A 65 year old woman developed a left lower lobe hospital acquired pneumonia following a elective laparoscopic procedure for which she was ventilated for 4 days. Twenty four hours post extubation, she developed hypoxic respiratory failure with bilateral patchy shadowing on chest X-ray. She was reintubated and subsequently grew Pseudomonas aeruginosa from tracheal aspirate.
How do we diagnose Ventilator Associated Pneumonia (VAP)?Read More »
A young woman was admitted with respiratory failure requiring invasive ventilation. She had bilateral lobar consolidation and positive urinary pneumococcal antigen. She was ventilated with protective lung strategies but required FiO2 of between 0.8-1.0. A PEEP of 18 was set. She was ventilated for over 2 weeks, and was tracheostomised but was discharged from the ICU after 3 weeks.
How is PEEP utilised in the ventilatory strategies in the management of Adult Respiratory Distress Syndrome?Read More »
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 »
A 28 year old male presented to the Emergency Department with an upper gastrointestinal bleed. This was managed with resuscitation and endoscopic diathermy and adrenaline injection This was his first presentation to secondary care with complications from his significant alcohol intake. He reported drinking at least 50 units of alcohol per week. Ultrasound examination demonstrated an enlarged liver with changes consistent with steatosis. On day 3 of his admission, he became tachycardic, tachypnoeic and increasingly lethargic. Examination revealed jaundice, bi-basal lung crepitations and mild confusion. Investigation confirmed an acute hepatitis by blood chemistry and repeat ultrasound. In the absence of any other cause, a diagnosis of acute alcoholic hepatitis was considered.
In patients with acute alcoholic hepatitis, does pentoxifylline reduce mortality?Read More »
A 55 yr old man developed severe necrotizing pancreatitis with multiorgan failure. One week into his illness he had developed multiple intra-abdominal collections and had high intra-abdominal pressures. Initial conservative management failed, percutaneous drainage of his collections failed to reduce the abdominal pressures, and he underwent decompressive laparotomy.
What is the evidence behind the current guidelines for the measurement of intra-abdominal hypertension and the use of decompressive laparotomy in the management of Abdominal Compartment Syndrome?Read More »
A 63 yr old woman collapsed at home and was brought into ED with a GCS of 3/15. She was a known hypertensive and hypercholesterolaemic. CT scan revealed a Fisher grade 3 subarachnoid haemorrhage. A ruptured middle cerebral artery was secured 24 hours later. She extubated on day 3 with a GCS of 13, but dropped her GCS to 10 on day 5 and was treated for vasospasm, which included continuing the nimodipine and simvastatin from her admission.
What is the evidence for ‘statins’ for the prevention of Vasospasm in Aneurysmal Subarachnoid Haemorrhage?Read More »
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 »
A 48 year old lady was admitted to critical care whilst suffering from sepsis secondary to severe cellulitis of her leg. She was obese with a BMI of 38 and was managed with insulin and oral anti-hyperglycaemics for type 2 diabetes mellitus. A doppler scan was unable to exclude a DVT. She had a further deterioration 30 hours later. Her sinus tachycardia accelerated to 130 bpm, along with a drop in blood pressure to 100/40. Arterial blood gas demonstrated an increasing A-a gradient as his FiO2 increased. Although such changes can occur in sepsis, the acute onset led to concerns regarding venous thromboembolism and pulmonary emboli.
A 55 year old presented to ED following a witnessed VF arrest. He received bystander CPR and several shocks from the ambulance crew. He was intubated at the scene, and transferred to ED with return of spontaneous circulation. He had primary PCI to LAD and was transferred to the ICU for therapeutic hypothermia. He was kept at 33 degrees for 24 hours, and rewarmed over 8 hours. He extubated 2 days late with no cognitive impairment, and mild weakness in one arm.
What is the evidence for and against Targeted Temperature Management (TTM) post cardiac arrest?Read More »
A 85 year old man presented with acute bowel obstruction. He had a history of hypertension and diverticulitis disease, but was active for his age. He was not known to have coronary or any other vascular pathology. At laparotomy, a large diverticulitis abscess was identified. When this was manipulated, he developed an SVT with a ventricular rate of 210 bpm which progressed to VT. He received 1 mg adrenaline and 2 minutes CPR in total, with no electrical shocks. At this point perfusion and pressure returned. Surgery was expedited and simplified. He remained intubated and ventilated on ITU post-operatively. ECG demonstrated global t-wave inversion. He required noradrenaline and adrenaline to maintain blood pressure. During the initial 48 hours, his haemoglobin (Hb) fell from 11.9 g/dl to 8.1 g/dl, raising the suggestion of packed red cell (PRC) transfusion.
What is the most appropriate threshold to transfuse packed red cells in critically ill patients?Read More »
ICM Case Summaries 