Category: Domain 3

Disease Management

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 »

Understanding acute kidney injury

Understanding Acute Kidney Injury

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A young man was presented to ED with confusion and a profound metabolica acidosis after ingesting around 400ml of ethylene glycol-based anti-freeze. His GCS deteriorated and he required intubation. He was commenced on iv ethanol and commenced on haemodiafiltration. He initially had a polyuric acute kidney injury, but became anuric after 24 hours. His acidosis normalised within 36 hours, and his creatinine peaked at 549. His urine output improved after a week of oligoanuria and his creatinine reached a baseline of around 150.

What are the diagnostic criteria for acute kidney injury?

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Nitric Oxide for Refractory Hypoxaemia in ARDS

Nitric Oxide for Refractory Hypoxaemia in ARDS

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A 65 year old woman developed a hospital acquired pneumonia 24 hours after a multilevel spinal fixation. She became progressively more hypoxic and required intubation. She remained profoundly hypoxic despite FiO2 1.0, paralysis, lung protective ventilation and inverse ratios. She was established on inhaled nitric oxide therapy as anticoagulation for ECMO was felt to be contraindicated. This resulted in an rapid but modest increase in SpO2. Over the next days, her recovery was complicated by pneumothoraces requiring chest drains, but she remained on iNO for several days, and weaned off the ventilator at around day 10.

Does nitric oxide have a role to play in hypoxemia secondary to ARDS?Read More »

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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Septic Cardiomyopathy

Septic Cardiomyopathy

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A middle aged man developed septic shock secondary to community acquired pneumonia. He was ventilated and commenced on noradrenaline therapy. He had an echo on admission that showed a structurally normal heart with normal biventricular function. He remained statically unwell for several days and had a further deterioration on day 4 with further bilateral consolidation seen on CXR. Repeat echocardiography showed a well filled, but globally impaired heart with an ejection fraction of 10-20%. He was commenced on additional inotropic support, but continued to deteriorate, developed multiorgan failure and died.

Is septic cardiomyopathy reversible? What is the current best treatment?Read More »