Management of Variceal Bleeding

A 50 year-old man with a history of alcoholism attended to the emergency department having been found at home comatose.

He had a reduced Glasgow coma score on admission and was vomiting blood. He was not protecting his airway and was tachypnoeic, tachycardic and had a reduced systolic blood pressure. His oxygen saturations were low and there were coarse crackles on his chest. Old notes showed that on previous endoscopy oesophageal and gastric varices were found. He was cachectic with hepatosplenomegaly but no signs of ascites.. He was rumoured to be abstinent from alcohol and had been previously well up to one day ago when he was last seen. There was some report that he had been behaving oddly over the last 5 days though.

 

Supplemental oxygen was provided and the decision to intubate was made. An initial attempt to insert a Sengstaken-blakemore tube was abandoned until the patient was intubated using a rapid sequence intubation technique. The gastric balloon was inflated and put under tension. Blood tests showed a reduced haemoglobin level but no clotting abnormality. Transfusion of packed red cells was made.

Medical therapy included beginning a course of prophylactic antibiotics. Terlipressin was started at 2mg intravenously four times daily. He was also started on high dose proton pump inhibitors, lactulose and thiamine supplements.

The gastric balloon was left inflated for 10 hours and as there was no haemodynamic sign of further bleeding was then deflated. Oesophagogastrocopy the next morning on the intensive care unit showed only grade 1 varices with no recent stigmata of bleeding and some mild gastric erosions.

He continued to be haemodynamically stable and sedation was weaned. He did not wake up as expected on sedation hold and his ammonia level was found to be raised. Over the course of the next 2 days he improved and was extubated successfully and discharged to the ward.

Describe the management of variceal bleeding.

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Faecal Peritonitis: The Role of Laparostomy

A 68-year-old previously fit woman was admitted with left lower abdominal pain and signs of cardiovascular shock. She had had a 2 day history of crampy left lower abdominal pain and altered bowel habit. Clinically she had a diagnosis of bowel perforation with generalised peritonitis. She was exhibiting signs of shock with a pronounced tachycardia and a reduced systolic blood pressure.

She was started on fluid resuscitation and intravenous antibiotics. After her cardiovascular system stabilised she was taken to the operating theatre where she had a laparotomy. A sigmoid perforation was found with four quadrant faecal contamination. A Hartmann’s procedure was performed. A laparostomy was decided upon at the first instance, and was covered with a VAC dressing.

She was transferred to the intensive care unit (ICU) still intubated and ventilated.

Her condition rapidly worsened on the ICU. She required vasopressor support intra-operatively and her requirements rapidly escalated. She seemed to stabilse over the next 36 hours. Her condition then worsened and she was taken back to theatre for a washout of her peritoneal cavity. A number of collections were found and further soiling of her abdomen was evident. Her condition remained the same for the next 12 hours but then started to show an improvement again. She continued to make a good response to treatment over the next 3-4 days. She had another washout at 4 days. She was extubated on day 5 and invasive monitoring and cardiovascular support was no longer needed.

 

What is the role of laparotomy in the management of faecal peritonitis?Read More »

Diagnosing Ventilator Associated Pneumonia

A 64 year old lady who had been admitted with acute pancreatitis due to gallstones. She was initially admitted to the intensive care unit for cardiovascular management and management of her electrolyte imbalance. After a few days she was intubated for hypoxia.

She developed pancreatic necrosis and pseudocyst formation. These were drained by percutaneous drains whereby she showed some improvement with more stability in her cardiovascular system. She had two failed extubations and then had a tracheostomy placed. She was weaned from the ventilator but then remained on 40-45% of oxygen for a number of weeks. Serial scans showed a static nature to her pseudocysts. Her inflammatory markers remained static at a moderate level over this time. It was felt that she had a ventilator associated pneumonia and was started on antibtiotics. She then showed improvement a number of days later. She was further weaned from the ventilator and decannulated. She needed recannulation later and suffered another episode of ventilator associated pneumonia which was treated. Eventually a number of months later she was discharged to the ward and then home.

How can we diagnose ventilator associated pneumonia?

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Mechanical Ventilation of Chronic Obstructive Airways Disease

A 68-year-old went into respiratory arrest on the chest ward. He had been admitted 2 weeks previously for an exacerbation of chronic obstructive airways disease (COAD). He has had two previous episodes of reduced conscious level due to hypercapnoea, which resolved with non-invasive ventilation and oxygen titration.

He was immediately intubated on the ward and transferred to the intensive care unit for ventilation. Hypoxia was corrected to a PaO2 >8.0kPa with a moderate FiO2. However he remained very difficult to ventilate and maintained a persistently high PaCO2. The highest level was 21kPa. He was treated with B2 agonist nebulisers, anti-muscarinic nebulisers, systemic steroids, aminophylline infusions, magnesium infusions and a ketamine infusion. He also needed vasopressor support and for a period of time continuous renal replacement therapy. After a week when his ventilator pressures reduced he had an uneventful percutaneous tracheostomy. Sedation was then reduced and he was awake and spontaneously breathing but with a high level of support. He was recurrently troubled by episodes of bronchospasm and air trapping. The lowest settings for inspiratory pressure were 14 cmH2O. He deteriorated a number of times before care was withdrawn and he died 20 days later.

Can we predict which COAD patients will benefit from mechanical ventilation?

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Albumin Use in Critical Illness

A 70-year-old woman was admitted to the surgical ward with abdominal pain. CT scans showed some dilated loops of small bowel. She remained on the surgical ward for 5 days with minimal resolution of her symptoms. She was taken to theatre for exploratory laparotomy where she was diagnosed with faecal peritonitis from a perforated diverticulum. She had a washout and a Hartmanns procedure was performed.
She became unstable during her laparotomy requiring vasopressors and was taken to the intensive care unit postoperatively.  She was left with a laparostomy with a VAC dressing applied. She was treated with lung protective ventilation and remained cardiovascularly unstable. Two days later she was taken back to theatre for a further washout and closure of her abdomen. She developed an ileus and was then started on total parenteral nutrition. An oesophageal doppler monitor was placed to help guide her fluid status. She was extubated on day 4 post op but her filling status remained a problem to gauge. Her fluid balance became very positive and she became very oedematous. Her albumin level dropped significantly. It was then decided to give her daily intravenous albumin.
What evidence is there for the use of albumin in critically ill patients?

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Predicting Weaning from Mechanical Ventilation

A 60 year old man was electively admitted to the intensive care unit following a combined kidney pancreas transplant. Diabetes mellitus was the cause for his end stage renal failure. He was admitted for overnight HDU care, and was discharged the following day. He had delayed graft function thought to be related to a prolonged cold ischaemic time of the kidney. He would need dialysis until the function of the transplanted kidney improved. Four days later whilst on the ward he became hypotensive, became unconscious and suffered a cardiac arrest. He was successfully resuscitated and was readmitted to ICU.

In the ICU he required a blood transfusion as his haemoglobin level had dropped. He was taken to theatre for a re-laparotomy and a graft pancreatectomy was performed and all bleeding was stopped.

He continued to suffer from delayed kidney graft function and needed intermittent dialysis. After two days he was on minimal respiratory support and on sedation hold was deemed ready for extubation. He was extubated successfully and remained so for the next 12 hours. He then had an episode of bradycardia and had a markedly reduced cardiac output. He was re-intubated and stabilised. A temporary pacing wire was inserted to control potential episodes of bradycardia.

His condition remained stable over the next day and was again extubated. His oxygenation needs increased over the next 12 hours and was placed on non- invasive ventilation. This stabilised him over the next 12 hours but he suffered from retained secretions and was re-intubated. He then suffered with an ileus and had abdominal distension which complicated his respiratory function. He had a tracheostomy placed and remained on mechanical ventilation for 2 weeks. He was difficult to wean as he suffered set backs related to acute sputum retention and a ventilator associated pneumonia.

This patient had been extubated twice with some degree of morbidity associated with it as he had to be reintubated. It would also be reasonable to assume that this increased his length of stay on the ICU slowed down his ICU discharge. Deciding when to extubate a patient seems to be still a difficult decision to make in some cases and the experience of senior clinicians remains an important role.

For those who have not accumulated this level of clinical experience are there tools available to help them in deciding when and who could be weaned and extubated from mechanical ventilation?Read More »

Arthrogryposis & Paediatric Difficult Airway

EMERGENCY MANAGMENT OF A DIFFICULT AIRWAY IN AN INFANT WITH ARTHROGRYPOSIS MULTIPLEX CONGENITA

A 4 month old infant with arthropgryposis multiplex congenital was admitted to the paediatric assessment unit. The infant had been acutely unwell over the preceding 12 hours with respiratory compromise and a productive cough with green sputum. He had signs of respiratory distress with a RR of 40, pulse oximetry showed SpO2 of 85% on air and only 90% with a facemask, reservoir bag and high flow oxygen. It was felt that the infant would need to be intubated and ventilated. Two months before the infant had had a respiratory arrest on the neonatal ward and was unable to be intubated. That situation was resolved by mask ventilation and rescue with an LMA. There were obvious concerns that direct laryngoscopy would be unsuccessful and may precipitate a terminal decline in the patient’s condition.

The infant’s breathing was supported by bag/mask ventilation whilst he was transferred to an ENT theatre. Further anaesthetic support and an ENT surgeon were sought. I.v. access was established through a scalp vein. Ventilation was switched to an Ayres T piece with Jackson-Rees modification. Induction of anaesthesia was initiated with sevoflurane and oxygen. Direct laryngoscopy showed a Lehane and Cormack grade 4 view.

A rigid bronchoscope with video camera monitor was used by the ENT surgeon to obtain a view of the glottis. An epidural catheter was placed down the side port of the bronchoscope and was directed through the vocal cords. The bronchoscope was removed and a fine bore suction catheter was railroaded over the epidural catheter to give more stiffness. The positions of the end of the catheters were checked with the bronchoscope. A size 3.0cm uncuffed endotracheal tube was then railroaded over the catheters into trachea. Position and length were confirmed with the bronchoscope and ventilation was continued. The arrangement is shown in Figure 1.

The child was then transferred to the adult ICU where a retrieval team arrived to transfer the patient to a PICU.

What is arthrogryposis? Describe some methods for achieving control of the difficult paediatric airway.Read More »