Predicting Outcomes of Mechanical Ventilation in patients with COPD

August 25, 2015September 5, 2015 ICM Case SummariesLeave a comment

An elderly man with an infective exacerbation of COPD deteriorated during his medical admission with type 2 respiratory failure. He was commenced on ward-based non-invasive ventilation while establishing further history. He was on home nebulisers, was awaiting assessment for home oxygen, and was limited to household mobility only. He could not climb stairs. He had secondary polycythaemia. After discussion with the patient and family, a ward-based ceiling of care was set. He remained on NIV for several days before being weaned off and discharged to a rehabilitation facility after a two week admission.

Can we predict outcomes for patients with respiratory failure and COPD who require invasive ventilation?Read More »

On-Demand Re-Laparotomy for Severe Secondary Peritonitis

August 25, 2015September 5, 2015 ICM Case SummariesLeave a comment

An elderly man underwent an elective open left hemicolectomy for a splenic flexure tumour. On day 4 he was admitted to the intensive care due to fevers, fast AF and hypotension. He developed respiratory failure and required intubation. CT abdomen revealed free fluid in the abdomen, and emergency laparotomy found anastomotic breakdown and faecal peritonitis. He was washed out, and had further bowel resection and his abdomen was closed. He developed anuria requiring renal replacement therapy and continued to have persistently raised inflammatory markers. On day 9 he had a further deterioration and repeat CT revealed several large collections. He underwent relook laparotomy and washout, but continued to deteriorate and died 48 hours later.

Do patients with severe secondary peritonitis benefit from on-demand relaparotomy or planned relaparotomy?Read More »

ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

August 25, 2015September 5, 2015 ICM Case SummariesLeave a comment

A middle aged man had a sudden collapse with no precipitating features. His GCS on presentation was 3, with unequal but reactive pupils and CT brain showed a large subarachnoid bleed with midline shift. Neurosurgical opinion was to observe for clinical improvement, after which an intervention might be indicated. He was sedated on ICU and his MAP maintained above 80mmHg with noradrenaline. Nimodipine was commenced and mannitol was administered. After 24 hours he had a sedation hold and he began to localise and open eyes spontaneously. He was transferred to the neurosurgical unit.

Should all patients with non-traumatic intracranial haemorrhage have intracranial pressure (ICP) monitoring established?Read More »

Management of Hepatic Encephalopathy in Acute Liver Failure

August 25, 2015September 5, 2015 ICM Case SummariesLeave a comment

A 30 year old woman with a background of substance abuse and deliberate self harm was found collapsed and semi-conscious following an overdose of co-codamol and was presenting late. It was possible that she had taken around 100g paracetamol. Her GCS was 11, and she had grade II/III hepatic encephalopathy. Her bilirubin was 60 and she had significant transaminitis with a lactic acidosis. . She was commenced on N-acetylcysteine despite undetectable paracetamol levels. Liver US was normal. Early repeat bloods showed worsening jaundice, transaminitis and rising INR. She was transferred to the regional liver unit initially for monitoring, but was subsequently admitted to the liver HDU. She did not require a liver transplant and recovered with conservative management.

What is the optimum management of hepatic encephalopathy in acute liver failure?Read More »

Prone Ventilation in ARDS

August 24, 2015September 5, 2015 ICM Case SummariesLeave a comment

An 63 year old woman with a history of bronchiectasis required intubation for a community acquired pneumonia. Several days into her ICU admission she developed a rapid worsening in her oxygenation and new bilateral pulmonary infiltrates. She also required increasing vasopressor support and began to develop multiorgan failure. She was paralysed and ventilated with inverse ratios but remained profoundly hypoxic. She was proned with no effect on oxygenation. She was commenced on inhaled nitric oxide with no effect. She continued to rapidly deteriorate and died shortly after.

Does prone ventilation in ARDS improve mortality?

Vasopressin for Adults with Septic Shock

August 24, 2015September 5, 2015 ICM Case SummariesLeave a comment

A 70 year old man with known prostatic malignancy and stage III chronic kidney disease developed fevers, left flank pain, urinary frequency and confusion. He deteriorated rapidly in ED becoming hypotensive and drowsy. He had a lactic acidosis. CT abdomen was showed left hydronephrosis and hydroureter and was suggestive of an infected obstructed kidney. During the scan he became peri-arrest and was intubated. There was a logistical delay in achieving nephrostomy, and he was requiring escalating levels of noradrenaline. Vasopressin was commenced in order to maintain his mean arterial pressure and reduce the noradrenaline requirement from 0.8mcg/kg/min. Nephrostomy was achieved around 12 hours later and he subsequently made a full recovery.

What is the role of Vasopressin for Adults in Septic ShockRead More »