Hypertonic Saline for Raised Intracranial Pressure

Hypertonic Saline for Raised Intracranial Pressure

A 40 year old male was brought into ED following a high speed road traffic accident. The patient was ejected from the vehicle. The patient was managed according to ATLS guidelines. He suffered extensive injuries including facial fractures, traumatic subarachnoid haemorrhage and multiple intra-cerebral haemorrhages, a flail chest and thoracic and cervical spine injuries. Once stabilised, the patient was transferred to the neurosurgical intensive care unit where an intra-cranial pressure (ICP) monitor was inserted to measure intracranial pressures. His ICP was persistently raised despite optimising respiratory parameters, deep sedation, muscle relaxation and then mannitol. A decision was made to commence an infusion of hypertonic saline 2.7% according to the local protocol. The ICP improved rapidly and stabilised and removed the need to proceed with surgical decompressive craniotomy.

What is the evidence for the use of hypertonic saline in the treatment of acutely raised intracranial pressure?Read More »

High Frequency Oscillatory Ventilation in ARDS

High Frequency Oscillatory Ventilation in ARDS

A 45 year old female presented to A&E with a 5 day history of worsening SOB, cough productive of green sputum, lethargy, anorexia, fever and rigors. She had no co- morbidities and was active and independent with a good exercise tolerance. On examination she looked unwell, clammy and drowsy. Her respiratory rate was 35 breaths per minute and SpO2 of 84% on 15 Litres of oxygen via a non-rebreathing mask. Her blood pressure was 88/40 mmHg with a heart rate of 140 per minute despite having received 3 litres of fluid. Arterial blood gas showed PaO2 6.0kPa, pH 7.28, PaCO2 7.1 kPa, Bicarbonate 14 mmol/l, BE -11 and Lactate 8.6 mmol/l. Chest radiograph demonstrated significant bilateral consolidation with infiltrates consistent with ARDS. PaO2:FiO2 was calculated as 15 indicating severe ARDS presumed secondary to CAP.

She was managed as per sepsis guidelines. Oxygen therapy was continued and CPAP was initiated due to the hypoxia whilst an ICU bed was being prepared for admission. Noradrenaline was commenced at 0.2mcg/kg/min which continued to increase. Repeat arterial blood gases confirmed worsening type 2 respiratory failure and the patient was clinically exhausted. A modified rapid sequence induction was performed and IPPV commenced. Her oxygenation remained a problem and despite a FiO2 of 1.0 and PEEP of 20 his SpO2 remained 85% and PaO2 6kPa. The patients’ sedation was deepened and muscle relaxant administered. Lung protective ventilation was continued however arterial blood gases continued to worsen. The decision was made to convert the patient from conventional ventilation (CV) to High-Frequency Oscillator Ventilation (HFOV). The initial ABGs after an hour of HFOV showed an improvement as did subsequent numbers. This mode of ventilation was continued for a further 48 hours and then converted to CV. Gas exchange continued to improve. Over the course of the following 4 weeks the patient had a tracheostomy performed to aid weaning. She subsequently developed a Ventilator Associated Pneumonia and worsening ARDS required a further period of HFOV. Improvement continued and the patient was successfully decannulated and discharged from ICU.

What is the evidence base for high frequency oscillatory ventilation in ARDS?

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Lactate Physiology and Predicting Disease Severity

Lactate Physiology and Predicting Disease Severity

A middle aged man presented with urosepsis after several days antibiotic therapy in the community. He was in septic shock, with tachypnoea, tachycardia and hypotension. He had raised inflammatory markers and acute kidney injury. His initial lactate level was 14mmol/L with a significant metabolic acidosis (base deficit 21). He was commenced on iv antibiotics, noradrenaline and renal replacement therapy. Lactate levels cleared to less than 2mmol/L over the next 24hrs. He weaned off noradrenaline in 72 hours and CVVHDF over the next 5 days.

How is lactate produced and what is its significance in predicting the severity of critical illness?

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Corticosteroids in Septic Shock

Corticosteroids in Septic Shock

A week after an elective colectomy, a 70yr old man developed septic shock and multiorgan failure secondary to anastomotic breakdown. He was managed according to surviving sepsis guidelines with source control, early antibiotics, fluids and noradrenaline. The patient remained hypotensive and refractory to noradrenaline therapy, and had vasopressin and low dose hydrocortisone infusion commenced.

What is the evidence for the use of corticosteroids in septic shock?Read More »

Intensive Care Acquired Weakness

Intensive Care Acquired Weakness

A cardiovascularly fit 65 year old man was admitted with septic shock secondary to community acquired pneumonia, which progressed to multi-organ failure. During his recovery it was noted that he had generalised weakness with no focal neurology. He underwent respiratory weaning, and rehabilitation therapy over the next 4 weeks but had persistent weakness at his ICU discharge.

How can ICU-acquired weakness be diagnosed and managed?Read More »

Delirium on the ICU

Delirium on the ICU

A 67 year old with signficant cardiovascular comorbidities presented with a fractured neck of femur after a fall. She had a hemiarthroplasty performed under GA with fascia iliaca blocks, and went to HDU postoperatively. She became acutely confused during the first postoperative night with hallucinations and paranoia. She was CAM-ICU positive and was given haloperidol to control her agitation.

What is the optimum management of delirium on the ICU?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