An elderly man was admitted with an acute abdomen and free air visible under the diaphragm on CXR. He was fluid resuscitated before undergoing emergency laparotomy, where a perforated duodenal ulcer was oversewn. He was admitted to ICU postoperatively, extubated the next morning and deemed fit for discharge to the surgical ward later that day. Due to a lack of surgical beds, he was eventually discharged from ICU at 22:30. Eight hours post discharge, he was urgently re-referred to ICU after being found moribund on the ward. Before he could be seen and assessed he suffered an unrecoverable asystolic arrest. Review of his observation charts showed that there had been a clear deterioration in recorded observations, including hypotension for the two preceeding hours. However, the Early Warning Score had been calculated incorrectly, and no escalation had occurred.
What evidence is there that rapid response systems are effective in preventing patient deterioration and improving outcomes?
A patient underwent a laparotomy due to bowel perforation with peritonitis and septic shock and required ventilation for several days. He was sedated with midazolam and fentanyl. After extubation he became agitated overnight, pulled out his invasive monitoring lines and was attempting to climb out of bed.
How should his acute confusional state be managed?Read More »
A cardiovascularly fit 65 year old man was admitted with septic shock secondary to community acquired pneumonia, which progressed to multi-organ failure. During his recovery it was noted that he had generalised weakness with no focal neurology. He underwent respiratory weaning, and rehabilitation therapy over the next 4 weeks but had persistent weakness at his ICU discharge.
How can ICU-acquired weakness be diagnosed and managed?Read More »
A 67 year old with signficant cardiovascular comorbidities presented with a fractured neck of femur after a fall. She had a hemiarthroplasty performed under GA with fascia iliaca blocks, and went to HDU postoperatively. She became acutely confused during the first postoperative night with hallucinations and paranoia. She was CAM-ICU positive and was given haloperidol to control her agitation.
What is the optimum management of delirium on the ICU?Read More »
A large 60 year old man developed septic shock and multiorgan failure secondary to a severe community acquired pneumonia. On the twelfth night of his ICU admission he became increasingly agitated and pulled out his vascath, NG tube and dislodged his tracheostomy. The resulting loss of airway led to a severe desaturation event before he was anaesthetised and reintubated, with loss of around 500ml blood from the haemofiltration circuit and vascath wound haemorrhage. He was commenced on regular haloperidol, but his CAM-ICU remained positive for 48 hours. Haloperidol was continued for 4 days, and he had a prolonged respiratory wean.
How is delirium best managed on the intensive care unit?Read More »