Selfassessment case histories

1. A 52-year-old man underwent an elective colonoscopy for investigation of constipation. Two hours later he developed severe abdominal pain and vomiting. The duty doctor diagnosed colonic perforation, which was confirmed by x ray film. The surgical team was informed and part of his large bowel was resected at laparotomy. Later, the patient's observations are as follows: temperature 38°C, pulse 110 per minute, RR 30 per minute, BP 90/50 mmHg and poor urine output. He is mildly confused. Investigations show: Hb 10-5 g dl-1, WBC 20 x 109 litre-1, platelets 70 x 109 litre-1, Na 135 mmol litre-1, K 4-7 mmol litre-1, urea 15 mmol litre-1 (BUN 41-6 mg dl-1), and creatinine 150 ^mol litre-1 (1-8 mg dl-1). Arterial blood gases on 5 litres per minute via a simple face mask showed: pH 7-26, PO2 8-2 kPa (63 mmHg), PCO2 5-3 kPa (40-7 mmHg), bicarbonate 17-5 mmol/l, BE - 8. A CVP line has been inserted after 1500 ml colloid. The initial reading is 12 mmHg. What is your further management?

2. A 50-year-old lady was seen in the Emergency Department and treated for a urinary tract infection on the basis of symptoms and a positive urine dipstick. The next day she returned having collapsed. On arrival her observations were as follows: alert, pulse 120 per minute, temperature 38°C, BP 80/50 mmHg, RR 20 per minute, SaO2 95% on air, urine output normal. What is your management and what other immediate tests do you perform?

3. A 19-year-old intravenous drug user was admitted with a severe hand infection secondary to injecting with dirty needles. His hand and arm were becoming increasingly swollen. He is alert but his other observations are: BP 70/40 mmHg, pyrexial, RR 20 per minute, SaO2 95% on air, pulse 130 per minute. He has no peripheral venous access possible. Describe your management.

4. A 45-year-old lady with severe rheumatoid arthritis is admitted with a painful right hip. She is on monthly infusions of immunosuppressant therapy for her rheumatoid disease as well as daily steroids. Her admission blood tests show a raised C-reactive protein and neutrophil count. Her vital signs on admission are: BP 130/60 mmHg, temperature 36-7°C, RR 16 per minute, SaO2 98% on air, and pulse 80 per minute. She is alert. However, 24 hours later she develops hypotension (BP 75/40 mmHg) and a tachycardia (110 per minute). A blood culture report is phoned through as "Staphylococcus aureus in both bottles". She is alert, apyrexial, with a respiratory rate of

24 per minute and SaO2 of 87% on air. What is your management?

5. A 50-year-old man is admitted with pneumonia. He is seen by a junior doctor and prescribed intravenous antibiotics and fluids. When you review him, his vital signs are as follows: BP 90/50 mmHg, pulse 100 per minute, RR 30 per minute, SaO2 85% on 5 litres per minute via a simple face mask, temperature 39°C, and he is alert. What do you do next?

6. A 40-year-old man is admitted with abdominal pain, which is diagnosed as acute pancreatitis (amylase of 2000 units litre-1). He is given a high concentration of oxygen, intravenous fluids, and analgesia. Six hours later he develops a poor urine output. His vital signs are: BP 95/60 mmHg, pulse 120 per minute, RR

25 per minute, SaO2 90% on 10 litres per minute via a reservoir bag mask, temperature 38°C, and he is alert. Blood lactate is 2-8 mmol litre-1 (normal 0-7-1-2 mmol litre-1). What is your management?

7. A 60-year-old lady develops a poor urine output following an emergency endoscopic retrograde cholesytopancreatogram (ERCP) for common bile duct stones and ascending cholangitis. Her vital signs are: BP 100/75 mmHg, pulse 80 per minute, RR 20 per minute, SaO2 97% on air, temperature 37-5°C, and she is alert. What is your management?

8. A 30-year-old man is admitted with a severe gastrointestinal bleed and receives 14 units of packed red blood cells plus other colloids during 4 hours of stabilisation followed by upper gastrointestinal endoscopy. He is then transferred to theatre for surgical repair of a large bleeding duodenal ulcer. Twenty four hours after surgery he is still ventilated and has increasing oxygen requirements. A chest x ray film shows bilateral patchy infiltrates. His vital signs are: BP 110/70 mmHg, pulse 110 per minute, RR 14 per minute (ventilated), SaO2 95% on 60% oxygen, temperature 37°C. What is the diagnosis and what is your management?

9. A 29-year-old lady arrives in the resuscitation room drowsy with the following vital signs: BP 80/50 mmHg, pulse 130 per minute, RR 28 per minute, SaO2 95% on 10 litres per minute via a reservoir bag mask, temperature 38-5°C. Her arterial blood gases show: pH 7-3, PaO2 35-5 kPa (273 mmHg), PaCO2 3-5 (26-9 mmHg), bicarbonate 12-7 mmol/l, BE - 10. She has a petechial rash on her trunk. She responds to voice. Her bedside glucose measurement is 6-2 mmol litre-1 (103 mg dl-1) and there is no neck stiffness. What is your management?

Self-assessment - discussion

1. Bacterial peritonitis has caused severe sepsis. Mortality associated with perforation varies according to site - <5% for small bowel and appendix, 10% for the gastroduodenal tract, 20-30% for the colon, and 50% for postoperative anastomotic leaks. This man has signs of organ dysfunction, hypoperfusion (low BP, urine output, and metabolic acidosis), and possibly DIC. The PaCO2 is normal, though a compensatory respiratory alkalosis is expected. This is because he is unable to maintain a high minute volume indefinitely and is tiring. The immediate management includes ensuring a patent airway and administering a high concentration of oxygen. Assessment of breathing includes looking for signs of ARDS (note his PaO2 of 8-2 - a chest x ray film is indicated). For circulation, intravenous access followed by repeated fluid challenges is required. Intravenous analgesia should not be forgotten. Since the cause of the sepsis is known, appropriate antibiotics can be given. The initial CVP reading is 12 mmHg, but fluid should still be given because it is the response to a fluid challenge, not a single reading, that allows interpretation of the CVP and volume status. If the patient is adequately filled but still hypotensive and oliguric, a vasopressor should be administered to increase renal perfusion pressure. Early referral to the ICU team is imperative.

2. Immediate management in this case includes assessment of the airway and giving a high concentration of oxygen (for example, 15 litres per minute via a reservoir bag mask), examining the chest, and an assessment of the circulation (pulse, blood pressure, skin temperature, etc.). She is alert. Immediate tests in acutely ill patients always consist of arterial blood gases and a bedside glucose measurement. As intravenous access is required, blood cultures, haematology, and biochemistry can be taken at the same time. The likeliest source of sepsis in this case is the urine and this should be cultured. Successive fluid challenges are required to restore organ perfusion and the attending doctor should stay with the patient until satisfied that this is the case but, if this fails, the patient should be referred to the ICU for treatment with vasoactive drugs.

3. Again this patient needs assessment and treatment of A, B, C -high concentration oxygen and several fluid challenges in this case. A CVP line is indicated immediately because of his lack of peripheral venous access. The swelling could be cellulitis, but search also for soft tissue crepitus. The presence of a rapidly progressing site of infection with severe systemic symptoms and signs is suggestive of necrotising fasciitis, which requires urgent surgical debridement as well as intravenous antibiotics. Check the creatinine kinase levels as the patient may also be developing compartment syndrome with rhabdomyolysis.

4. Check A, B, and C. The airway is secure. Examination of breathing reveals a respiratory rate of 24 per minute and low oxygen saturations (87% on air). Oxygen therapy is required, for example 15 litres per minute via a reservoir bag mask. In the circulation, fluid challenges are required in order to treat hypoperfusion. However, capillary leak and other changes in the lung mean that pulmonary oedema can develop with normal left ventricular function. If fluid loading does not improve blood pressure and perfusion, invasive monitoring and vasopressors are required. In this case the source of sepsis is known (staphylococcal septic arthritis) and high dose intravenous antibiotics should be given. Advice should be taken on surgical drainage of the affected hip. If she is on a significant dose of long-term steroids, these will need to be increased. The low oxygen saturations and high respiratory rate could indicate the development of ARDS. Taken together, these signs indicate severe sepsis and consideration should be given to the aggressive prevention of full blown multiple organ dysfunction syndrome. This patient requires early admission to ICU. Mortality increases with increasing organ failure (Table 7.3).

5. Assess the airway by asking the patient a question. If he is alert and talking, the airway is secure. Administer a higher concentration of oxygen (for example, 15 litres per minute via a

Table 7.3 Mortality and number of failing organ systems

Number of failing organs

ICU patients (%)

Mortality (%)

0

35

3

1

25

10-5

2

17

25-5

3

12

51-5

4

6-5

61

5

3-0

67

6

1-5

91

reservoir bag mask). Next, assess breathing. His respiratory rate is raised and examination of the chest will be consistent with pneumonia. Then assess circulation. Is there hypovolaemia or hypoperfusion? Fever and increased respiratory rate caused by pneumonia cause dehydration. Arterial blood gas analysis may indicate hypoperfusion. His hypotension may respond simply to a fluid challenge. If severe sepsis is present, the hypotension may not respond to fluid challenges alone. In that case, invasive monitoring is required to be sure the patient is adequately filled, followed by the use of vasoactive drugs. The patient should be referred to the ICU.

6. The management in this case is the same - A, B, C. In this patient, attention to detail may prevent the multiple systemic complications of severe acute pancreatitis, especially respiratory failure, renal failure, and infection. The classic presentation in severe cases is SIRS (systemic inflammatory response syndrome) and MODS (multiple organ dysfunction syndrome). Mortality is as high as 20-30%. This patient requires oxygen and fluid challenges immediately. Make your goals known to the nursing staff. Aim for:

• reduction in lactate or base deficit.

Look for developing ARDS and the need for early ventilation. This patient requires ICU care. If the hypoperfusion does not respond to fluid challenges, invasive monitoring and vasoactive drugs are required in order to:

• restore an effective circulating volume

• restore adequate perfusion

• maintain an adequate cardiac output and oxygen delivery.

7. Again, this lady requires assessment of airway, high concentration oxygen therapy, assessment of breathing and circulation followed by fluid challenges. Note that a blood pressure of 100/75 mmHg is causing hypoperfusion here - in some patients this is a normal blood pressure. Antibiotics are required. She needs referral to the ICU if fluid challenges fail to correct the hypoperfusion. How many fluid challenges would one give in this situation? At first, clinical endpoints of blood pressure, pulse, peripheral skin temperature, and respiratory rate may be used to assess volume status. However, after several fluid challenges, there is potential for fluid overload without improvement in perfusion, especially in the context of capillary leak. Invasive monitoring is then helpful in assessing volume status and in the administration of vasoactive drugs.

8. This patient has received a massive blood transfusion, which can cause ARDS. Arterial blood gases would show a large A-a gradient from intrapulmonary shunting. The ventilator may calculate lung compliance which would be low and typical of developing acute lung injury. The management in this case is to continue invasive ventilation on the ICU. The various ventilation strategies employed are discussed in the chapter.

9. This patient has severe sepsis according to the definition at the beginning of the chapter. The arterial blood gases show a metabolic acidosis indicating hypoperfusion. Ensure a patent and protected airway, give a high concentration of oxygen (for example, 15 litres per minute via a reservoir bag mask), assess and treat any breathing problems, assess and treat any circulation problems, and assess conscious level. A full examination and appropriate investigations (including blood and other cultures) should follow. In this case, fluid challenges are required. The petechial rash is a clue to the possible cause of sepsis and intravenous antibiotics should be given to cover meningococcal and staphylococcal infections.

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