Category: 2013

The Role of ECMO in ARDS

The Role of ECMO in ARDS

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A middle aged man with acute pancreatitis developed multiorgan failure and was admitted to the ICU and required ventilation and noradrenaline. He became progressively more hypoxic despite lung protective ventilation, paralysis, inverse ratios and a restrictive fluid regime. He developed bilateral pneumothoraces requiring chest drains. He was retrieved to the nearest refractory hypoxia centre and established on VV ECMO. On the third day of ECMO therapy he developed lateralising signs and was found to have had a large intracranial haemorrhage. Treatment was subsequently withdrawn.

Do patients with ARDS benefit from ECMO?Read More »

Understanding acute kidney injury

Understanding Acute Kidney Injury

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A young man was presented to ED with confusion and a profound metabolica acidosis after ingesting around 400ml of ethylene glycol-based anti-freeze. His GCS deteriorated and he required intubation. He was commenced on iv ethanol and commenced on haemodiafiltration. He initially had a polyuric acute kidney injury, but became anuric after 24 hours. His acidosis normalised within 36 hours, and his creatinine peaked at 549. His urine output improved after a week of oligoanuria and his creatinine reached a baseline of around 150.

What are the diagnostic criteria for acute kidney injury?

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Nitric Oxide for Refractory Hypoxaemia in ARDS

Nitric Oxide for Refractory Hypoxaemia in ARDS

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A 65 year old woman developed a hospital acquired pneumonia 24 hours after a multilevel spinal fixation. She became progressively more hypoxic and required intubation. She remained profoundly hypoxic despite FiO2 1.0, paralysis, lung protective ventilation and inverse ratios. She was established on inhaled nitric oxide therapy as anticoagulation for ECMO was felt to be contraindicated. This resulted in an rapid but modest increase in SpO2. Over the next days, her recovery was complicated by pneumothoraces requiring chest drains, but she remained on iNO for several days, and weaned off the ventilator at around day 10.

Does nitric oxide have a role to play in hypoxemia secondary to ARDS?Read More »

Organ Donation

Improving Rates of Organ Donation

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A 75 year old man with stage 3 chronic kidney disease and ischaemic heart disease was resuscitated from a witnessed out of hospital VF arrest. CT head on admission showed a large intracranial haemorrhage with midline shift and effacement of ventricles. Neurosurgical intervention was thought to be futile. There were some family members abroad, who wanted to be present when treatment was withdrawn so care was continued for 24 hours awaiting their arrival. On the day that treatment was planned to be withdrawn, the possibility of organ donation was raised by a team member. The specialist nurse for organ donation (SNOD) was contacted, but was delayed by several hours. The local ICU consultant made the initial approach to the family when they were all present which was promising. A subsequent conversation took place when the SNOD arrived. Consent for organ donation was eventually refused. The family felt that further delay to treatment withdrawal was inappropriate.

How can we improve rates of consent for organ donation on the ICU?Read More »

Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis

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A young woman presented with a 2 week history of fever, sweats and had developed a maculopapular rash. She had been commenced on oral antibiotics a week earlier for a presumed lower respiratory tract infection. After her admission, her rash developed into generalised bullous lesions and she became hypotensive and oliguric. A dermatologist diagnosed toxic epidermal necrolysis.

How should Toxic Epidermal Necrolysis be managed?
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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 »

Mechanical Ventilation in patients with COPD

Predicting Outcomes of Mechanical Ventilation in patients with COPD

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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

On-Demand Re-Laparotomy for Severe Secondary Peritonitis

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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

ICP Monitoring in Non-Traumatic Intracranial Haemorrhage

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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 »

Hepatic Encephalopathy in Acute Liver Failure

Management of Hepatic Encephalopathy in Acute Liver Failure

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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 »