Prescribes drugs and therapies safely
A week after an elective colectomy, a 70yr old man developed septic shock and multiorgan failure secondary to anastomotic breakdown. He was managed according to surviving sepsis guidelines with source control, early antibiotics, fluids and noradrenaline. The patient remained hypotensive and refractory to noradrenaline therapy, and had vasopressin and low dose hydrocortisone infusion commenced.
What is the evidence for the use of corticosteroids in septic shock?Read More »
A 62 year old lady with a metallic aortic valve was admitted to the cardiac unit for urgent surgical repair of a severely regurgitant mitral valve. He was normally on warfarin for his metal valve. This was stopped and unfractionated heparin commenced on day 4 once his INR level had dropped below the therapeutic range. The patient’s platelet count was 147*10^9/L on admission. By day 4 it had dropped to 85*10^9/L. After heparin was started it dropped further to a nadir of 55*10^9/L on day 8.
Could this be due to heparin induced thrombocytopenia? What investigations are required and how should we treat it?
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A patient with polytrauma develops compartment syndrome with an ischaemic leg 24hrs into his admission. He undergoes revascularisation and fasciotomies, but develops rhabdomyolysis and acute kidney injury with a CK that peaks at over 100,000.
Is there a role for mannitol and bicarbonate in the management of his rhabdomyolysis and AKI?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 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 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 40 year old man with pre-existing mental health problems presented after an overdose of 6g of amitriptyline. He was deeply unconscious and required invasive ventilation. He was commenced on bicarbonate therapy and hyperventilated to pH 7.5. Around 12 hours after admission he developed tonic-clonic seizures, a broad complex tachycardia and subsequently suffered a cardiac arrest that was refractory to defibrillation, adrenaline and amiodarone. He was given additional 8.4% bicarbonate and further defibrillation attempts and was successfully resuscitated after 90 minutes.
What is the rationale for the use of sodium bicarbonate in the management of amitriptyline overdose?Read More »
A 19 year old man experienced a head on collision as the driver of a car. He suffered significant lower limb open fractures, pelvic fractures, lung injuries and a small subarachnoid bleed. Initial management was performed in ED and included oxygen, IV access and fluid, lower limb and spine immobilisation, and analgesia. He underwent a trauma series CT scan, which identified the various injuries given above. At no point was his level of consciousness a concern, and he maintained his own patent airway throughout. He did not show signs of haemodynamic instability or evidence of life threatening haemorrhage. Tranexamic acid (TXA) was not given.
What is the evidence for using tranexamic acid in trauma?
A 65 year old woman underwent an elective mitral valve repair (MVR) and four vessel coronary artery bypass graft (CABG) procedure. Pre-operatively she was diagnosed with chronic kidney disease (CKD) secondary to hypertensive nephropathy, and chronic airway disease secondary to smoking. Her baseline creatinine was 275. Surgery was uneventful but in the post-operatively period she developed pulmonary oedema and worsening acute kidney injury (AKI). On day 2 her creatinine reached 420 and oliguria occurred (urine output < 0.5 ml kg-1 hr-1). Non-invasive respiratory ventilation provided adequate support and maintained a normal blood PaCO2 and pH, although her base excess drifted to -7 mmol l-1.Dopamine was administered at 2–10 μg kg-1 min-1, titrated to MAP ≧ 75 mmHg; pericardial pacing continued to maintain sinus rhythm at 60 bpm; her CVP was 14 mmHg and stable. Furosemide was started and given by a continuous infusion of 10 mg hr-1 after an initial bolus of 100 mg to try and help with diuresis.
Is there any evidence to support the use of loop diuretics in acute kidney injury?
A 40yr old multiparous woman required an emergency Caesarean section, during which she had a 3.5L blood loss requiring a B-Lynch suture, a Rusch balloon and 4 units of packed red cells. She suffered a further 1.5L postpartum vaginal bleed, returned to theatre and underwent a subtotal hysterectomy during which she received a massive transfusion. Postoperatively, she had a further 1.5L bleed and had a Rusch balloon reinserted. She was given recombinant Factor VIIa and regular tranexamic acid. Haemostasis was achieved and she left hospital with her healthy baby boy 8 days later.
What is the evidence for using recombinant FVIIa and antifibrinolytics in major obstetric haemorrhage?Read More »
ICM Case Summaries 