Nutrition in the Intensive Care Unit

Nutrition in the Intensive Care Unit

A middle aged man is admitted with abdominal pain and vomiting. He has a history of alcohol excess. A CT scan shows evidence of pancreatic necrosis. Supportive care is initiated and an NGT placed for supplementary enteral nutrition. After 3 days, he is referred to ICU as his oxygen requirements have increased and he is requiring non-invasive ventilation. It is noted that he has had very large gastric aspirates. Parenteral nutrition is commenced at this point.

What is the evidence for enteral versus parenteral feed as a source of nutrition in critically ill patients?Read More »

Tracheostomy in the Intensive Care Unit

Tracheostomy in the Intensive Care Unit

A 47-year-old male was admitted to the intensive care unit (ICU) following a high-speed motorcycle accident. He had a number of injuries including bilateral pneumothoraces, multiple spinal fractures, an open-book pelvis fracture, and a brachial plexus injury. Bilateral chest drains were inserted and external fixation of the pelvis was performed. The patient was extubated eventually at day 15 but required reintubation within 12 hours because of a poor cough and sputum retention 

What are the indications for a tracheostomy and when shout it be considered?

Read More »

Heparin Induced Thrombocytopenia

Heparin Induced Thrombocytopenia

A 62 year old lady with a metallic aortic valve was admitted to the cardiac unit for urgent surgical repair of a severely regurgitant mitral valve. He was normally on warfarin for his metal valve. This was stopped and unfractionated heparin commenced on day 4 once his INR level had dropped below the therapeutic range. The patient’s platelet count was 147*10^9/L on admission. By day 4 it had dropped to 85*10^9/L. After heparin was started it dropped further to a nadir of 55*10^9/L on day 8.

Could this be due to heparin induced thrombocytopenia? What investigations are required and how should we treat it?
Read More »

Hepatorenal Syndrome

Hepatorenal Syndrome

A 54 year old man with a history of alcohol excess was admitted under the medical team with an upper gastro-intestinal bleed. He had a background of pulmonary fibrosis that limited his exercise tolerance to 30 yards. Antibiotics, terlipressin and fluid resuscitation, including blood, were given. An oesophago-gastro-duodenoscopy demonstrated severe portal gastropathy but no active bleeding or varices. An abdominal ultrasound demonstrated cirrhosis and some moderate ascites. On day two of the patient’s hospital admission he was admitted to the intensive care unit (ICU) with respiratory failure and non-invasive ventilation was started. Over the next few days his condition deteriorated and he required vasopressor support. By day 6 the patient was oliguric, and his creatinine had risen from 102 to 155 µmoles/l.

What is the cause for his acute kidney injury? Could it be hepatorenal syndrome? Read More »

ECMO for Respiratory Failure

ECMO for Respiratory Failure

A 40 year old lady was admitted under the medical team with pneumonia. She was normally well with no history of respiratory illnesses. On day two of her hospital admission she became more hypoxic necessitating continuous-positive-airway-pressure. Her condition rapidly worsened and her chest x-ray showed diffuse bilateral infiltrates. An echocardiogram demonstrated normal systolic function. She was intubated and ventilated. Despite sedation, ARDSnet ventilation, paralysis and then proning her, she remained severely hypoxaemic. A therapeutic bronchoscopy was performed prior to proning but did not improve her condition.

Should she be referred for consideration of ECMO and was is this evidence to support it’s use?

Read More »

Hypertriglyceridaemia Induced Acute Pancreatitis

Hypertriglyceridaemia Induced Acute Pancreatitis

A young man is admitted to the surgical unit with several months of worsening abdominal pain. It has become much more severe over the last 24 hours. A CT scan shows evidence of acute pancreatitis with no gallstones or biliary duct dilatation.. He is normally well with no history of alcohol excess. His triglyceride level is elevated at 83.7mmol/L and a diagnosis of hypertriglyceridaemia induced acute pancreatitis is made. 

What is hypertriglyceridaemia induced acute pancreatitis and how is it treated?

Read More »

Meet the team

ICM Case Summaries is brought to you by:


Administrators and Lead Editors


Prad photo 3

Prad Shanmugasundaram

Consultant ICM and Anaesthesia

Buckinghamshire Healthcare NHS Trust

twitter icon copy


Version 2

Steve Mathieu

Consultant ICM and Anaesthesia

Portsmouth Hospitals NHS Trust

twitter icon copyTBLwicsportsmouth


Jamie

Jamie Strachan

ICM and Anaesthesia Specialty Registrar

Oxford University Hospitals NHS Trust

twitter icon copyoxicm1-e1425844523268


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