Sat27November0445PM 45

A 65-year-old man with acute abdominal pain and a distended abdomen is admitted to the Intensive Care Unit with a blood pressure of 70/40 mmHg and a pulse rate of 120 beats per minute. He is anuric, has an oxygen saturation of 93% on high flow oxygen, and a tympanic temperature of 39°C. He has received one litre of Hartmann's solution in the Emergency Department.

The following arterial blood gas results are available:

pH: 7.22

BE: -13.5

lactate: 6.5 mmol/L

K+: 5.9 mmol/

Which of the following should be the immediate management of this patient?

(Please select 1 option)

Fluid resuscitate with colloid/crystalloid This is the correct answer

Commence haemodiafiltration

Arrange an abdominal CT scan

Institute cardiac output monitoring

Commence inotropic support Incorrect answer selected

Explanation

The patient has signs of severe sepsis secondary to an intra-abdominal catastrophe. The patient has evidence of organ dysfunction (hypotension, anuria, hypoxia, and a raised lactate). The patient will need aggressive fluid resuscitation and monitoring on the Intensive Care Unit. This might eventually be guided by central venous pressure (CVP), cardiac output (CO), and other dynamic measures of cardiovascular filling: (pulse pressure variation (PPV) or stroke volume variation (SVV).

If fluid resuscitation fails to improve renal perfusion pressure, inotropic support will be required. The patient will also require antibiotics and an urgent exploratory laparotomy and source control. A CT scan prior to theatre is unlikely to change the management of the patient and may delay definitive management.

Whilst a metabolic acidosis and hyperkalaemia are indications for renal support it is not a priority in this case. Should the patient's metabolic status deteriorate in the postoperative period, renal support is an option.

Answer Statistics

1

86%

2

2%

3

5%

4

9%

Times answered: 360