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.
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 and source guide.
Scenario 1: Early low-output physiology
Paired synthetic application examples. Integrated workup and test reasoning.
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. Integrated workup and test reasoning.
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boundary: The earlier claim that beta-blockade should be avoided because heart rate is not the main driver is withdrawn.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. Integrated workup and test reasoning.
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. Integrated workup and test reasoning.
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. Integrated workup and test reasoning.
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.