Category: 3.1

Manages the care of the critically ill patient with specific acute medical conditions

ECMO for Respiratory Failure

ECMO for Respiratory Failure

Steve Mathieu1 Comment

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?

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Transfusion in Sepsis

Transfusion in Sepsis

ICM Case Summaries1 Comment

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 »

Botulism

Botulism

ICM Case Summaries1 Comment

A young female IV drug abuser presented with dysarthria, diplopia and weakness with loss of her gag reflex. She had recently had an abscess wound on her arm debrided. She was intubated for airway protection, and underwent early tracheostomy. She was treated with intravenous antibiotics and botulism antitoxin after electromyography and nerve conduction studies were consistent with a diagnosis of botulism. She was weaned from the ventilator within 2 weeks and the Health Protection Agency later confirmed the presence of botulism neurotoxin A from wound swabs.

What are the clinical features of Botulism and how is it managed?Read More »

ICU Admission with Haematological Malignancy

Outcomes of ICU Admission with Haematological Malignancy

ICM Case Summaries5 Comments

An middle aged woman presented with a blast crisis following acute transformation of preexisting chronic myelomonocytic leukaemia. She failed to respond to several cycles of chemotherapy and underwent allogeneic bone marrow transplant. She subsequently developed neutropaenic septic shock and was found to have fungal pulmonary abscesses. Her sepsis was aggressively managed on ICU and she made steady progress and eventually recovered, and was discharged from hospital 5 weeks after her ICU admission.

What is the current evidence related to the mortality and morbidity associated with admission to intensive care for patients with haematological malignancy?Read More »

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 »

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 »

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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Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis

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A young woman presented with a 2 week history of fever, sweats and had developed a maculopapular rash. She had been commenced on oral antibiotics a week earlier for a presumed lower respiratory tract infection. After her admission, her rash developed into generalised bullous lesions and she became hypotensive and oliguric. A dermatologist diagnosed toxic epidermal necrolysis.

How should Toxic Epidermal Necrolysis be managed?
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