Blogger Craig Denmade
Presenter Rinaldo Bellomo
Great turnout for this more intimate session kicked off by Rinaldo Bellomo. He starts by presenting a case of rapid evolving multisystem organ failure following complex cardiac surgery for endocarditis. The patient undergoes a return to theatre due to complications with valve seating where they spend a long period of time of cardiopulmonary bypass. Post-operatively they are ‘relatively well’ despite the insult but are cold (35.5 oC) and coagulopathic. Deterioration occurs whereby filling with 4% albumin solution and vasopressor therapy is initiated with a combination of adrenaline, milrinone and noradrenaline. Lactate climbing beyond 10 mmol/L! A working diagnosis of severe vasoplegic shock with ischaemic hepatitis is postulated. Bellomo asks the audience how to proceed from here sparking some great debate!
Severe hyperlactataemia (lactate >10) in the ICU is associated with very high mortality (78.2%, Haas et al. ICM 2015). The patient continues to deteriorate with severe splanchnic and renal ischaemia into a state of persistent vasoplegic shock. The audience question Bellomo:
- Is this truly vasoplegic shock or is the patient over-constricted?
- Do we believe the figures from CO monitoring? Are they accurate?
- What about RRT to correct the metabolic state?
- Steroids? Bellomo: “patients will live or die, steroids won’t!”
- Is there an alternative diagnosis e.g. Gut infarction?
What did Bellomo do? Deliver splanchnic ECMO!
In his own words, “Splanchnic rescue. What the hell?!”
Closing statement: “Cool stuff, he lived”. Bellomo is due to publish a case series within the next 6 months.
- Case series due within next 6 months (Bellomo)
Presenter Rinaldo Bellomo
Next up, a more typical case for discussion! An obese, hypertensive, diabetic 81 year old patient receiving an elective knee replacement in a private hospital. Develops post-operative anuria and hypotension. Blade empty on ward scan by nurse. The orthopaedic surgeon phones a friend, a nephrologist colleague, for advice. Patient receives a urinary catheter and a significant volume of IV fluid over a short period, cue emergency medical admission!
Patient hypotensive in pulmonary oedema with AKI.
Once again, some great debate! The audience favour NIV and arterial line. Did she really need the knee doing?
Furosemide challenge sparked some healthy debate. Barbara Philips asks whether the bolus dose furosemide for overload is the same in AKI as for CKD? Lui Forni tells us that it’s proportional to GFR (needs to be delivered to tubule to work). The audience question the venodilatory effect of frusemide – how useful? Bellomo feels this is modest at best.
Audience question: What would you have done if you were called first?
- Bellomo: pressure is important, ICU admission & vasopressor infusion
- Lui Forni: see the patient myself!
Audience question: Why renal failure in first place?
- Inflammatory response > hypotension > hypoperfusion
- Bellomo: blood cultures negative, no significant blood loss, no significant hypotension intraoperatively although “anaesthetic notes are always false!”
- Superb interaction from the audience: Analgesic infiltration cocktail (containing adrenaline & NSAID) and tourniquet time also postulated as a cause for the renal failure.
Patient outcome: Survived. Discharged ICU – day 5. Home – day 10.