# Simulated case set: Mechanical support and goals of care

> **Educational work by a pre-medical student — not medical advice.** Not a clinical protocol, prescription, or patient handout, and not for patient care. See [DISCLAIMER](DISCLAIMER.md).

Entirely synthetic independent premedical study material. Revised 27 October 2026. The author confirmed that scenarios are independent of real encounters/charts. This reconstruction preserves the earlier topic coverage while withdrawing unsupported medication doses, device adjustments and automatic escalation thresholds. Earlier versions remain in Git history.

## How to use these worked examples

Read the paired patient examples and integrated clinical narratives linked under each scenario. The examples explain interpretation and conditional care decisions; no student answers or scoring are required. See the [procedure-organized CTICU casebook](CTICU_PROCEDURE_EXAMPLES.md) and [source guide](references/bibliography.md).

## Scenario 1: Early low-output physiology

[Paired synthetic application examples](APPLIED_CASES.md#icu-05-01). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-05-01).

**Synthetic vignette:** A fictional bypass recipient has borderline pressure, rising lactate, oliguria and RV dysfunction.

**Worked example interpretation**

Assess effective perfusion and congestion together; acceptable MAP does not resolve the low-flow question. Do not automatically withhold decongestion or lower PEEP without the broader assessment. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.

**Interpretation boundary:** No automatic decision to withhold diuresis or lower PEEP follows from RV dysfunction alone.

## Scenario 2: Aortic repair and agitation

[Paired synthetic application examples](APPLIED_CASES.md#icu-05-02). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-05-02).

**Synthetic vignette:** A fictional aortic-surgery patient has agitation, intermittent hypertension and hypoxemia.

**Worked example interpretation**

Compare pain, respiratory and neurologic explanations before treating agitation as an isolated sedation problem. Heart rate and pressure both matter in the aortic context; a sedative or antihypertensive is not selected by agitation alone. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.

**Interpretation boundary:** The earlier claim that beta-blockade should be avoided because heart rate is not the main driver is withdrawn. No replacement antihypertensive regimen is prescribed.

## Scenario 3: Chronic LVAD low-flow alarms

[Paired synthetic application examples](APPLIED_CASES.md#icu-05-03). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-05-03).

**Synthetic vignette:** A fictional LVAD patient has low-flow alarms, anemia, rising LDH and RV dysfunction.

**Worked example interpretation**

Compare device, rhythm and loading explanations; hemolysis markers do not uniquely identify thrombosis. No empirical speed, fluid or transfusion change follows from the alarm; device-specific expert assessment is required. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.

**Interpretation boundary:** A low-flow alarm does not justify empiric speed, fluid or transfusion changes outside specialist assessment.

## Scenario 4: VV-ECMO with hypoxemia

[Paired synthetic application examples](APPLIED_CASES.md#icu-05-04). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-05-04).

**Synthetic vignette:** A fictional adult on VV-ECMO has hypoxemia, rising lactate, oliguria and high sedation requirements.

**Worked example interpretation**

Consider recirculation, native-lung disease, hemoglobin, flow and demand; one circuit gas does not settle systemic oxygen delivery. Sweeping gas and blood flow affect different processes; no automatic paralysis, transfusion or sedative escalation is inferred. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.

**Interpretation boundary:** A normal post-membrane value does not prove that all circuit-related causes are absent or make transfusion/paralysis automatic.

## Scenario 5: Explicitly chosen comfort-focused care

[Paired synthetic application examples](APPLIED_CASES.md#icu-05-05). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-05-05).

**Synthetic vignette:** A fictional adult with advanced illness has separately chosen a comfort-focused plan after a goals-of-care discussion.

**Worked example interpretation**

Document the separately chosen comfort-focused goals and assess distress, benefit and unwanted effects over time; do not infer these goals from DNR alone. Proportionate symptom treatment is individualized; routine sedative combinations or disease-driven targets are not substituted for the expressed priorities. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.

**Interpretation boundary:** Comfort-only goals are explicitly supplied here and are not inferred from DNR/DNI. Sedative combinations are not automatically appropriate; choices require proportionate symptom-focused assessment by the treating team.