Sun21November0437PM 19

A 19-year-old woman presents in severe hypovolaemic shock. She has been suffering with non-haemorrhagic diarhoea and vomiting after eating steak at a restaurant four days ago. She is not keeping any fluid down.

Blood pressure is 60/40 mmHg, pulse rate/min, apyrexial, respiratory rate 28/min, cap refill is prolonged. She has cool and mottled peripheries. You are very concerned and suspect that this may be Escherichia coli toxin 0157:H7 contamination.

Blood test reveal:

Hb 140 g/L

WCC 13 ×109/L

Plts 120 ×109/L

Na 138 mmol/L

K 5.6 mmol/L

Creat 278 mmol/L (normal baseline in this patient)

Urea 18 mmol/L

Bicarb 15 mmol/L

Lactate 2.8 IU/L

Which of the following treatment modalities would you choose to institute in this patient?

(Please select 1 option)

Crystalloid based fluids Correct

Penicillin based antibiotics

Fluoroquinolone based antibiotics

Colloid based fluids

Renal replacement therapy

Explanation

Fluid resuscitation with colloid-containing solutions in patients with hypovolaemic shock not due to bleeding has been associated with an increased need for renal replacement therapy and with death. As a result, crystalloid solutions have become the preferred solution for resuscitation in this cohort.

Though this patient has non-haemorrhagic diarrhoea, she may well have the E. coli 0157 toxin in her system. Confirmation of this will take time; the highest yield of the toxin is usually found in the stool after six days. Supportive management must commence urgently and it is impossible to wait for confirmation of infection.

There is no evidence to support antibiotic therapy in patients with enterohaemorraghic E. coli (EHEC) strains. In fact, there is some evidence to suggest that antibiotics may precipitate haemolytic uraemic syndrome (HUS). HUS consists of a triad of acute renal failure, thrombocytopenia and microangiopathic haemolytic anaemia. It is a major complication of the EHEC infections with high mortality rates. Renal replacement therapy is often required to stabilise these patients.

This patient requires rapid volume repletion and re-assessment before considering renal replacement therapy. As there is currently no evidence of bleeding, fluid resuscitation using an intravenous crystalloid preparation would be ideal. This school of thought separating use of colloid and crystalloid has been challenged by the CRISTAL study. However general consensus remains that use of crystalloid in hypovolaemic shock not due to bleeding results in better outcomes, including less need for renal replacement therapy.

Reference:

Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013;310(17):1809-17.

Wiedermann CJ. Hydroxyethyl starch--can the safety problems be ignored? Wien Klin Wochenschr. 2004;116(17-18):583-94.

Answer Statistics

1

91%

2

2%

3

5%

4

1%

5

3%

Times answered: 289