Category: 3.3

Recognises and manages the patient with circulatory failure

Vasopressin in Septic Shock

Vasopressin in Septic Shock

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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 Treatment was withdrawn around 48 hours post-operatively.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 »

Intralipid in Antihypertensive Overdose

Intralipid in Antihypertensive Overdose

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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?

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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 »

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 »

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 »

vasopressin for adults in septic shock

Vasopressin for Adults with Septic Shock

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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 »