peritoneum could be seen. The duodenal sump and NG drainage started to turn red. All
arterial and venous puncture sites began oozing blood. Further clinical data included:
BP 70/52 HR 140 Resp 14 Temp 35.8
o
C (96.4
o
F) PAP 44/26 mmHg PCWP 24 mmHg CVP 8
mmHg CO 2 L/min CI 1.1 L/min/m
2
SVR 2000 dynes/sec/cm
2
pH 7.14 PCO
2
49 mmHg PO
2
46 mmHg SaO
2
85% HCO
3
-
12 mmol/L Lactic acid 3.0 mEq/L Na
+
152 mmol/L Creatinine 3.4 mg/dl Amylase 290 U/L Lipase 3.9 U/L ALT 100 U/L AST 82 U/L FDP
39 Platelets 75,000/mm3 PT 22 sec PTT 98.5 sec Fibrinogen 130 mg/dl Ck 640 U/L Troponin I
>50
Final developments: Despite attempts to reduce afterload with sodium nitroprusside (Nipride) and
increase contractility with dobutamine (Dobutrex), Mr. Budd's hemodynamic status failed even
further. When his cardiac rhythm deteriorated into VF, resuscitation efforts were unsuccessful. An
autopsy revealed several small abscessed areas in the lung, acute hepatic failure, multiple
hemorrhagic areas, and an acute MI.
1. Discuss the magnitude of bacteremia and sepsis in hospitalized patients and the relationship
between these two diagnoses.
2. What are the risk factors for infection and development of septic shock? Identify those that
applied to Mr. Budd?
3. Discuss the rationale for use of a pulmonary artery catheter in septic shock.
4. What organisms most commonly cause septic shock? In which sites is infection most often
seen?
5. What pathologic processes occur with septic shock? What are the efforts of these processes on
the patient's vascular tank, volume, and pump?
6. Discuss clinical, laboratory and therapy changes that occurred on Mr. Budd's second
postoperative day.
7. What is the rationale for each of the therapeutic modalities ordered for Mr. Budd on the second
postoperative day.
8. Discuss the clinical changes that occurred during Mr. Budd's sixth postoperative day.
9. What is the rationale for each of the therapeutic modalities ordered on the sixth postoperative
day. How many milliliters per hour should be infused for each of the drugs listed.

3. 48
Could you please answer 5-9

4. ED: John Budd, a 72-year-old, arrived in the
emergency department unconscious, with stab
wounds to the upper right abdomen and lower
right chest that were sustained in his home
while fighting off a burglar. The paramedics
secured two large-bore intravenous catheters in
his right and left anticubital spaces and infused
lactated Ringer's solution wide ope in both sites.
An endotracheal tube was inserted, and
ventilation with resuscitation bag at 100%
oxygen was begun. Medical antishock trousers
(MAST) were in place. Pressure dressings to
both wounds were secured. A 5-cm (2 inch) stab
wound to his right lower chest and a 7.5-cm (3
inch) stab wound to his upper right abdomen
were inspected. Chest tubes were inserted into
the upper-right and lower-right midaxillary
regions. Immediately, 500 ml of red drainage
returned via the lower chest tube. His heart rate
was 125 bpm, and the monitor showed sinus
tachycardia without ectopy. His blood pressure
was 70/50 mmHg. Inserting a Foley catheter
resulted in drainage of 400 ml clear, dark yellow
urine. After infusion of more than 2000 ml of
lactated Ringer's solution, Mr. Budd was sent to
surgery, still in a hypotensive state.
Preoperative body weight was 74 kg (165 lb).
Surgical intervention: During surgery, a right
thoracotomy and right abdominal laparotomy
were performed. The right chest wound was
explored, and a lacerated intercostal artery was
ligated. Exploration of his upper-right abdominal
wound revealed more extensive damage. The
liver and the duodenum were lacerated.
Extensive hemorrhage and leaking of intestinal
contents were apparent after opening the
peritoneum. Mr. Budd's injuries were repaired,
the peritoneal cavity was irrigated with antibiotic
solution, and the incisional sump drains were
placed in the duodenum. During the 4-hour
surgery, Mr. Budd received 6 U of blood and an
additional 3 L of lactated Ringer's solution. A
48

5. pulmonary artery catheter and right radial
arterial line were inserted.
ICU, Immediate Post-op: When Mr. Budd
arrived in the surgical ICU, he was receiving
ventilation support. Ventilator settings were as
follows:
Assit - mode Rate 12 FiO
2
60% Vt 800 ml
Vital signs and hemodynamic parameters
immediately after surgery were:
BP 92/52 HR 114 Resp 12 Temp 36.2
o
C
(97.2
o
F) PAP 20/8 mmHg PCWP 6 mmHg CVP
4 mmHg CO 5L/min CI 2.9 L/min/m SVR 1040
dynes/sec/cm
2
Arterial blood gas values were normal. Except
for a WBC of 13.6 and a hemoglobin of 10 g/dl,
Mr. Budd's other laboratory values were within
normal limits.
ICU, PO Day1: Mr. Budd remained drowsy and
received ventilatory support for 24 hours. His
pain was controlled by IV morphine sulfate. The
nasogastric tube continued to drain large
amounts of green fluid, and an incisional
duodenal sump tube drained large amounts of
greenish brown fluid. His chest and abdominal
dressings remained dry. Breath sounds were
diminished on the right side but clear on the left.
His chest tubes continued to drain small
amounts of bloody fluid. Urine output was 40 to
60 ml/hr. His abdomen was slightly firm and
distended, and he had no bowel sounds.
ICU, PO Day2: Mr. Budd's condition remained
stable until his second PO day. At this time he
became difficult to arouse but did respond to
commands. His respirations were 28
breaths/min, shallow, and labored. His urine
output dropped to 20 ml/hr. His skin became
warm, dry, and flushed. Other clinical data
included:
BP 80/50 HR 132 Temp 36.2
o
C 997.2
o
F) PAP
14/7 mmHg PCWP 4 mm Hg CVP 2 mmHg CO
8 L/min CI 4.7 L/min/m
2
SVR 560
dynes/sec/cm
2
WBCs 22.0 Glucose 270 mg/dl

6. Culture and sensitivity reports from wound
drainage indicated gram-negative bacilli.
Appropriate IV antibiotics were administered as
well as IV hydrocortisone and naloxone
(Narcan). A pharmacy consultation to formulate
and calculate nutritional needs was done and
total parenteral nutrition was started. Infusion of
lactated Ringer's solution was increased to 150
ml/hr and dopamine at 5mcg/kg/min was started
with a concentration of 200 mg/250 ml of D5W.
ICU, PO day 6: By the sixth postoperative day,
Mr. Budd's condition had deteriorated
dramatically. His skin was cool, mottled, and
moist. His sclerae were yellow tinged. He no
longer responded to stimuli. A norepinephrine
(Levophed) drip infusion at 6 mcg/min with a
concentration of 4 mg/250 ml D5W along with a
dopamine drip at 2 mcg/kg/min was begun. His
monitor show sinus tachycardia with short runs
of VT. ST-segment elevation, T-wave inversion,
and the development of Q waves over most of
the anterior V leads on his ECG. A 75 mg bolus
of lidocaine was given followed by a continuous
infusion at 2 mg/min with a concentration of 2
g/500 ml D5W. His breath sounds revealed
crackles throughout his chest. Urinary output
was only 3 to 5 ml/hr and was grossly bloody.
His abdomen was enlarged and firm. His
abdominal suture line had dehisced, and the
peritoneum could be seen. The duodenal sump
and NG drainage started to turn red. All arterial
and venous puncture sites began oozing blood.
Further clinical data included:
BP 70/52 HR 140 Resp 14 Temp 35.8
o
C
(96.4
o
F) PAP 44/26 mmHg PCWP 24 mmHg
CVP 8 mmHg CO 2 L/min CI 1.1 L/min/m
2
SVR
2000 dynes/sec/cm
2
pH 7.14 PCO
2
49 mmHg PO
2
46 mmHg SaO
2
85% HCO
3
-
12 mmol/L Lactic acid 3.0 mEq/L
Na
+
152 mmol/L Creatinine 3.4 mg/dl Amylase
290 U/L Lipase 3.9 U/L ALT 100 U/L AST 82
U/L FDP 39 Platelets 75,000/mm3 PT 22 sec

7. PTT 98.5 sec Fibrinogen 130 mg/dl Ck 640 U/L
Troponin I >50
Final developments: Despite attempts to reduce
afterload with sodium nitroprusside (Nipride)
and increase contractility with dobutamine
(Dobutrex), Mr. Budd's hemodynamic status
failed even further. When his cardiac rhythm
deteriorated into VF, resuscitation efforts were
unsuccessful. An autopsy revealed several
small abscessed areas in the lung, acute
hepatic failure, multiple hemorrhagic areas, and
an acute MI.
1. Discuss the magnitude of bacteremia and
sepsis in hospitalized patients and the
relationship between these two diagnoses.
2. What are the risk factors for infection and
development of septic shock? Identify those that
applied to Mr. Budd?
3. Discuss the rationale for use of a pulmonary
artery catheter in septic shock.
4. What organisms most commonly cause septic
shock? In which sites is infection most often
seen?
5. What pathologic processes occur with septic
shock? What are the efforts of these processes
on the patient's vascular tank, volume, and
pump?
6. Discuss clinical, laboratory and therapy
changes that occurred on Mr. Budd's second
postoperative day.
7. What is the rationale for each of the
therapeutic modalities ordered for Mr. Budd on
the second postoperative day.
8. Discuss the clinical changes that occurred
during Mr. Budd's sixth postoperative day.
9. What is the rationale for each of the
therapeutic modalities ordered on the sixth
postoperative day. How many milliliters per hour
should be infused for each of the drugs listed.