Echocardiography on ICU

A 50 year old female presented with acute kidney injury and sepsis.  She required fluid resuscitation, haemofiltration and cardiovascular support for 2 days, following which she was discharged to the renal ward for on-going haemodialysis. She underwent dialysis every 2-3 days for the next 3 weeks. Whilst on the ward she deteriorated acutely one evening, developing respiratory distress, followed by a respiratory arrest. She was intubated and ventilated transferred to the critical care unit.

A CTPA was negative for pulmonary embolus, but showed large bilateral pleural effusions. Tracheal suctioning was initially clear but later copious blood stained secretions were removed. A bedside cardiac echo performed by the consultant intensivist showed a globally sluggish left ventricle, which was overfilled, and the inferior vena cava measured 3cm also suggesting fluid overload. A trial of furosemide failed and she was aggressively haemofiltered to remove the excess fluid. Troponin was only mildly raised, and not thought to be suggestive of an acute cardiac event. She was extubated 24 hours later, but had two further episodes of flash pulmonary oedema requiring non-invasive ventilatory support whilst haemofiltration was re-commenced for fluid balance reasons. In total twelve litres of fluid were removed, with significant improvement in the patient’s condition. Repeat echocardiography prior to discharge showed an improving left ventricular function and IVC measurement of 2cm with greatly increased compliance.

What is the evidence that focussed echocardiography helps guide decision-making in intensive care?Read More »

Heparin Induced Thrombocytopaenia

 

A 75 year old was admitted to the Cardiac Intensive Care Unit following aortic valve replacement for severe aortic stenosis. He had no other significant past medical history. He remained intubated and ventilated overnight until cardiovascularly stable, and was extubated the following morning. He suffered bleeding into the pericardial drains, and went back to theatre on day 3. He remained intubated on his return from theatre. On day 7 it was noticed that he had developed thrombocytopenia, with a platelet count of 34, reducing from 103 the previous day. A heparin induced thrombocytopenia (HIT) screen was sent, and he was changed to alternative anticoagulation.

The HIT screen was positive. His platelet count fell further and he continued to bleed slowly from any puncture sites and from around his mouth and gums. He remained intubated and ventilated and developed a requirement for inotropic support. Transfusions of platelets were required for any intervention. He was anticoagulated with lepirudin to prevent thrombosis. His platelet count continued to remain in single figures over the next 10 days despite treatment with steroids. Unfortunately he deteriorated, suffering an arterial thrombosis in his arm, renal failure and developed a necrotic skin rash all over his body, likely to be related to the HIT. Following discussions with his family, who felt he was suffering and would not want a poor quality of life, treatment was withdrawn on day 26 of his intensive care stay and she died.

What are the clinical implications of heparin-induced thrombocytopaenia?Read More »

Pneumococcal Sepsis

An elderly man with a background of ischaemic heart disease, severe aortic stenosis and type 2 diabetes mellitus presented following recent travel from Hong Kong with shortness of breath and hypoxia. A chest X-ray confirmed left lower lobe consolidation (CRP 502, WCC 22) and he was commenced on broad spectrum antibiotics (Tazocin and Clarithromycin). Over the following 12 hours he deteriorated on the ward, with worsening hypoxia, hypotension and anuria.

He required emergency admission to intensive care for intubation and ventilation, and required inotropic support. He developed a severe metabolic acidosis and rising lactate, for which  haemofiltration was commenced. Vasopressin was added, followed by dobutamine, and hydrocortisone started for inotrope resistant hypotension. He remained ventilated on 100% oxygen, with high pressure support. He had a positive pneumococcal antigen, and high dose benzylpenicillin was added to his antibiotic regime, along with Oseltamivir (Tamiflu). Despite 12 hours of intensive therapy his acidosis worsened and he failed to respond to increasing doses of inotropic support, dying 30 hours after presentation to hospital.

What are the clinical features of pneumococcal sepsis?Read More »

Massive Transfusion in Upper Gastrointestinal Haemorrhage

A 55 year old male presented with acute upper abdominal pain and haematemesis. He had admitted drinking alcohol to excess. Following admission, he had a further significant episode of haematemesis associated with haemorrhagic shock. An emergency oesophagogastrectomy (OGD) was arranged in theatre. His pre-procedure haemoglobin was 60g/L.  OGD revealed large amounts of fresh blood in the stomach, which prevented identification of the bleeding point. The patient had a number of oesophageal varices, attempts were made to band these but this did not stop the bleeding. A partial gastrectomy was undertaken. The patient received a total of 18 units of red blood cells, 14 units of flesh frozen plasma and 2 units of platelets and cryoprecipitate before being taken to Intensive Care intubated and ventilated.

On the Intensive Care Unit he was warmed and repeat blood tests were sent to ensure correction of his coagulopathy. Haemoglobin was recorded as 9.4g/dL and the APTTr was normal. The following day when he was normothermic and cardiovascularly stable he was woken and extubated. He was discharged to the ward the following day.

When should we transfuse in upper gastro-intestinal haemorrhage? Are there any adjunctive therapies that can help?Read More »

Coiling versus Clipping Subarachnoid Haemorrhages

Coiling versus Clipping Subarachnoid Haemorrhages

A 40 year old female presented with a severe sudden onset headache, and deteriorated in the emergency department with worsening agitation and confusion requiring intubation and ventilation for her own safety. A CT scan diagnosed a Fisher Grade 4 subarachnoid haemorrhage and obstructive hydrocephalus. Clinical presentation was scored as Hunt and Hess grade 4 or World Federation of Neurosurgeons grade 4. The patient was transferred to the local tertiary Neurocritical care unit where an extra-ventricular drain was inserted overnight. The following day the patient underwent coiling of her right middle cerebral artery aneurysm in the radiology suite. A Magnesium infusion and Nimodipine therapy were commenced to reduce the risk of vasospasm. On initial sedation hold she woke up agitated so she had an early tracheostomy placed to allow controlled wake up. She had a straightforward respiratory wean from the ventilator over the next few days. Neurological recovery was good (Glasgow coma score improved to 14/15) and the patient was discharged to the ward for on-going neuro rehabilitation and repatriation to the base hospital.

What are the risks of clipping vs coiling subarachnoid haemorrhages?Read More »

Haemofiltration in Sepsis

Haemofiltration in Sepsis

A young IV drug user was admitted with septic shock secondary to staphylococcal sepsis with bilateral shadowing on CXR. He rapidly required intubation due to hypoxia, and institution of vasopressor support. He had a significant metabolic acidosis and consequently was commenced on haemofiltration. Transthoracic echocardiography revealed a large tricuspid vegetation. After 48 hours of haemofiltration, his acidosis haf normalised, and pressor requirements had reduced. He had a prolonged respiratory wean before being transferred to a cardiothoracic centre.

What is the role of haemofiltration (or other modes of renal replacement therapy) in severe sepsis and septic shock?
Read More »

Meet the team

ICM Case Summaries is brought to you by:


Administrators and Lead Editors


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Prad Shanmugasundaram

Consultant ICM and Anaesthesia

Buckinghamshire Healthcare NHS Trust

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Steve Mathieu

Consultant ICM and Anaesthesia

Portsmouth Hospitals NHS Trust

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Jamie Strachan

ICM and Anaesthesia Specialty Registrar

Oxford University Hospitals NHS Trust

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Editor



Dr F RiccioFran Riccio

ICM Clinical Fellow

Portsmouth Hospitals NHS Trust

 

 


Contributors


ICM Case Summaries would like to thank:

Adrian Wong  twitter icon copy

Consultant ICM & Anaesthesia. Oxford University Hospitals NHS Trust

David Garry twitter icon copy

Consultant ICM & Anaesthesia. Oxford University Hospitals NHS Trust

Dave Slessor twitter icon copy

Specialty Registrar in Intensive Care and Emergency Medicine. Health Education Wessex

Sam Clark

Critical Care Echocardiography Fellow. Oxford University Hospitals NHS Trust

Helen Vollmer twitter icon copy

Specialty Registrar in Intensive Care Medicine and Anaesthesia. Royal Berkshire Hospital NHS Foundation Trust

Duncan Chambler twitter icon copy

Specialty Registrar in Intensive Care Medicine and Anaesthesia. Health Education Wessex

Tahir Ali

Specialty Registrar in Intensive Care Medicine and Anaesthesia. Health Education North East (ICM), Health Eduction Thames Valley (Anaesthesia)

Akshay Shah twitter icon copy

Academic Clinical Fellow in Intensive Care Medicine, Specialty Registrar in Anaesthesia. Oxford University Hospitals NHS Trust

Mirae Shin twitter icon copy

Academic Clinical Fellow in Intensive Care Medicine. Oxford University Hospitals NHS Trust

Stuart McKechnie

Consultant ICM and Anaesthesia, Oxford University Hospitals NHS Trust

Craig Walker twitter icon copy

Consultant ICM, St John’s Hospital, Livingston. Consultant EM, Royal Infirmary of Edinburgh

Katherine Francis

Specialty Registrar in Anaesthesia, Oxford University Hospitals NHS Trust

Stephen Shepherd twitter

Specialty Registrar in ICM and Anaesthesia, Barts Healthcare NHS Trust

Ben Harris twitter

Specialty Registrar in Intensive Care Medicine and Anaesthesia. Health Education Wessex

Emma Fitzgerald twitter

Consultant ICM and Anaesthesia. Queen Alexandra Hospital, Portsmouth

David Hepburn twitter

Locum Consultant ICM. Royal Gwent Hospital, Newport