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Patient Care Vignette

A 64-year-old woman presents to the emergency department after a motor vehicle collision. She has bilateral pneumothoraxes and a grade IV liver laceration causing massive intra-abdominal hemorrhage. She is intubated and bilateral thoracostomy tubes are placed. The patient then undergoes emergent exploratory laparotomy, where the liver is packed, and the abdomen is left with a temporary closure device. Massive transfusion is performed, with nearly 10 liters of blood components given. She is brought intubated to the ICU for further stabilization, where a team of critical care physicians, advanced practice providers (APPs), and nurses assume responsibility for her care, managing respiratory failure, titrating medication infusions, correcting metabolic and coagulation abnormalities, and administering additional blood products.

After 2 days, the patient returns to the operating room, but abdominal closure is impossible due to edema. She develops agitated delirium and her sedation regimen is modified for safety. She develops acute kidney injury requiring renal replacement therapy. The ICU APP inserts a temporary dialysis catheter, and continuous renal replacement therapy (CRRT) is initiated. Prophylactic anticoagulation is initially held due to ongoing bleeding, and on day 3, the bedside nurse notes swelling of the right leg; a deep venous thrombosis (DVT) of the right common femoral vein is diagnosed by ultrasound. The surgical service is concerned about recurrence of bleeding with anticoagulation, so an inferior vena cava (IVC) filter is placed. A registered dietitian estimates the patient’s nutritional requirements and enteral nutrition via feeding tube is initiated, first at a low dose, then cautiously advanced to provide full nutrition.

The next 2 weeks are marked by both clinical progress and setbacks. On her fourth surgery for serial exploration and washout, her midline abdominal incision is successfully closed. A heparin infusion is initiated for the DVT after her bleeding risk is deemed to be low. Unfortunately, she develops ventilator-associated pneumonia, and despite appropriate broad-spectrum antibiotic therapy, ventilator weaning proves to be difficult. The patient has no existing advanced directive, so the APP discusses the case with the patient’s primary care provider and leads a multidisciplinary conversation with the patient’s family to explore her wishes in the setting of critical illness. They agree on continuing with life-supportive measures, so percutaneous tracheostomy and percutaneous endoscopic gastrostomy (PEG) tubes are placed. Afterwards, sedation and ventilator support are more easily weaned, and she eventually tolerates spontaneous breathing through her tracheostomy with no sedation and minimal supplemental oxygen. Her CRRT is transitioned to intermittent hemodialysis. Physical and occupational therapists evaluate her and find her to be severely deconditioned, unable even to sit on the edge of the bed without assistance; a structured therapy plan is started, and she is recommended for placement in an acute inpatient rehabilitation facility.

She is transferred to a stepdown unit, where she is gradually liberated from more and more of the therapies initially required in the ICU. At one point the critical care team is consulted for a new borderline fever, and she is ...

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