每日一题_2022.08.22

A 57-year-old woman sustained an unwitnessed fall at home. She underwent a craniotomy for subdural hematoma, and is now admitted to the ICU on mechanical ventilation. On postoperative day three, she develops acute respiratory distress syndrome, with a fever and worsening leukocytosis of 23,000/mm3. She is intolerant to tube feeding, with abdominal distention. She is on pressure-regulated volume control (PRVC) ventilation with fraction of inspired oxygen 80%, positive end-expiratory pressure 12 cm H2O, respiratory rate 18 breaths/min, tidal volume 490 mL (7 mL/kg).
Arterial blood gas results: pH 7.32, partial pressure of carbon dioxide 48 mm Hg, partial pressure of oxygen 62 mm Hg, oxygen saturation 90%.

Which of the following is the most appropriate next step in this patient’s management?

A. After a pulmonary recruitment maneuver, change the ventilation from PRVC to airway pressure release ventilation.

B. Start broad-spectrum antibiotics for presumed ventilator-associated pneumonia (VAP).

C. Start broad-spectrum antibiotics, after obtaining a bronchoalveolar lavage specimen for bacteriology, for presumed VAP.

D. Obtain abdominal and pelvic CT.

E. Obtain CT angiography of the chest.

答案解析：

脓毒症是急性呼吸窘迫综合征 (ARDS) 的最常见原因。 当易患严重感染或新发发热或低血压的患者出现 ARDS 时，应首先考虑其病因。 该患者可能患有先前存在的社区获得性肺炎，或早期呼吸机相关性肺炎。 然而，伴有胃肠道表现的严重 ARDS（部分动脉氧压/吸入氧分数比为 62/0.8 = 78）引起了对错过腹内灾难的严重担忧，这可能是患者跌倒的原因。 机械通气管理很重要，但不是优先事项。 肺栓塞可以包括在鉴别诊断中，但不能解释喂养不耐受和白细胞增多。

正确答案：D