Necrotising Fasciitis - Advances in diagnosis and management

Necrotising Fasciitis – Advances in diagnosis and management

A 40 year old man underwent a minor elective day case lower limb soft tissue operation. 72 hrs later he began to feel unwell and developed fevers and rigors. He was seen first thing in the morning with increasing pain and inflammation extending up from the foot to the knee. Intravenous antibiotics were started on admission. He was in theatre having a debridement by late morning, by which time the inflammation had spread to the inner thigh. He was in profound septic shock with disseminated intravascular coagulopathy. During the debridement, it was noted that the inflammation had spread to his pelvis. He had a laparotomy and it was determined that the resection he would require was unsurvivable. Treatment was withdrawn and he died on the operating table.

How is necrotising fasciitis diagnosed and how is it managed?

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Therapeutic Hypothermia after Cardiac Arrest (Peri-TTM)

Therapeutic Hypothermia Post-Cardiac Arrest (Peri-TTM)

An elderly man was resuscitated from out-of-hospital VF cardiac arrest. He remained deeply comatose post ROSC and was ventilated on the intensive care. His temperature control was not actively managed unless hyperthermia developed. 24 hours post admission he started to have myoclonic jerks and his pupils were fixed and dilated. CT brain showed evidence of severe hypoxic ischaemic injury. Treatment was withdrawn at 72 hours after discussion with family.

What is the rationale for the use of therapeutic hypothermia after cardiac arrest?Read More »

Management of Delirium

Management of Delirium

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 »

Management of the Open Abdomen

Management of the Open Abdomen after Severe Abdominal Sepsis

A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.

How is an open abdomen managed after severe abdominal sepsis?Read More »

Understanding acute kidney injury

Understanding Acute Kidney Injury

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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Organ Donation

Improving Rates of Organ Donation

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 »

Mechanical Ventilation in patients with COPD

Predicting Outcomes of Mechanical Ventilation in patients with COPD

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 »

Hepatic Encephalopathy in Acute Liver Failure

Management of Hepatic Encephalopathy in Acute Liver Failure

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 »

vasopressin for adults in septic shock

Vasopressin for Adults with Septic Shock

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 »