425) A 80 day old african american woman with advanced dementia is admitted to the intensive care unit for overwhelming sepsis secondary to a urinary tract infection. At presentation she was hypoxemic and was subsequently, intubated and placed on a ventilator. Blood and urine cultures are obtained and she is started on antibiotics A chest x-ray post-intubation shows endotracheal tube in place and bilateral diffuse alveolar infiltrates. On examination, his pulse is 110/min, Blood pressure is 110/80 mm Hg and respiratory rate is 18/min with the patient on Assist-Control mode on the ventilator. Pulse oximetry reveals 88% on Fio2 90%. Chest examination reveals diffuse crackles. Cardiac examination reveals tachycardia, there is no S3 gallop. Brain natriuretic peptide level is 50 pg/ml . A 2D echocardiogram shows normal left ventricular function with an ejection fraction of 60%. His ventilator settings are as follows : Assist-Control mode; Fio2 ( Fraction of inspired oxygen) : 90%, Respiratory rate : 18/minute, Tidal Volume : 500 ml, PEEP ( Positive End expiatory Pressure) : 5 cm H20 . Arterial blood gas analysis reveals ( on Fio2 70%): pH : 7.36, pCo2 : 45 mmHg, pO2 : 55 mm Hg, Bicarbonate : 23 Meq/L
Which of the following is indicated at this time?
A) Intravenous Furosemide
B) Swan-Ganz Catheter Placement
C) Increase PEEP by 3 cm H20
D) Increase Tidal Volume to 650 ml
E) Increase Fio2 to 100%