CICM SAQ 2010.2 Q10

Questions

A 63 year old man was admitted after a community cardiac arrest. He is currently day 5 post admission with uncertain neurological prognosis. He developed bilateral chest infiltrates yesterday and was started on ampicillin/clavulanic acid for a presumed nosocomial pneumonia. He has subsequently become progressively hypotensive requiring moderate dose noradrenaline. He is pyrexial 39.2C, he is anuric on dialysis and has an ALT 495U/L (<40) and a blood glucose of 2.3 mmol/L (4 – 6).

  • a) List the likely causes of the pulmonary infiltrate.
  • b) List likely reasons for the raised ALT.
  • c) The patient has a plasma lactate of 6.2 mmol/L. What are the likely causes of the raised lactate in this patient?

Answers

Answer and interpretation

a) List the likely causes of the pulmonary infiltrate.

  • Cardiac Failure
  • Nosocomial /aspiration Pneumonia
  • Fluid overload secondary to renal failure
  • ARDS
  • Drug reaction (less likely)

b) List likely reasons for the raised ALT.

  • Liver ischaemia at the time of the cardiac arrest
  • Ongoing liver ischaemia with possible venous hypertension secondary to cardiac
  • failure
  • Septic hepatic dysfunction
  • Drug reaction

c) The patient has a plasma lactate of 6.2 mmol/L. What are the likely causes of the raised lactate in this patient?

  • Lactate overproduction:
    Catecholamine infusion
    Low cardiac output state with global hypoperfusion
    Organ ischaemia (bowel or other organ ischaemia)
    Sepsis with mitochondrial dysfunction
  • Decreased lactate catabolism:
    Liver failure
    Renal Failure (especially lactate containing dialysate)

Exams LITFL ACEM 700

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CICM

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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