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Case History

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Image not available. The patient discussed in Chapters 5 and 6 has been in the high-dependency unit (HDU); despite initial improvements in his condition he is now deteriorating. He is hypoxic and is being given continuous positive airway pressure (CPAP) therapy for respiratory failure, requiring 90% oxygen to achieve PO2 8 kPa and looks increasingly tired. Despite adequate fluids, the patient is hypotensive and has been anuric for the last eight hours.

How should this patient's condition be managed in an intensive care setting?

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Background

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Image not available. The patient is reaching the limit of what the HDU can offer. If the patient's care is to continue with an aim of achieving recovery he will need support for his respiratory system - most likely in the form of positive pressure ventilation. He will need inotropes to support his hypotension, and will need renal support in the form of dialysis or haemofiltration. While some of these therapies can be provided in an HDU setting, the need for these therapies together will necessitate admission to an intensive care unit (ICU).

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How should this patient's condition be managed in an intensive care setting?

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The provision of ventilation is often via an endotracheal tube, which necessitates the administration of sedatives so that the patient can tolerate the tube. This initially renders the patient unconscious. A side effect of many sedatives is a drop in blood pressure, which may need further treatment. The endotracheal tube can later be removed as the patient's condition improves and they are able to breathe independently, or may be replaced by a tracheostomy which is more easily tolerated by patients and is believed to allow easier weaning of the patient. The use of an endotracheal tube increases the risk of the patient developing a nosocomial pneumonia. Steps are taken to reduce this risk, including the use of antiseptic mouthwash and good oral hygiene.

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Hypotension is treated by ensuring adequate fluid resuscitation of the patient, guided by central venous pressure (CVP) or other measures of filling. Then the provision of inotropes and vasoconstrictors can be used to improve the blood pressure. The most commonly used drug is noradrenaline (norepinephrine), which acts to improve vascular tone and blood pressure; in patients with inadequate cardiac output dobutamine or adrenaline (epinephrine) can be used to improve cardiac function.

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Many patients in the ICU will suffer an acute kidney injury (AKI).1 This is defined as any of the following:

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  • Serum creatinine rises by 26 mol/l within 48 hours

  • Serum creatinine rises 1.5-fold from the reference value, which is known or presumed to have occurred within one week

  • Urine output is <0.5 ml/kg/h for more than six consecutive hours.

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To prevent AKI the patient should be adequately resuscitated and blood pressure maintained at a level which will ensure renal perfusion. There is no evidence that diuretics or dopamine will alter the course ...

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