Medical Management of Abdominal Compartment Syndrome

Medical Management of Abdominal Compartment Syndrome

An elderly man was admitted after a Hartman’s procedure with primary closure for a perforated sigmoid diverticulum with four quadrant peritonitis. Postoperatively, he remained ventilated and noradrenaline dependent. His intra-abdominal pressures gradually rose from 15 to 24mmHg. Urine output was poor, and he required peak pressures of 28cmH2O to achieve 6ml/kg tidal volumes. Vasopressor requirements gradually increased and a diagnosis of abdominal compartment syndrome was made. Medical management was attempted with fluid resuscitation, increased sedation, aspiration of nasogastric tube and neuromuscular blockade. However this did not improve the intra-abdominal pressures so the patient returned to theatre laparostomy and VAC dressing. On return from theatre, intra-abdominal pressures stabilised between 12 and 15mmHg. Noradrenaline requirements fell and urine output improved. The abdomen was closed on day 5 and he was discharged from ICU on day 10.

What non-surgical strategies can be used to reduce intra-abdominal pressure?

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Use of PEEP in ARDS

Use of PEEP in ARDS

A young woman was admitted with respiratory failure requiring invasive ventilation. She had bilateral lobar consolidation and positive urinary pneumococcal antigen. She was ventilated with protective lung strategies but required FiO2 of between 0.8-1.0. A PEEP of 18 was set. She was ventilated for over 2 weeks, and was tracheostomised but was discharged from the ICU after 3 weeks.

How is PEEP utilised in the ventilatory strategies in the management of Adult Respiratory Distress Syndrome?Read More »

Statins for Subarachnoid Haemorrhage

Statins for Subarachnoid Haemorrhage

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 »

Sodium Bicarbonate in Amitriptyline Overdose

Sodium Bicarbonate in Amitriptyline Overdose

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 »

Botulism

Botulism

A young female IV drug abuser presented with dysarthria, diplopia and weakness with loss of her gag reflex. She had recently had an abscess wound on her arm debrided. She was intubated for airway protection, and underwent early tracheostomy. She was treated with intravenous antibiotics and botulism antitoxin after electromyography and nerve conduction studies were consistent with a diagnosis of botulism. She was weaned from the ventilator within 2 weeks and the Health Protection Agency later confirmed the presence of botulism neurotoxin A from wound swabs.

What are the clinical features of Botulism and how is it managed?Read More »

Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

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 »

Glycaemic Control on the ICU

Glycaemic Control on the ICU

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 »