Category: Case Summary

IV Immunoglobulin for Necrotising Fasciitis

IV Immunoglobulin for Necrotising Fasciitis

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A 40 year old woman presented with painful swelling of the right side of the neck. She had previously suffered a haematological malignancy and received a bone marrow transplant. A presumptive diagnosis of necrotising fasciitis was made and the neck, shoulder and chest underwent surgical debridement. Postoperatively, the patient remained ventilated in septic shock. Further debridement was required at 24 hours. Group A streptococcus was grown from the debrided tissue and IV immunoglobulins was commenced. The patient gradually weaned from support and was discharged from ICU several days later.

Does IV immunoglobulin have a role to play in the treatment of necrotising fasciitis?Read More »

Management of Delirium

Management of Delirium

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A large 60 year old man developed septic shock and multiorgan failure secondary to a severe community acquired pneumonia. On the twelfth night of his ICU admission he became increasingly agitated and pulled out his vascath, NG tube and dislodged his tracheostomy. The resulting loss of airway led to a severe desaturation event before he was anaesthetised and reintubated, with loss of around 500ml blood from the haemofiltration circuit and vascath wound haemorrhage. He was commenced on regular haloperidol, but his CAM-ICU remained positive for 48 hours. Haloperidol was continued for 4 days, and he had a prolonged respiratory wean.

How is delirium best managed on the intensive care unit?Read More »

Hypertensive Reversible Posterior Leukoencephalopathy

Hypertensive Reversible Posterior Leukoencephalopathy

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A 65 year old chronic hypertensive man underwent a bone marrow transplant for acute myeloid leukaemia. He was subsequently treated for neutropaenic sepsis. He developed acute confusion and a subsequent drop in GCS requiring intubation. CT head and CSF investigation was normal. EEG was non-diagnostic. He was persistently hypertensive on the ICU. Review of notes showed that his anti-hypertensive medications had been omitted since admission, and that his ward blood pressures had been persistently elevated. Antihypertensives were established and the blood pressure improved. The neurological features improved with the blood pressure. A subsequent MRI confirmed the diagnosis.

What are the clinical features of Reversible Posterior Leukoencephalopathy Syndrome (RPLS)?Read More »

Intralipid in Antihypertensive Overdose

Intralipid in Antihypertensive Overdose

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A middle aged man presented after having taken a mixed antihypertensive overdose of ramipril, amlodipine and bendroflumethiazide. He had refractory hypotension despite fluids, noradrenaline, adrenaline vasopressin and calcium infusions.  After discussion with toxicologists he was given 20% intralipid as per the AAGBI guidelines for LA toxicity. There was an immediate but transient improvement in his BP with two bolus doses of intralipid. Over the subwequent hours and days, he stabilised and weaned off his vasopressor support. There was no long-lasting organ dysfunction.

What is the evidence for the use of intralipid in the management for antihypertensive overdose?

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Early Goal Directed Therapy for Severe Sepsis

Early Goal Directed Therapy for Severe Sepsis

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An elderly man presented with urosepsis. He was in septic shock with a lactate of 8.2 on presentation. He was commenced on antibiotics and fluid resuscitated in the Emergency Department and his lactate was remeasured as 6.1. His ScvO2 was measured as 54%, rising to 63% after further fluid challenge. He was fluid resuscitated and commenced on noradrenaline to maintain a MAP of 65. He recovered from his urosepsis and was discharged from hospital 5 days later.

What is the evidence for and against Early Goal Directed Therapy for the management of severe sepsis?Read More »

Management of the Open Abdomen

Management of the Open Abdomen after Severe Abdominal Sepsis

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A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.

How is an open abdomen managed after severe abdominal sepsis?Read More »

Use of Albumin in Septic Shock

Use of Albumin in Septic Shock

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A 40 year old woman presented with 4 days of abdominal pain, distended abdomen and faeculent vomiting. She was in septic shock on presentation and laparotomy revealed a sigmoid perforation with four quadrant peritonitis. Postoperatively she was extubated, but dependent on noradrenaline. Overnight, her vasopressor requirements escalated despite additional fluid resuscitation. Transthoracic echo suggesed hypovolaemia, and as she was hypoalbuminaemic she was given regular boluses of 20% albumin which resulted in transient improvments in blood pressure. Despite a return to theatre for further washout, she developed multiorgan failure and died.

What is the evidence behind the use of Albumin as a resuscitation fluid in patients with septic shock?Read More »

Intraabdominal Hypertension & Abdominal Compartment Syndrome

Intraabdominal Hypertension & Abdominal Compartment Syndrome

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A 35 year old was admitted following a simultaneous kidney pancreas transplant. The procedure had been complicated and she had received a large volume transfusion and crystalloid infusion.Her initial intraabdominal pressures were elevated at 22cmH2O on admission to the intensive care. It continued to escalate over the next 48 hours peaking at 29. She was managed with sedation, NG tube and abdominal perfusion pressures kept above 60mmHg. The tranplanted pancreas remained functional, but the renal transplant showed delayed graft function. On day 4 there was a reduction in her abdominal pressure and her urine output correspondingly increased.

What is the current evidence for the management of intra abdominal hypertension (IAH)?Read More »

Pulmonary Vasculitis and Haemorrhage

Pulmonary Vasculitis and Haemorrhage: The Role of Plasmapharesis

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A 65 year old woman investigated for malaise by her GP and found to have a creatinine of 993 and urea of 47.3. She was admitted to hospital to await renal assessment and commencement of dialysis, but became acutely breathless and hypoxic. CXR showed bilateral pulmonary consolidation. She was intubated due to her respiratory failure and frank blood was suctioned from her tracheal tube. Investigations for pulmonary-renal syndromes led to a positive cANCA and a presumptive diagnosis of Wegener’s granulomatosis. She was pulsed with methylprednisolone and commenced plasmapheresis. Despite this she continued to deteriorate and subsequently died.

What is the role of plasmapheresis in pulmonary vasculitides and pulmonary haemorrhage?

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The Role of ECMO in ARDS

The Role of ECMO in ARDS

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A middle aged man with acute pancreatitis developed multiorgan failure and was admitted to the ICU and required ventilation and noradrenaline. He became progressively more hypoxic despite lung protective ventilation, paralysis, inverse ratios and a restrictive fluid regime. He developed bilateral pneumothoraces requiring chest drains. He was retrieved to the nearest refractory hypoxia centre and established on VV ECMO. On the third day of ECMO therapy he developed lateralising signs and was found to have had a large intracranial haemorrhage. Treatment was subsequently withdrawn.

Do patients with ARDS benefit from ECMO?Read More »