Clinical problem-solving: Patient management in critical care (Resolución de problemas clínicos: Manejo de paciente en terapia intensiva)

INITIAL CLINICAL EXPOSURE: A man of 37 years, born in Arica, public health professionals, Weight: 90kg, Height: 1,75mts. He arrives from sea levelin May 31 for soccer game Bolivia vs Chile. He is admitted to emergency room in June 2 of same year. He presentsan apparent acute abdomen. He is scheduled for a laparoscopy. It culminates in removal of a phlegmonous appendix.During admission and during the process Foley catheter damages the posterior urethra, being impossible the placement thereof.Because the apparent oliguria at 36 hours post surgery. Ultrasound reveal a bladder with just 25ml fi ltering. Resident physiciansdecide to implement saline volume loads in amount of about 1200cc with the presumption of oliguria secondary to postsurgicaldehydration. He presents at that time a HR: 88 x min, RR: 22 x min, SBP: 80/50mmHg and To: 37°C. Within hours, the patientbegins to have breathing diffi culty, shortness of breath that is increasing progressively after in the night he debuts with a frankrespiratory failure, and was taken to Intensive Care Unit (ICU). In the morning medical visit, the patient is disoriented, withhyperhidrosis, tachypnea and tachycardia (42 and 122 x minrespectively) with sinking in the clavicular and suprasternalfossa plus sign of Hoover. The PVC is 28cms of H2O with S3at mesocardium hiperfonétic. FIO2 arterial saturation is 72%,using of a Hudson mask. Auscultation allows rales and cracklesaudible even at distance. The clinical picture above interrupts the visit and the medical team proceeds immediately with patient management, requesting laboratories, blood gases and chest radiographs. -EXPOSICIóN CLíNICA INICIAL: Varón de 37 a os, natural de Arica, de ocupación salubrista, peso: 90Kg, Talla: 1,75mts que llega procedente de nivel del mar, en fecha 31 de Mayo, para el partido de futbol de Bolivia vs Chile. Es admitido al Servicio de Emergencias enfecha 2 de Junio del a o en curso, por presentar un aparente abdomen agudo, siendo programado para una laparoscopía, misma que culmina con la extirpación de un apéndice flegmonoso. En el transcurso de su admisión y durante el procedimiento de la colocación de la sonda Foley, se da a la uretra posterior, siendo imposible la colocación de la misma. Debido a la aparente oliguria del paciente, a las 36 horas del postquirúrgico, se determina por ecografía, que la vejiga arroja solamente un filtrado de 25 ml. Los médicos residentes deciden implementar cargas de volumen salino en cantidad de aproximadamente 1200cc con la presunción de una oliguria secundaria a deshidratación post quirúrgica, presenta