Glycaemic Control on the ICU

August 27, 2015September 5, 2015 ICM Case SummariesLeave a comment

A 76 year old man with no comorbidities was admitted to the intensive care unit following an oesophagectomy. During routine blood sugar monitoring, his blood glucose was found to be just over 10 for two consecutive readings so he was commenced on a variable rate insulin infusion. Six hours later, despite hourly monitoring, he had a blood sugar of 3.6. The insulin infusion was stopped and his blood sugar rose back to normal levels. He suffered no apparent ill effects from his hypoglycaemic episode.

What is the rationale behind current glycaemic control on the intensive care unit?Read More »

Necrotising Fasciitis – Advances in diagnosis and management

August 26, 2015September 5, 2015 ICM Case SummariesLeave a comment

A 40 year old man underwent a minor elective day case lower limb soft tissue operation. 72 hrs later he began to feel unwell and developed fevers and rigors. He was seen first thing in the morning with increasing pain and inflammation extending up from the foot to the knee. Intravenous antibiotics were started on admission. He was in theatre having a debridement by late morning, by which time the inflammation had spread to the inner thigh. He was in profound septic shock with disseminated intravascular coagulopathy. During the debridement, it was noted that the inflammation had spread to his pelvis. He had a laparotomy and it was determined that the resection he would require was unsurvivable. Treatment was withdrawn and he died on the operating table.

How is necrotising fasciitis diagnosed and how is it managed?

Vasopressin in Septic Shock

August 26, 2015October 5, 2015 ICM Case SummariesLeave a comment

An elderly man presented with an acute abdomen. At operation, he was found to have four-quadrant peritonitis due to a perforating sigmoid tumour. He underwent a hemicolectomy and had a defunctioning stoma formed. Postoperatively, he required 0.7mcg/kg/min noradrenaline to maintain a MAP 65mmHg. A vasopressin infusion was commenced and his noradrenaline requirements decreased. However, he developed acute kidney injury and subsequent multiorgan failure. Treatment was withdrawn around 48 hours post-operatively.

Is vasopressin safe to use in septic shock? What are the benefits?Read More »

IV Immunoglobulin for Necrotising Fasciitis

August 26, 2015September 5, 2015 ICM Case SummariesLeave a comment

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 »

Intralipid in Antihypertensive Overdose

August 26, 2015September 4, 2015 ICM Case Summaries1 Comment

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?

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 »