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1、Tales from the Land of Alice,Wei-Yun Mak (ICU Registrar)9/8/2011,Ms. LF,26yo female German tourist Nil medical history Nil medications Nil known allergies Non-smoker Occasional ETOH Nil recreational drugs,Travels,Travelling with partner (of 8 years) for 3 months 2.5 months in Thailand Arrived in Mel
2、bourne 1/52 ago Flight to Adelaide and drove to Uluru,Uluru Clinic,Presented 1200 1/7 sore throat, fever, infected finger nail PR 140 BP 150/100 SpO2 99% RA T40 Chest clear, throat NAD, mild paronychia Rx flucloxacillin 2g IV Told to present to Alice Springs ED Investigation of fever in traveller,Al
3、ice Springs ED,Presented 1720 S/B ED RMO Dx URTI Rx aspirin + aspalgin D/C home,Alice Springs ED,Represented to triage after 10/60 New onset facial angioedema, SOB, throat tightness O/E stridor Rx adrenaline IM 0.3mg x3 + 0.5mg Adrenaline 5mg neb x3 Adrenaline infusion 60mcg/min for 20/60 Hydrocorti
4、sone 200mg,Alice Springs ED,Referral to ICU made, but cancelled due to recovery & also admission not preferred due to costs Observed in ED for 3/24 D/C home 0000 Retired to family room in ED, as would otherwise be sleeping in their car,Alice Springs ED,Emerged from family room 0230 Pointing to chest
5、 and neck, clasping throat, unable to speak Rx adrenaline 1mg IM Poor response and quick neurological deterioration ICU paged for assistance,Alice Springs ED,On ICU arrival to ED PR 160 BP inaccurately recording ?100-150 SpO2 70% BVM Widespread inspiratory/expiratory crepitations E4V1M3 Anaesthetics
6、 registrar/consultant + ICU consultant notified to attend,Alice Springs ED,Copious pink frothy sputum leaking from mouth Rolled onto R) lateral position to facilitate further sputum passage & suction SpO2 ?30-40% RSI propofol/fentayl/suxamethonium 1st pass ETT by anaesthetic registrar oedematous air
7、way ETT passed “where the bubbles were coming out” pink froth persisting via ETT,Alice Springs ED,R) brachial arterial line + L) femoral CVC PR 160 BP 100 on adrenaline infusion SpO2 60-70% BVM with PEEP valve Cyanotic hands, knees, feet Transfer to ICU 0400,Alice Springs ICU,Deteriorating haemodyna
8、mics & respiratory function Infusions adrenaline 20mcg/min noradreanaline 16mcg/min vasopressin 2units/hour midazolam 5mg/hour fentanyl 50mcg/hour SIMV PEEP 20 PS 10 Vt 360mL FiO2 100%,Alice Springs ICU,PR 170 MAP 65 T40.2 WCC 18.9 platelets 309 CUE/LFT/CMP normal INR 1.8 APPT 48 (initially normal)
9、CK 374 TpI 3.7 TTE only subcostal views obtainable contractile ventricles, RV normal size, nil pericardial effusion,Supportive Treatment,hydrocortisone 200, ranitidine 50, phenergan 50 meropenem, gentamicin, vancomycin oseltamivir 300 frusemide 120 actrapid infusion amiodarone infusion active coolin
10、g (IVT, ice clothing) omeprazole 40 heparin 5000,Best Friends Forever,Royal Prince Alfred Hospital ECMO retrieval referred Royal Northshore Intensivist consulted paralysis (rocuronium infusion) continuous inhaled prostacyclin PEEP reduced to 10 prone position several hundred mL oedema suctioned,RPA
11、Arrival,Cannulation of R) IJV & R) femoral vein VV ECMO commenced Cost of ECMO retrieval AUD37,000,RPA ICU,Paronychial abscesses Pseudomonas, staphylococcus ECMO for 5/7 extubated Neurologically normal Oliguric renal failure CRRT Flash APO, oedematous vocal cords reintubated,Acute Respiratory Distre
12、ss Syndrome,Definition,Requires no history of chronic lung disease Requires all 4 features: Acute onset Bilateral infiltrates (radiologically similar to pulmonary oedema) No evidence of elevated left atrial pressure PaO2/FiO2 200mmHg (vs. ALI 201-300mmHg),Diagnosis of Exclusion,Cardiogenic Pulmonary
13、 Oedema CXR pulmonary venous congestion, Kerley B lines, cardiomegaly, pleural effusions BNP 100 TTE severe AV or MV dysfunction, severe reduced LVEF Pulmonary artery catheter (but evidence suggests no value) Pneumonia, diffuse haemorrhage, miliary TB, malignancy,Common Causes,Sepsis Aspiration Pneu
14、monia Pneumococcus, Legionella, Pneumocystis, Staph aureus, enteric G-, respiratory viruses Staph aureus, pseudomonas, enteric G- Severe trauma Massive transfusion 15units and TRALI (following upper airway obstruction),Supportive Management,Sedation/analgesia Paralysis cisatracium infusion had stati
15、stically significant reduced 90-day mortality & more ventilator-free days Haemodynamic monitoring PAC compared to CVC had 2x catheter-related complications especially arrhythmias Nil benefit in mortality, lung function, organ failure,Supportive Management,Enteral feeding only if head-up to reduce in
16、cidence of VAP Glucose control Nosocomial pneumonia early identification & broad-spectrum antibiotics avoid supine, mouth care, avoid over-sedation DVT prophylaxis GI prophylaxis,Hypoxaemia Management,Fluid management CVP 0.5,Oxygen-Sparing Methods,Prone position improves oxygenation & possible survival benefit Decrease O2 consumption reduce fever, anxiety, pain, respiratory muscle use anti-pyretics, sedation, analgesia, paralysis Improve O2 delivery Hb 7 as transfusion increases risk of dying once ARDS is established inotropes if cardiac output is low,
